3Nnm3w do Aavaan tvnouvn 3NOia3w do Aavaan tvnouvn 1 / If-' x v NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE S Wl ±w? 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BY HENRY N. GUERNSEY, M.D., FORMERLY PROBaSSOB «P«©«MB!BB4C&..41N_P DISEASES OF WOMEN AND CHILDREN IN THE H0MC30PATHIC MEDICAL COLLEGE OF PENNSf LVANf A ? TBQBMSSO&, OF MATERIA MEDICA IN THE HAHNEMANN MEDICAL COLLEGE OF PHILA- DELPHIA ; MEMBER OF THE AMERICAN INSTITUTE OF HOMCEOPA- THY ; HONORARY MEMBER OF THE HAHNEMANNIAN SOCIETY OF MADRIS DE TTXLIO, ETC. WITH JYUMfiHOZTS IZZZTSTftATIOJYS. SECOND EDITION. REVISED, ENLARGED AND GREATLY IMPROVED. BOERICKE & TAFEL, NEW YOKE: 145 Grand St. PHILADELPHIA: 635 Arch St., and 125 South Eleventh Street. ENGLAND: HENRY TURNER & CO., LONDON AND MANCHESTER. 1873. WQ I8Y3 Entered according to Act of Congress, in the year 1873, by H. N. GUERNSEY, M.D., In the Office of the Librarian of Congress, at Washington. Sherman & Co., Printers, Philada. Westcott & Thomson, Slereotyp«r$ and Electrotypers, Philada. PREFACE TO THE FIRST EDITION. In preparing this work for the press, I need not remark upon the great interruption a large practice and the great labor of lecturnig one hour or more every day in the week for six months out of the twelve upon some medical subject, and many other duties at the College besides, have occasioned. Very many physicians can testify to the all-engrossing of almost every moment of time in conducting a large practice. Add to this the labor as above indicated, and most physicians can understand that it is an easy matter for many imperfec- tions to creep into a work of this size, prepared under such pressing circumstances. No one can be more conscious of these imperfections than myself. This being the pioneer of all works of this kind ever published, it will be an easy mat- ter to offer criticisms and to improve on the issue of future editions. The same reasons have compelled the long delay in the publication of the work, due entirely to the impossibility of more rapidly supplying the copy. Nor indeed could the work have made its appearance so promptly, but for the assistance rendered by my friend and colleague, J. H. P. Fkost, M. D., in preparing the physiological parts, description of diseases, etc., and in carrying the whole through the press. Both the author and publisher desire to acknowledge the liberality of Messrs. Lindsay & Blakiston in furnishing a considerable part of the illustrations employed in this work. The plan of treatment may seem to some rather novel, and perhaps, on its first view, as objectionable, inasmuch as it may seem like prescribing for single symptoms; whereas such is 7 8 PREFACE TO THE FIRST EDITION. not the fact. It is only meant to state some strong charac- teristic symptom, which will often be found the governing symptom, and on referring to the Symptomen Codex all the others will surely be there if this one is. There must be a head to everything; so in symptomatology—if the most in- terior or peculiar, or key-note, is discernible, it will be found that all the other symptoms of the case will be also found under that remedy that gives existence to this peculiar one, if that remedy is well proven. It will be necessary, in order to prescribe efficiently, to discover in every case that which characterizes one remedy above another in every combination of symptoms that exists. There is certainly that, in every case of illness, which pre-eminently characterizes that case, or causes it to differ from every other. So in the remedy to be selected, there is or must be a combination of symptoms—a peculiar combination, characteristic, or more strikingly key- note. Strike that and all the others are easily touched, attuned or sounded. There is only one key-note to any piece of music, however complicated, and that note governs all the others in the various parts, no matter how many variations, trills, accompaniments, etc. Such a work as the present was needed, indeed urgently called for, and I have spared no pains to render it useful to students and to the junior members of the profession, for whom it was especially designed, and to whom it is respectfully dedicated by THE AUTHOB. PREFACE TO THE SECOND EDITION. In placing before the profession a second edition of his work the author desires to call attention to the fact that he has endeavored to make it more acceptable and valuable by a thorough revision of the entire text of the first edition; by rewriting parts, and even whole chapters, wherever it was deemed necessary to do so ; by a free consultation of the most recent authorities, thus bringing it up to the advanced opin- ions of the day; and especially by the addition of much new material, chiefly gathered from the writings of experienced homoeopathic practitioners, from the valued verbal communi- cations of numerous esteemed professional friends, and from personal experience. While, however, new measures of practice have been introduced, nothing has been recommended that has not fully borne the test of practical experimentation. Thus, for instance, in the use of the forceps in breech pres- entations, mentioned on page 260, while it may seem to many a novel and problematical procedure, yet it has re- ceived the endorsement of Dr. James Kitchen, of Philadel- phia, one of the most experienced and skillful of accoucheurs, of the author, and of other practitioners. It is proper that the author should here place on record an expression of his increased confidence in the methods of practice strictly medical which were laid down in the first edition of the work, and which were regarded by certain critics as chimerical. Increased experience has only served 9 10 PREFACE TO THE SECOND EDITION. to add to the author's faith in the efficiency of homoeopathic medication in the greatest exigencies of life, and this faith has been additionally strengthened by the related experience of many of the most eminent and skillful practitioners of the homoeopathic school. The Clinical Index, it is hoped, will prove a great help to the busy practitioner. By it the therapeutical parts of the work may be read " cross-wise," as Dr. Hering expresses it, which will facilitate the selection of the remedy at the bed- side. A copious General Index has been supplied to this edition, a glance at which will indicate the additions and improvements that have been made. The author desires to express his thanks to the many friends who have kindly made suggestions for the improve- ment of this edition, and to acknowledge his special obliga- tions to Dr. B. J. McClatchey, of Philadelphia, editor of the Hahnemannian Monthly, for valuable assistance in pre- paring the material for, and carrying the work through, the press. 1423 Chestnut Street, Philadelphia, August 1, 1873. A Treatise on Obstetrics. CHAPTEB I. THE BONES OF THE PELVIS. OBSTETRICS, as a science and as an art, has relation to the phe- nomena of pregnancy and parturition considered as physiological processes. Its study naturally includes a consideration of the develop- ment necessary to the occurrence of pregnancy, the period of preg- nancy itself, and the conditions which, succeeding parturition, may be regarded as its consequences. At the same time, however, all inequalities in form and function, and all difficulties and disorders attendant upon, connected with, or following after these processes, with their proper treatment, must be thoroughly understood, in order that the student may become an accomplished and successful ac- coucheur and physician. The anatomy and physiology of the pelvis, therefore, and of the parts of which it is composed, of the organs which it contains, and of those which are functionally associated with them, demand the first attention. And it is to be remembered that no mere description of these several organs and regions can alone be sufficient to impart a knowledge of them adequate to the purposes of the obstetrician, for the bones of the pelvis and their relations to each other, the pelvis as a whole and its relations to the mechanism of pregnancy and parturition, and the soft parts in situ, must be care- fully and scrutinizingly studied, on the skeleton and on the cadaver. In describing the anatomy of these parts and organs, a well-formed adult—having passed through the successive stages of progressive development, from the embryonic formation to that of maturity—is taken as a standard. The Pelvis is composed of four bones—viz., the sacrum, the coccyx, and the ossa innominata. The sacrum and coccyx form the posterior part of the pelvis, and are placed on the median line, while 11 12 bones of the pelvis. the ossa innominata form the sides and front. These bones unitedly form a cavity or basin (xs/ms, a basin), which gives general support to the contents of the abdomen, and the surfaces of which afford places of attachment to numerous muscles. In the adult it occupies the centre of the body, and is interposed between the lower end of the vertebral column, to which it gives support, and the inferior extremi- ties, upon which it rests; articulating superiorly with the last lumbar vertebra, and inferiorly with the femoral bones. In the erect position it is placed obliquely with regard to the trunk of the body; the inner surface of its anterior wall—the symphysis pubis—looking upward and backward, while the inner surface of its posterior wall—the sacrum—looks downward and forward. A brief description of the several bones which compose the pelvis will prepare the way for a more particular account of it. The Sacrum is the largest bone of the series of vertebra?, and is situated at the lower part of the spinal column and at the superior and posterior part of the pelvis, presenting the appearance of a wedge forced between the ossa innominata. It is concave in front and con- vex behind, and is curved upon itself from above downward and for- ward. Superiorly it articulates with the last lumbar vertebra. This articulation, owing to the projection forward of the anterior part of the articulating surface of the sacrum, and to the projection backward from this point of the body of the bone, forms a considerable promi- nence called the sacro-vertebral angle, or promontory of the sacrum, the angle being obtuse relatively with the lumbar portion of the vertebral column. Inferiorly the sacrum articulates with the coccyx. It is from four to four and a half inches in length and of nearly equal breadth, but in consequence of its spongy texture and the numerous foramina by which it is perforated, it is the lightest bone, for its size in the skeleton. It is triply wedge-shaped, as will be shown by the following description: In the first place, it is wider at its base, supe- riorly, than at its apex, having a breadth above of four and a half inches, from which it rapidly tapers toward its coccygeal extremity • secondly, it is broader on its anterior than on its posterior surface • and, thirdly, while the antero-posterior thickness of the bone at its base is two and a half inches, that of the apex is usually not more than two lines. It presents for examination an anterior and a pos- terior surface, two lateral surfaces, a base, an apex, and a central canal. The anterior surface is comparatively smooth and concave. This concavity is an important feature in the construction of the pelvis • THE sacrum. 13 varying in degree in different subjects, being usually estimated at from one-half to three-fourths of an inch. In the middle of this depres- sion there are four transverse ridges, which show the lines of union of the five segments of bone of which the sacrum is originally com- posed. At the ends of each of these ridges are the anterior sacral foramina—eight in number—through which pass the anterior branches of the sacral nerves. These foramina are rounded in form, the supe- rior being the largest and the inferior the smallest. Opposite to the extremities of the ridges above described, the margins of the foramina are beveled to form a groove, which runs toward the lateral mar- gins of the bone, so that on their outer side the nerves transmitted are in a great measure protected from pressure by the descending head, during parturition, by being thus sunk below the surface of the bone. On the inner side, the transverse ridges themselves answer a similar purpose of preventing undue pressure upon the nerves, which pass as it were beneath them. External to these foramina, on either side, are the lateral masses of the bone, which complete its anterior surface. The posterior surface is very rough, irregular, convex and much narrower than the anterior surface. Along the median line it is studded with eminences—rudimentary spinous processes—which af- ford greater surface and security to the muscles that originate from, and that are inserted into, the sacrum. These processes and tubercles form an irregular bony ridge, whose projections afford greater firm- ness of attachment to the numerous ligaments which unite this bone to the os innominatum of either side; while the general contour of the ridge itself renders the convexity of this posterior surface even greater than the corresponding concavity of the anterior surface. This convexity presents in both directions, longitudinally and laterally; so that the slope from the posterior surface inclines toward each lateral border, as well as toward the base above and the apex below. At the base of the spinous ridge, and immediately external to it, are the lamince, broad and well marked superiorly, but narrower and less pronounced as the apex is approached; while external to the laminae are a series of indistinct tubercles which correspond to the articulating processes of the lumbar vertebrae. The first or upper pair are large and well developed, the second and third more indistinct, and the fourth and fifth, which are usually blended together, are called the sacral cornua, and articulate with corresponding processes of the coccyx. External to these processes on either side are four posterior sacral foramina, through which are transmitted the posterior branches of the sacral 14 BONES OF THE PELVIS. nerves. On the outer side of these foramina, a second series of indis- tinct tubercles will be found, which constitute the rudimentary pos- terior transverse processes of the sacral vertebrae. The sacral canal extends centrally throughout the greater part of the bone. In its lower portion it is often incomplete in consequence of the non-development of the spinous processes and laminae. It is triangular above, follows the curvature of the sacrum, and is both narrowed and flattened from before backward in its descent toward the apex. It gives lodgment to the sacral nerves, which pass out through the anterior and posterior sacral foramina by which the canal is perforated. Each lateral border is divided into two distinct parts, a superior or iliac and an inferior part. The superior, auricular or ear-shaped part is covered by cartilage for articulation with the ilium. Posteri- orly it is marked by irregular impressions, to which the posterior sacrao-iliac ligaments are attached. The inferior part of the lateral border is thin and curved, and gives attachment to the greater and lesser sacro-ischiatic ligaments and to some portions of the gluteus maximus muscle. The anterior branch of the fifth sacral nerve passes through a small indentation at the lower edge of this border and at its angle of junction with the coccyx. The base is directed upward and a little forward, and is largest in its transverse diameter. In the middle and anteriorly it is sur- mounted by a transverse oval surface, placed obliquely, to correspond with the body of the last lumbar vertebra, with which it is articulated by the medium of intervertebral cartilage. Upon each side of this articulating facet a smooth surface is observed, concave transversely, convex from before backward, inclined forward, covered in the recent subject by the anterior sacro-iliac ligaments, and continuous with the iliac fossa. The anterior margin of these surfaces is formed of a rounded lip or border, which separates them from the anterior sur- face, and forms the posterior part of the superior strait, as will be hereafter shown. Behind the -articulating surface is observed the orifice of the sacral canal, and the two articular processes of the upper segment of the bone. The apex is directed downward and a little forward, and presents a transverse oval surface by which it is articulated with the coccyx. In the female the sacrum is broader than in the male; less curved especially in its upper part; and directed more obliquely backward : thus at the same time increasing the projection of the promontory of the sacrum, and the capacity of the cavity of the pelvis. THE ILIUM. 15 The pyriformis and coccygeus muscles are attached to the sacrum on either side; the gluteus maximus and erector spinse behind. The Coccyx corresponds to the sacrum in general appearance, shape, and mode of formation. From the gradual diminution in size, from above downward, of the four or five pieces of which it is composed, it presents the form of an inverted triangular pyramid. Its anterior surface is concave, and marked by three transverse grooves. It gives attachment to the levator ani muscle, the anterior sacro-coccy- geal ligament, and affords support to the lower portion of the rectum. The posterior surface is convex, marked by similar grooves, and pre- sents on each side a row of tubercles. The superior and largest pair of these—the cornua of the coccyx—project upward to articulate with the cornua of the sacrum; by which articulation the fifth sacral foramina is formed, for transmitting the posterior branch of the fifth sacral nerve. The posterior surface of the coccyx is covered in by and gives attachment to the posterior sacro-coccygeal ligament, and has attached to it some fibres of the gluteus maximus muscle. The borders of the bone are thin, and give attachment to the coccygeus muscle and the sacro-sciatic ligaments. To the rounded apex is at- tached the tendon of the external sphincter ani muscle. The only articulation of the coccyx is with the sacrum above, by means of an oval articulating surface. The Os Innominatum is so called from the impossibility of giving it a truly descriptive name. The bone is developed from three primary centres of ossification, and in early life consists of three separate pieces, which are then regarded as distinct bones, and named the ilium, the ischium and the pubis. These subsequently become united to form a single bone, but in the maturer subject the same names are employed to designate the respective portions of this large, irregular and anoma- lous bone. The ilium occupies the side, the ischium the inferior and posterior portion, and the pubis the anterior part of the pelvis. These three bones coalesce on either side, uniting at the acetabulum or cup-shaped cavity for the reception of the head of the femur, and at the ascending and descending ischio-pubic rami, and thus form the os innominatum. It will be more convenient first to describe by itself each of these constituent bones; afterward to consider them as they unite to form one single bone. The Ilium, the largest of the three, presents an external and an internal surface, an anterior and a posterior border, and a crest. The external surface, or dorsum of the ilium, is bounded above by 16 BONES OF THE PELVIS. the crest; below by the acetabulum; and in front and behind by the anterior and posterior borders. It is alternately convex and concave, broad and smooth, forms the external iliac fossa, and is crossed in a curved direction by three lines—the superior, middle and inferior curved lines. It gives attachment, principally, to the gluteus maximus, medius and minimus muscles, which make up the full and rounded contour of the hip. The internal surface is bounded above by the crest, below by a well- marked ridge called the ilio-pectineal line, and in front and behind by the anterior and posterior borders. It may be divided into two parts. The anterior part is a smooth and concave surface, of con- siderable extent, called the internal iliac fossa, or venter of the ilium, and gives lodgment and attachment to the iliacus interims muscle. The posterior portion, lying behind the iliac fossa, consists of two portions; a superior, which is rough, uneven and irregularly shaped, gives attachment to the sacro-iliac ligaments; and an inferior or auricular portion, which is uneven, is covered with cartilage in the recent state, and articulates with the corresponding ear-shaped portion of the lateral border of the sacrum. The crest of the ilium, longer in the female than in the male, is thick, convex, and arched. Its terminations in front and behind form prominent eminences, which are termed respectively the anterior and posterior superior spinous processes. The former, or anterior superior spinous process, gives attachment to Poupart's ligament, and to the sartorius and tensor vaginae femoris muscles. Into the latter, or posterior superior spinous process, are inserted strong ligaments which aid in firmly uniting the ilium to the sacrum. The outer edge or lip of the crest gives attachment to the tensor vaginae femoris, obliquus externus abdominis, and latissimus dorsi muscles, and the fascia lata—a dense fascia which covers in, and by its inner surface gives attachment to, the muscles of the hip and thigh. The inner lip has attached to it the transversalis, quadratus lumborum, and erector spinae muscles; while between the two attachment is given to the obliquus internus abdominis muscle. The anterior border of the ilium extends from the anterior superior spinous process to the ilio-pectineal eminence. It presents two de- pressions, which are separated by the anterior inferior spinous process. To the edge of the upper depression, which is a lunated notch, some fibres of origin of the sartorius muscle are attached, while the external cutaneous nerve passes across it. The straight tendon of the rectus femoris muscle arises from the anterior inferior spinous process. Be- tm THE PUBIS. 17 low this process is a shallow notch or groove, which completes the anterior border of the ilium, and across which the iliacus muscle passes. The posterior border, which is shorter than the anterior, extends from the posterior superior spinous process above to a deep notch be- low—the great sacro-sciatic notch—its termination being marked by a projecting process of bone, the posterior inferior spinous process. The upper portion of this border corresponds with that portion of the dorsum of the ilium which gives attachment to the sacro-iliac liga- ments ; the lower portion to the auricular surface which articulates with the sacrum. The Ischium, the second in size and lowest in position of the bones forming the os innominatum, is divided into a base or body and a ramus or branch. The base is the thickest part, and forms a larger portion of the acetabulum than does the ilium. From the posterior border of the bone arises the spinous process of the ischium, which marks the inferior boundary of the great sacro-sciatic notch. This process gives attachments to the gemellus superior, coccygeus, and levator ani muscles, and the lesser sacro-sciatic ligaments. Below it will be found a smaller notch, the lesser sacro-sciatic notch. The outlet of the pelvic cavity is sometimes materially affected by the ab- normal length and internal inclination of the spinous process or spine of the ischium; which hence becomes an important element in deter- mining the obstetric capacity of the pelvis itself. The tuberosity of the ischium forms the part upon which the body rests in the sitting position. It gives attachment to numerous muscles, and to some of the ligaments of the pelvis. The ramus of the ischium, thin and flattened, extends from the tuberosity upward and inward to join the ramus of the pubis. Its lower border forms part of the outlet, and its inner surface forms part of the anterior wall of the pelvis. The Pubis, the smallest of the three divisions of the os innomina- tum, with its fellow of the opposite side, forms the pubic arch or anterior portion of the pelvis. It may be divided for the sake of description into a body or horizontal ramus and a descending ramus. The horizontal ramus presents at its inner extremity the symphysis, marked on its surface by a number of transverse ridges separated by grooves, which serve for the attachment of the interarticular fibro- cartilage placed between the two pubic bones. The upper surface of this ramus is bounded posteriorly by a sharp ridge of bone, the linea ilio-pectinea, which marks the brim of the true pelvis. The internal surface of the horizontal ramus is smooth, and forms a portion of the 2 18 BONES OF THE PELVIS. anterior wall of the pelvis. The descending ramus is that portion of the bone which extends outward and downward to join with the ascending ramus of the ischium; the point of union is generally marked by a slight ridge. It becomes thin and narrow as it de- scends ; is smooth on its inner surface, and rough externally for the attachment of muscles. The pubic bones are not in actual contact at the symphysis, but are separated by fibro-cartilage, as mentioned above. These cartilages are remarkably adapted to promote elasticity of the pelvis. In some instances the state of this inter-pubic fibro- cartilage is such as to form a false joint, as it were, and to admit so much lateral movement between the pubic bones as to greatly impede locomotion. The acetabulum, or cotyloid cavity of the os innominatum, is the circular, cup-shaped depression for the reception of the head of the femur. The ischium forms something more, and the ilium something less, than two-fifths each of this depression, and the pubis the remain- der. Thus the acetabulum forms the centre of union of the three bones which compose the os innominatum; and these three original bones, which, for distinction's sake, have thus been separately de- scribed, unite to form the os innominatum, which latter must there- fore be regarded as one bone. The obturator, or thyroid foramen, or foramen ovale, as it is some- times termed, large and irregularly oval in the male, but smaller and triangular in shape in the female, is a large aperture situated between and formed by the ischium and the pubis. Formed on the same principle of the double arch which is seen on a larger scale in the construction of the pelvis, it gives lightness to the bone, with strength. Its margins, which are thin and uneven, have attached to them a strong membrane, the obturator ligament or membrane, which covers in the entire foramen excepting at its upper and outer part, at which point, by a notch in the bone and a corresponding hiatus of the membrane, a foramen is formed through which are transmitted the obturator vessels and nerve. A portion of intestine may descend through this opening and become strangulated. It will be perceived that the obturator membrane forms a part of the wall of the pelvis • and by its elasticity more room may be provided for the descending foetal head during parturition. It may be remarked, that the combi- nation of osseous and membranous constituents of the pelvic parietes serves, at the same time, to relieve the fcetal head and the soft parts of the mother from the danger of undue compression. The great sacro-sciatic notch is a deep, lunated depression, formed THE PUBIS. 19 by the ilium and ischium, extending from the posterior inferior spinous process of the ilium superiorly to the spine of the ischium inferiorly. In the recent state this notch is converted into a foramen by the lesser sacro-sciatic ligament Through it arc transmitted the pyriformis muscle, the gluteal vessels and nerve, and the internal pudic vessels and nerve. The os innominatum is formed by the union of the three bones thus separately described; and this bone, considered now as a unit, presents for study an external and an internal face, an anterior, a posterior, a superior and an inferior border. The external face of the os innominatum is occupied, in its upper and posterior portion, by the external iliac fossa. In its respective convex and concave surfaces, this fossa gives origin, insertion and attachment to the gluteus maximus, medius and minimus muscles. Anteriorly and superiorly appears the acetabulum or cotyloid cavity. Still more directly in front and beneath is found the obturator fora- men, already described as being nearly subtended by the obturator ligament. The internal face of the os innominatum is occupied, in its superior portion, by the internal iliac fossa and the auricular facet for articula- tion with the sacrum. Beneath is found the triangular surface which corresponds to the acetabulum and body of the ischium. Anteriorly appear the inner surface of the obturator foramen and membrane, and the internal faces of the ischio-pubic rami and symphysis pubis. The anterior border is concave, oblique above and horizontal in front; marked by the anterior superior and anterior inferior spinous processes and ilio-pectineal eminence, and terminated by the spine and angle of the pubis. The posterior border is irregular in shape, oblique from above downward and from without inward; marked by the posterior superior and posterior inferior spinous processes, great sciatic notch, spine of the ischium and lesser sciatic notch, and terminated by the tuberosity of the ischium. The superior border, or crest of the ilium, is convex and sinuously curved, being bent outward anteriorly and slightly inward posteriorly. It is terminated by the anterior superior spinous process in front, and by the posterior superior spinous process behind. The inferior border, shorter than either of the others, is marked above by the oval articulating surface which forms the symphysis pubis, below by the tuberosity of the ischium, and between the two we find the ischio-pubic rami. CHAPTEK II. THE ARTICULATIONS OF THE PELVIS, AND THE PELVIS AS A WHOLE. THE four bones which compose the pelvis are united by five articu- lations—the junction of the coccyx with the sacrum; the sacro- vertebral junction; the symphysis pubis, and the sacro-iliac symphyses. Each of these articulations is a true amphiarthrosis,—by some authors, however, classed as arthrodia,—a species of articulation in which cor- responding surfaces of bones are united together by an intermediate substance, yet admitting limited motion. These joints are each sup- plied with a partial synovial membrane, and it is supposed that dur- ing gestation the secretion from these membranes is more abundant. During this period, also, all shocks to either or all these pelvic bones are expended upon their elastic interarticular fibro-cartilages and syno- vial membranes, and the contents of the pelvis are thereby preserved from serious injury. In the Coccygeal Junction, or connection of the coccyx with the sacrum, there are found fibro-cartilages which cover each articulating surface. Between these cartilages is placed the synovial capsule. Thus the sacro-coccygeal articulation admits of free motion,__espe- cially backward,—by means of which the inferior outlet of the pelvis may be enlarged at least one inch in its antero-posterior diameter. This movement of the coccyx, so important in obstetric practice, is facilitated by the minor articulations of the small bones which com- pose the coccyx itself. In some rare instances these fibro-cartilao-es become completely ossified; as well at the junction of the coccyx with the sacrum, as at the points of union of the minor bones of the coccyx. In such cases the coccyx forms one continuous bone with the sacrum, greatly extending its curve, and constituting a formid- able obstacle to the passage of the head through the inferior strait in parturition. But ordinarily the mobility of the coccyx as a whole, and of the parts which compose it, increases during pregnancy; and so affords an additional advantage in labor. The anterior and posterior sacro-coccygeal ligaments support this articulation in front and behind. 20 the symphysis pubis. 21 In the Sacro-Vertebral Junction, or articulation of the base of the sacrum with the lower articulating surface of the last lumbar vertebra, is found the wedge-shaped interarticular fibro-cartilage com- mon to the inter-vertebral articulations. This fibro-cartilage is much thicker anteriorily than posteriorly, and assists in the formation of the sacro-vertebral prominence. The oblique processes of the sacrum, in conjunction with similar processes of the vertebra, complete the articulation, and at these points a synovial membrane is supplied. The movements common to the true spinal articulations may be accomplished, but to a limited extent only. The lumbar curve, which begins with the last dorsal vertebra, terminates at the sacro-iliac junc- tion,—the pelvic curve commencing at the same point, and terminating at the extremity of the coccyx. The sacro-vertebral ligament and the ilio-lumbar ligament are those which more immediately connect the spine with the sacrum and pelvis. The Symphysis Pubis, or articulation of the pubic bones in front, is formed by means of two dense oval-shaped fibro-cartilaginous plates, which cover the articulating surfaces of the pubic bones. The surfaces of these plates lying next to the bones are firmly connected to the bones themselves by nipple-shaped processes which fit within corre- sponding depressions on the osseous surface before described; while their opposing surfaces are connected by an intermediate fibrous elastic tissue, especially where the opposing convex surfaces of the pubic bones recede from each other. The interarticular fibro-cartilages vary greatly in thickness in different subjects, and project somewhat beyond the surface of the bones, especially behind. An interspace is left between them at the upper part of the articulation, which is larger in the female than in the male, and especially so during pregnancy and parturition. At this point the surfaces of the plates are lined by epithelium. This articulation is strengthened by several ligaments which traverse it in front and behind, above and below. These are termed, respectively, the anterior and posterior pubic ligaments, and the superior pubic and the sub-pubic ligaments. Their names are indicative of their positions and associations. The inferior surface of the sub- pubic ligament forms the upper boundary of the pubic arch. The strength and variety of these ligaments, which combine to strap the pubic bones together in every direction, and in the firmest possible manner, afford sufficient proof of the error of those obstetric writers who have supposed the symphysis pubis was intended to separate for the sake of enlarging the diameter of the pelvis in par- turition. Except in cases of serious deformity, the head is capable 22 THE SACRO-ILIAC SYMPHYSES. of being moulded (elongated) in its descent, so as to accommodate itself to the size and shape of the pelvis. But neither in such cases of serious deformity, nor in any other, does disarticulation of the pubic or sacro-iliac symphysis enable the pelvis to adapt itself to the size of the descending head. The Sacro-iliac Symphysis, of either side, is formed by the union of the superior, ear-shaped portion of the lateral border of the sacrum with the inferior, auricular portion of the posterior border of the ilium. Each of these articulating surfaces is covered with a layer of cartilage; the sacral layer being much thicker than the iliac. And both the sacral and iliac cartilaginous surfaces are covered by a delicate synovial mem- brane, which,, in the female,—especially in the pregnant state,—secretes a true synovial fluid. Thus,, as in the symphysis pubis, so in the sacro- iliac symphysis, a limited motion is provided for. The sacro-iliac symphysis is strengthened by several important liga- ments, which, without entirely preventing the motion just mentioned, assist in enabling these joints to sustain in safety the whole weight of the body. The anterior sacro-iliac ligament, composed of numerous thin bands, connects the anterior surfaces of the ilium and sacrum. The posterior sacro-iliac ligament occupies the depression between the sacrum and ilium,, behind the edges of the cartilaginous surfaces, and forms the most powerful bond of union between these two bones. This ligament consists of numerous short interlacing fasciculi, which pass in every direction from the sacrum to the ilium, and which from their fibrous and elastic nature are admirably fitted to maintain the necessary stability of this important articulation. In this general name of posterior sacro-iliac ligament are included also those which by some writers are described as superior and inferior sacro-iliac liga- ments. In addition to these, the greater and lesser sacro-sciatic liga- ments, which change th« greater and lesser sciatic notches of either side into foramina, at the same time serve to bind the ilium and ischium still more firmly to the sacrum, and contribute to the construction of the walls of the pelvis. It is doubtless true, as has been asserted by a number of writers that during pregnancy there occurs an increased afflux of fluids to all the parts concerned in that process, inclusive of those which constitute the articulations of the pelvis; and these articulations or symphyses become in consequence relaxed during the period of gestation, and do not return to their normal condition for a longer or shorter period after parturition. To so great an extent, indeed, may this relaxation and softening of the tissues and joints occur as to seriously interfere THE PELVIS AS A WHOLE. 23 with locomotion, which can only be performed with great difficulty and at the expense of considerable suffering. Difficult labor, too, may have a damaging effect upon the symphyses of the pelvic bones while in this relaxed condition, to the extent that standing or even sitting up in bed is rendered wellnigh impossible. The treatment of these disordered conditions, and of others arising during pregnancy and after parturition in consequence of the softening and relaxation of the pelvic joints, will be indicated in another chapter of this work. The Pelvis as a Whole. Having thus studied the separate bones which compose the pelvis, and examined the manner in which they are united and strengthened, and observed the nature of their articulations, we come to the con- sideration of the pelvis as a whole. In general, the pelvis may be divided into an external and an inter- nal surface, each of which needs to be studied by itself. The External Surface of the pelvis presents four regions. The anterior region extends from the symphysis pubis, on the median line, to the edge of the acetabulum on either side, and is principally cov- ered by the obturator externus and adductor muscles laterally, and in front by cellular tissue and the integument of the pubes. The pos- terior region is marked principally by the ridge formed by the spinous processes of the sacrum, the posterior sacral foramina, the inferior opening of the vertebral canal, the union of the sacrum with the coc- cyx, and the posterior surface of the coccyx itself. Each lateral region is formed superiorly by the external iliac fossa, mediately by the acetabulum, and inferiorly by the external surface of the tuberosity of the ischium. In this situation, likewise, is found the great sacro-sciatic notch. In the whole extent of its lateral surfaces the bones of the pelvis are separated from the integument by thick muscles. On its Internal Surface the pelvis is divided into the upper and larger or false pelvis, and the lower and smaller or true pelvis. The line of division extends on a level with the superior border of the symphysis pubis throughout the extent of the linea ilio-pectinea to the promontory of the sacrum. Thus, the superior pelvis is under- stood to include all that part above, and the inferior pelvis all that part below, the ilio-pectineal line. The inferior pelvis is that which is principally concerned in parturition, and which the accoucheur should therefore fully understand in all its parts and relations. Both the superior and inferior pelvic divisions are again divisible into four 24 INCLINED PLANES OF THE PELVIS. distinct regions. In the superior pelvis the anterior region is formed in the living subject by the muscular parietes of the abdomen. The pos- terior presents the sacro-vertebral symphysis and promontory, and extends to the sacro-iliac symphysis on either side. Each lateral region is constituted by the internal iliac fossa, covered by the iliacus internus and psoas muscles. In the lower or smaller pelvis the anterior region is composed of the posterior surface of the symphysis pubis; the posterior region consists of the anterior surface of the sacrum and coccyx. Each lateral region of this division of the pelvis may be again divided into an anterior and a posterior portion. The anterior portion is composed of the bony structure of this part of the pelvis, and corresponds to the inner surface or back part of the acetabulum, and to the interior surface of the body and tuberosity of the ischium. The posterior portion is rep- resented by the greater and lesser sacro-sciatic ligaments, and by the inner surface of the greater and lesser sciatic notches, which, by these ligaments, are converted into pelvic walls. The Inclined Planes of the Pelvis.—Inside the pelvis are found four inclined planes,—one anterior and one posterior on each side. These inclined planes may be demonstrated by dividing the pelvis itself into two lateral halves by vertical section through the symphysis pubis and median line of the sacrum; and by again divid- ing each of these lateral portions into anterior and posterior quarters by a transverse vertical section on the ilio-pectineal line, a little in front of the sacro-iliac symphysis, and terminating in the spine of the ischium. Each of the four quarters thus formed of the pelvis will be found to represent an inclined plane. And each of these inclined planes will be found to look in the same general direction. Thus each of the anterior inclined planes,—that is, the right and the left anterior__ will be seen to look from without inward, from above downward and from behind forward. In like manner both the rio-ht and the left posterior inclined planes will look from without inward from above downward, and from before backward. It was formerlv sup- posed that these several inclined planes, by influencing the rotation of the head of the foetus, through successive changes of direction ex- erted a powerful influence on the mechanism of labor. But, in point of fact, the rotation occurs principally after the head has so far passed through the inferior strait as to engage the soft parts and distend the perineum. And it may be now stated that these inclined planes serve in part to prevent the too rapid descent of the head, and in part to THE SUPERIOR STRAIT. 25 cause it to assume and maintain the most natural and favorable posi- tion in its course. In its general appearance the interior of the pelvis may be said to resemble the inner surface of an irregularly-shaped and truncated cone, tapering downward; although from the strongly-marked de- pression of the hollow of the sacrum the cavity of the pelvis seems larger than either the entrance above or the outlet below. The ilio- pectineal line—already described as dividing the greater from the lesser pelvis—together with the spine and crest of the pubes in front, and the anterior margin of the base of the sacrum and sacro-vertebral angle behind, constitute what is called the margin of the superior strait; and the corresponding border of the apex, bounded by the point of the coccyx posteriorly, by the inferior surfaces of the tuber- osities of the ischia laterally and by the pubic arch anteriorly, consti- tutes wThat is known as the inferior strait. The superior strait corre- sponds to what is by some termed the brim, as the inferior strait cor- responds to the outlet; while the intervening internal portion of the pelvis is indifferently named its cavity or excavation. The engage- ment of the head in the superior strait, its passage through the cavity or excavation, and its subsequent emergence through the inferior strait or outlet, constitute the most important events in the process of parturition. Hence the axes and dimensions, and in fact all the parts and relations of these straits and their intervening cavity, should be thoroughly understood. The Superior Strait. The superior strait or brim of the pelvis presents the shape of a curvilinear triangle with rounded angles,—■ having its base behind and its apex in front. The sacro-vertebral promontory, jutting in, as it were, gives a heart-shaped appearance to what might otherwise have been nearly oval. The psoas muscle on either side, by diminishing the transverse diameter, causes the superior strait to assume a more triangular form in the living subject than it presents in the skeleton; but by flexing the thighs upon the trunk, as during parturition, these muscles are relaxed, and the superior strait thereby becomes more nearly oval in shape and the descent of the fcetal head is facilitated. The boundaries of the superior strait are, the sacro-vertebral angle, the anterior border of the wings of the sac- rum, the linea ilio-pectinea, and the spine and crest of the pubes. The very great obstetric importance of this superior strait arises from the fact that it forms the first part of that bony canal through which the fcetal head must be transmitted, and through the somewhat contracted opening of which it must pass, almost before it acquires 26 ARTICULATIONS OF THE PELVIS. any of that elongated shape which it so often presents on emerging subsequently from the outlet or inferior strait. Fig. 1. c h, the plane of the superior strait prolonged beyond the pubes; c e, the plane of the inferior strait prolonged beyond the pubes; c d, shows the departure of this plane from the horizontal line; a b, the axis of the superior strait; h f, the axis of the inferior strait. The plane of the superior strait, its axis and its dimensions, form the most important points for consideration respecting it. The plane or surface of the superior strait may readily be demonstrated by cut- ting a piece of paper to fit it, making it extend antero-posteriorly from the sacral promontory to the superior border of the symphysis pubis, and transversely from the ilio-pectineal line of one side to that of the other. And when the female is in the erect position, it will be found that this plane presents an inclination of from fifty-five to sixty degrees to the horizon. The axis of this plane will of course be a line which shall fall at right angles upon its centre. Thus the axis of the superior strait must form the same angle with the vertical line that the plane of the strait forms with the horizontal line. And upon examination it is found that this axis extends from a point on the linea alba a little below the umbilicus to the articulation of the second bone of the os coccyx with the third. The inclination of the plane of the superior strait, and of course the direction of its axis, must vary with the changing position of the female; the inclination being diminished when the trunk is bent forward, as in stooping over, and becoming least in the recumbent position. But it is greatly increased when, in the ad- vanced stages of pregnancy, the female straightens up, and even leans backward as it were, in order to maintain her equilibrium. So in THE SUPERIOR STRAIT. 27 parturition, as will be more particularly explained subsequently, the position and flexure of the trunk will greatly affect the entrance of In the dimensions of the superior strait we note its different diame- ters and its circumference. The irregular shape of the figure of this strait renders its various diameters unequal. Different authors have enumerated quite a number; but the three principal diameters are all that are really of practical importance. These are, first, the antero- posterior diameter, which extends from the sacro-vertebral angle to the superior border of the symphysis pubis. This, which is also called the sacro-pubic or conjugate diameter, measures four and a half inches. The second, the transverse diameter, or long diameter, extends across the pelvis at its widest part, and at right angles with the anteropos- terior diameter. This, which is also called the iliac or lateral diame- ter—since it extends from the middle of the rounded border of the iliac fossa of one side to that of the other—measures five inches. The third is the oblique or diagonal diameter. This extends from the sacro-iliac symphysis to the ilio-pectineal eminence of the opposite side, and measures four inches and three-fourths. In consequence Of the space occupied by the soft parts, these dimensions are somewhat less in the living body. And we may allow at least one-quarter of an inch in the antero-posterior diameter, and one-half an inch in the transverse diameter. The circumference of the superior strait—bounded anteriorly by the 28 THE INFERIOR STRAIT. inner margin of the horizontal rami of the pubes, laterally by the 1I10- pectincal line, posteriorly by the promontory of the sacrum—measures from thirteen and a half to seventeen inches. The Inferior Strait.—The inferior strait is smaller than the superior, and in the skeleton much more irregular in form. This latter circumstance arises from the projection of the coccyx behind, and of the tuberosities of the ischia on each side. These projections form three deep notches, one on each side of the coccyx, and one im- mediately beneath the symphysis pubis. Thus this irregular border or periphery of the inferior strait is made up by the symphysis and descending rami of the pubes, by the tuberosities and ascending rami of the ischia, by the lower border of the posterior sacro-sciatic liga- ments, and by the extremity of the coccyx which projects inward. In parturition, however, the coccyx is usually pushed back, rendering the actual obstetric outlet nearly oval. This oval figure of the outlet may be demonstrated by placing the apex of the pelvis on a sheet of paper and tracing its outline with a pencil. And the figure thus obtained, compared with that of the brim of the pelvis, will show a gradual inclination of the wTalls of the pelvis downward and inward. The two lateral projections, the tuberosities of the ischia, extend somewhat beneath the extremity of the coccyx, and, being unyielding, alone support the entire weight of the body in the sitting posture. Hence it happens that transverse contractions of the pelvis at the in- ferior strait are more common than antero-posterior. The deep notch found anteriorly on the inferior strait corresponds to the summit or inferior margin of the arch of the pubes. This notch forms an im- portant feature in obstetric practice, and it is much broader in the female pelvis than in the male. At its base this arch is from three and a half to three and a quarter inches broad, but only from one and a quarter to one and a half inches wide at its apex; its height is from two to two and a half inches. As will be afterward noticed in de- scribing the process of parturition, this notch has very important relations to the fcetal head, affording to it a more ready exit in the first position. The still deeper notches which appear posteriorly on each side of the coccyx are subtended by the sciatic ligaments, Avhose elasticity is capable of materially adding to the pelvic dimensions at the moment of the final passage of the fcetal head. By the combination of double arches, both anteriorly and posteriorly, and from above downward the greatest possible strength has been preserved to the pelvis, with- the inferior strait. 29 out too much increasing; its weight; while at the same time the head is enabled all the sooner to emerge from its bony prison, by reason of these three important notches or arches in the periphery of the in- ferior strait, while the anterior notch—that of the pubic arch—also affords inestimable advantages to the accoucheur, in the introduction of the hand, the forceps or other instruments, when, from irregularity or contraction of the pelvis, from abnormal size of the head, or from other reasons, manual or mechanical interference becomes indispensable. The plane of the inferior strait may be demonstrated by applying a sheet of paper in the following manner. Upon an inverted pelvis in which the sacro-coccygeal articulation is still flexible, and in which the coccyx is retracted as far as possible, we place a piece of paper narrow enough to pass between the tuberosities of the ischium and be closely fitted to the summit of the pubic arch. This paper, thus rest- ing in front upon the inverted surface of the arch of the pubis and posteriorly upon the retracted extremity of the coccyx, will accurately represent the proper plane of the inferior strait. Hence it will be at once obvious that this plane is by no means parallel with that of the superior strait, the angle of inclination of the latter being from fifty- five to sixty degrees, and that of the former but from ten to eleven degrees. And as the planes of the two straits are not parallel, so neither will their axes be in the same line. Fig. 3. c d, the horizontal line; c e, the plane of the inferior strait (during labor) ; a b, the axis of the inferior strait. Thus, as is shown in Fig. 3, the plane of the inferior strait, with the coccyx retracted as it is in the last stage of labor—the only stage in which either the coccyx or in fact the inferior strait itself is particu- larly involved—inclines backward and downward at a very small angle 30 THE INFERIOR STRAIT. below the horizontal line, while, as shown in Fig. 1, the plane of the inferior strait in the ordinary condition of the pelvis—with the coccyx not retracted—inclines at a correspondingly small angle above the horizontal line. And the prolongation of the planes of the supe- rior and inferior straits to their point of union beyond the pubes shows that, instead of being parallel with each other in the human pelvis, they form an angle of not far from 45°, especially when the point of the coccyx is pushed back, as it is by the fcetal head in its passage through the inferior strait. The great advantage which must arise from this apparently irregular arrangement of the pelvic planes and axes, will be evident from a mo- ment's consideration of what must otherwise be the effect of gravity in the upright position, especially in the advanced stages of pregnancy. Even if the head and entire foetus were not impacted in the cavity of the pelvis, premature delivery must necessarily result from the con- stant and directly downward tendency of the'uterus and its contents. This is still further illustrated by comparison with the almost perfect parallelism which appears in the planes of the superior and inferior pelvic straits of quadrupeds. Here the gravid uterus is entirely sup- ported by the abdominal parietes, and the planes of the superior and inferior—or, more accurately speaking, anterior and posterior—straits are nearly parallel, and their corresponding axes nearly identical with each other and parallel with the trunk itself. The axis of the inferior strait is the line which, drawn perpendicular to its plane, falls upon it midway between the symphysis pubis and the extremity of the coccyx. When the coccyx is in its usual posi- tion, this line, extended, will strike the promontory of the sacrum; but when the coccyx is retracted, as in the advanced stages of labor, this line will fall upon the articulation of the first with the second bone of the sacrum. The axis of the inferior strait forms the same angle with that of the superior strait that the plane of the inferior strait forms with the corresponding plane of the superior strait. The diameters most important to be observed in the inferior strait correspond in number and in name to those of the superior strait, First, the antero-posterior or coccy-pubal diameter—extending from the extremity of the coccyx to the summit of the pubic arch—meas- ures four and three-quarter inches with the coccyx pushed back in labor, but only four and a quarter inches when it is not thus retracted. For practical purposes, therefore, the antero-posterior diameter of the inferior strait—taken at any period of labor when the head has not so engaged in that strait as to push back the coccyx—must be con- THE CAVITY OF THE PELVIS. 31 sidered as half an inch longer than the measure shows. The only exception to this will be in those cases in which, from complete ossi- fication of the coccygeal and sacro-coccygeal articulations, the coccyx forms one continuous curve and one solid bone with the sacrum. Fig. 4. A A, the antero-posterior or coccy-pubal diameter; B B, the transverse or bis- ischiatic diameter; C C, the two oblique diameters. The second diameter of the inferior strait is the transverse, con- jugate, or bis-ischiatic. It extends from the inner margin of one ischiatic tuberosity to the corresponding point on the opposite side, and measures four inches. The third diameter of the inferior strait is the oblique. It extends from the point of junction of the rami of the pubes and ischium to the middle of the great sacro-sciatic ligament of the opposite side, and measures about four inches. As previously stated, from the dis- tension of the ligamentous portions of the pelvic parietes the capacity of the inferior strait may be somewhat enlarged in this direction; and some authorities estimate the oblique diameter as practically equal, therefore, to four and a half inches. Naturally there are two oblique diameters to the inferior strait, the right and left oblique; but it is usually mentioned as one diameter, because—except in some not very common forms of pelvic distortion—the one will be exactly equal to the other. The circumference of the inferior strait is very irregular, owing to the projections of the coccyx posteriorly and the tubers of the ischia laterally. It measures about twelve inches. The Cavity of the Pelvis. That part of the canal of the pelvis which consists of the space between the superior and inferior straits is known as the cavity of the pelvis, or the excavation. From its situation, and consequent relation to the movements of the foetal 32 THE CAVITY OF THE PELVIS. head during parturition, it will be obvious that a thorough knowledge of this cavity, of its axes, planes and dimensions, is not only important in all ordinary cases of labor, but indispensably necessary to the suc- cessful management of all those of serious difficulty. This cavity is irregular in shape, contracted in its superior and inferior orifices, and greatly enlarged posteriorly by the concavity of the sacrum. The depth of the pelvis at the symphysis pubis in front is but one inch and a half; at the side, from the tuberosity of the ischium to the linea ilia, it is three inches and a half; and posteriorly, from the promontory of the sacrum to the extremity of the coccyx, the depth is four and three-fourths inches or five inches, according as the coccyx is in its natural position or retracted as in labor. If the curvature of the sacrum and coccyx be followed, this measurement will equal five and a quarter inches. The diameters of the excavation, taken at its centre, correspond in number and in name to those of the superior and inferior straits; and they are all of very nearly the same length of four inches and three-fourths. The antero-posterior diameter, extending from the sub- pubic ligament,—that is, from the summit or under surface of the pubic arch to the middle of the sacrum,—measures four inches and thrcc-fpiarters. But the line drawn from the sub-pubic ligament to the promontory of the sacrum will be found to measure but four inches and a half. The transverse and oblique diameters are each four inches and three-fourths in length. It should be borne in mind that the long diameter of the superior strait is the transverse, but that the antero-posterior is the long diameter of the inferior strait. The common plane and axis of the pelvic cavity ought to be well understood, as they represent the gradual change from the primary plane and axis of the superior strait above to the final plane and axis of the inferior strait beneath. Owing to the concavity of the sacrum, and to the slight convexity of the posterior surface of the pubic wall, the passage through the pelvic excavation represents a curve, which, if continued, would produce a circle. Consequently the plane which commences at the superior strait is constantly changing as we pass from above downward. And as the plane changes, so also must the axis of the plane, to cor- respond to it. Thus the general plane of the excavation will be represented only by a succession of differently inclined planes. So a corresponding series of axes must represent the general axis of the excavation. This general series of planes, and corresponding series of axes, is well illustrated in Fig. 5: thus a b represent the plane THE CAVITY OF THE PELVIS. 33 of the superior strait; i o, the plane of the inferior strait; c, the point of union of these two planes, if prolonged; then p q r s t—c, will represent tjie successive planes which must result from the curvature of the sacrum. It being borne in mind that the axis must Fig. 5. a b, the plane of the superior strait; i o, the plane of the inferior strait; c, the point where these two planes would meet, if prolonged; m n, the horizontal line; e /, the axis of the superior strait; g k, the axis of the excavation; p q r s t, various points taken on the sacrum to show the plane of the excavation at each point. always be regarded as perpendicular to (that is, at right angles with) its plane, the axis of the first plane, or that of the superior strait, will therefore be seen to be at right angles with its plane. And since the sacrum at this upper part of the pelvis forms a straight line, so the plane of the superior strait will form a right angle with it; and the axis of this plane will consequently be parallel with the sacrum. And so in fact in each successive instance; the plane of each succes- sive point of the cavity must be at right angles with the opposite point of the sacrum; and the axis of each successive plane must be at right angles with the plane itself, and of course parallel with the corresponding portion of the sacrum. These successive axes, thrown into a single line, will therefore form a curve exactly corresponding to the opposite curve of the sacrum. This general axis of the exca- vation, g, h, represents the line of direction which the fcetal head must necessarily pursue in its course through the canal of the pelvis. And as this line, in a geometrical point of view, is the result of a union of successive lines, so in a physiological point of view the course followed by the foetal head is the result of a combination of various and successive vital forces, whose progressive development 3 34 THE MALE AND FEMALE PELVIS COMPARED. can take place only in the direction rendered possible by the form and construction of the internal surfaces of the pelvic cavity. It has been remarked elsewhere that a change of position of the individual will effect a change in the direction of the planes and axes of the superior and of the inferior straits; but it is to be borne in mind that no change of position can in any degree affect the general axis or central curved line of the pelvic excavation. This is an im- portant obstetric fact which should be remembered, inasmuch as it is through this excavation and in the direction of its general axis that the foetus passes during the process of parturition, becoming curved upon itself in the passage; and the convexity of its curvature corresponds with the concavity of the sacrum, its concavity with the pubes. The Differences between the Male and Female Pelvis.— The pelvis of the male is smaller, narrower, deeper in its cavity, and more circular in its brim; the bones composing it are thicker and stronger, and the muscular impressions and eminences on their sur- faces more decidedly marked. The symphysis pubis is nearly double the depth of that of the female; the sacrum is straighter, and the sacro- sciatic notches and foramina smaller; the obturator foramen larger and more oval; the pubic arch is straight, much narrower, triangular in shape; its walls and the tuberosities of the ischia are less widely separated; the coccyx is more immovably attached to the sacrum; and in general the articulations are sooner anchylosed than in the female. The pelvis of the female is much wider; the acetabula are farther apart, although the knees approach each other even more than in the male, giving to the movement and gait of the female some distinguish- ing peculiarities. The iliac fossae are broader than in the male pelvis, and the spinous processes of the ilia more widely separated, hence the greater breadth of the hips in the female; and here Nature seems to have sacrificed the facilities of motion to the advantages of pregnancy and parturition. The superior strait is larger and more elliptical; the curve of the sacrum is deeper and more regular; the symphysis pubis is but half as deep as in the male ; and the pubic arch is broader, more rounded, and its lateral walls more widely divided. The entire pelvis is larger and more capacious, and so constructed, in its several arches and ligaments, as to combine the greatest possible lightness elasticity and strength with the most suitable form and dimensions for sustaining the gravid uterus above its brim, or enabling the full- grown foetus to be transmitted through its canal. In early childhood the pelvis seems disproportionably small. It is the uses of the pelvis. 35 narrow and long, and the abdominal protuberance which is seen in the foetus and in newly-born infants, and even still later in the case of rachitic children, is due to its thus forcing upward some of the parts which should be contained within it. But as the female child advances in life the pelvis becomes gradually, although slowly, de- veloped, until, at the period of puberty, it experiences, within a short time, an alteration so extensive and so strongly marked as to change perceptibly the form and contour of the hips. At nine years of age the antero-posterior diameter measures two inches and seven-eighths, and the transverse diameter, two and three-fourths; while at fourteen years of age the antero-posterior diameter measures three inches and three-fourths, and the transverse, four and a half. The Uses of the Pelvis.—The pelvis of the female, as in the male, affords a general support to the abdomen and its contents. In the pregnant female it especially supports the gravid uterus upon its anterior arch and iliac wings. Within the cavity of the pelvis the uterus of the unimpregnated female, the ovaries and Fallopian tubes are safely enclosed, while the delicate and sensitive external organs of generation are securely protected beneath. From its relation to the lower portion of the spinal column, and from the maimer in which it is placed upon its femoral supporters, the pelvis may be regarded as the structural base or foundation of the human body; while, from the study of the functions which it performs in connection with the organs which it contains, it will no less obviously be seen to be the true physiological centre of the entire human system. From improper management in childhood and youth, from too long and too frequent indulgence in unnatural positions, from habitual over-exertion of a particular kind, from accidental injuries, and especially from disease and softening of the bones, the pelvis may become contracted, strained and distorted in every direction, and so more or less incapable of performing its most important uses in the support of the body and in parturition. So also, from similar and corresponding causes, the organs which it contains may become more or less disordered and in- capable of performing their vital functions. In the former case mechanical difficulties and obstructions embarrass the accoucheur. The consideration of these difficulties, and of the appropriate means for overcoming them, we reserve as a sequel to the normal process of parturition. In the latter case the physician has to contend with various forms of functional disorder or structural disease. The con- sideration of these disorders and of their appropriate remedies we shall take up hereafter. 36 the muscular tissues of the pelvis. CHAPTER III. THE MUSCULAR TISSUES OF THE PELVIS. THE study of the bony skeleton of the pelvis forms the only true basis for understanding this most important part of the body, as it exists in life; and it is only now, as we come to the examination of the pelvis clothed with muscular and other living tissues and supplied with organs, that its real study begins. Occupying the middle ground between the upper and lower part of the body, the pelvis affords at- tachment to two classes of muscles. The first class is for completing, enclosing and perfecting the abdo- men. The muscles of this class, by their great power of distension, afford every needful facility for the development and support of the foetus in the pregnant state. These muscles, which form the anterior abdominal parietes, by yielding to the pressure exerted from against PELVIS, WITH SOFT PARTS, SEEN FROM ABOVE. A, section of the aorta; B, the vena cava inferior ; C, the internal iliac artery, aris- ing, together with D, the external iliac, from the primitive iliac trunk ; E, external iliac vein; F, the iliacus internus, and G, the psoas magnus muscles ; H, the rectum . I, the uterus with its appendages; K, the bladder, the fundus of which is depressed, so as to bring the womb into view. the rigid posterior walls, cause the gravid uterus to project over the arch of the pubes, and thus hinder it from settling downward through the superior strait. The muscles of the second class are those which, connecting the pelvis with the lower extremities, are concerned in locomotion. There the muscular tissues of the pelvis. 37 are but four sets of these muscles on the inner surface of the pelvis. The principal of these are the iliacus internus and psoas magnus; next in size and relative importance come the pyriformis and obturator internus muscles. The iliacus and psoas magnus, while being them- selves protected by the iliac fascia, serve to line and cushion the iliac fossse and bones of the upper pelvis, thus preventing the uterus from receiving injury in the latter months of gestation from the shocks and concussions inseparable from active exercise. These two muscles, as they become conjoined in passing over the lateral parts of the superior strait to be inserted into the lesser trochanter of the femur, have the effect to change the base of the curvilinear triangle of the pelvis from the rear to the front, and to lessen the transverse diameter half an inch; these two being the only muscles in the pelvis that do lessen any of its diameters. The iliacus, however, from its thinness, neither too much encroaches upon the concavity of the iliac fossse, nor indeed does it, so much as the psoas, diminish the size of the pelvic cavity. And the shortening of the transverse diameter may be in a great mea- sure obviated by flexing the thighs upon the abdomen in labor, thus relaxing the psoas muscles and reducing the diminution of the pelvic cavity to the smallest possible amount. The pyriform muscles, which arise principally from the outer mar- gins of the sacrum, pass immediately out of the pelvis through the great sacro-sciatic foramina of either side to be inserted into the great trochanter of the femur. The internal obturator muscles arise from the margin of bone which forms the inner side of the obturator fora- men, and from the internal surface of the obturator membrane, and leaving the pelvis through the lesser sacro-sciatic notch, or more properly foramen, are likewise inserted into the great trochanter in front of the pyriformis. These muscles are thin and flattened and project so slightly beyond the bony surface which lies adjacent to them as to encroach but slightly, if at all, upon the capacity of the pelvic cavity. This may be said also of the coccygei muscles, which, arising from the spines of the ischia and lesser sacro-sciatic ligaments and inserted into the margins of the coccyx, do not encroach laterally upon the diameters of the pelvis. Thus we have the entire pelvic cavity covered by fascia and suffi- ciently supplied with muscular tissue for all its uses, without so much diminution of its size as to obstruct the foetus in its descent. Indeed, the obturator internus and pyriformis muscles, covering the obturator and sciatic foramina, afford increase of room by giving way as the head makes pressure upon them in its descent. 38 THE PERINEUM. The antero-posterior diameter is slightly diminished by the attach- ment of the bladder to the posterior surface of the arch of the pubes, and the cellular tissue which everywhere lines the pelvic parietes slightly diminishes the general capacity of the pelvis. When this cellular tissue becomes loaded with fat, as is the case with fleshy women, it may offer a serious obstacle in parturition. The rectum, in passing down over the anterior surface of the sacrum and to the left of its promontory, does not materially hinder the process of labor, un- less loaded with indurated fecal matter, and the uterus, although occu- pying a middle ground between the bladder and rectum, does not diminish any diameter of the pelvis in labor, for at such times it is usually entirely above the superior strait. The Pertxeum may be said to form the floor of the pelvis. It is composed of muscular tissue, fascia, and intervening areolar and adi- pose tissue, and is exceedingly elastic and distensible. The female perineum extends laterally between the tuberosities of the ischia and antero-posteriorly from the apex of the coccyx to the posterior commissure of the vulva. The anus divides the perineum into two portions; that extending between the coccyx and the anus constituting the posterior perineum; that extending from the anus anteriorly to the vulva being the anterior perineum, or perineum proper. It is larger in the male than in the female. The muscles entering into the composition of the perineum are arranged into two layers, the upper of which is concave superiorly and comprises the levatores ani and coccygeal muscles, while the lower, which has its concavity looking downward, comprises principally the transversus perinei, sphincter ani and constrictor vaginae muscles. Of these muscles, the levatores ani are the most important in an obstetrical point of view. They are broad and thin muscles, which arise anteriorly from the posterior surfaces of the bodies and rami of the pubes; posteriorly from the spine of the ischium; while the intervening portion arises between two layers of the descending pelvic fascia. The posterior fibres are inserted into the sides of the lower portion of the coccyx, while the middle and anterior fibres pass downward, converging toward each other, to be inserted into a central line or raphe at the centre of the perineum. In addition to these points of insertion, numerous fibres are blended with those of the sphincter ani, transversus perinei and constrictor vaginae muscles. It will be seen, from this description, that these levator muscles exert a powerful influence by their con- traction upon the entire perineum, and might very properly be called levatores perinei. In a condition of rigidity they may offer a very THE PERINEUM. 39 serious obstacle to the descent of the child, the presenting part of which in its passage downward impinges upon this muscular floor, and must push it downward and forward in order to effect delivery. Fortunately, however, these tissues are usually softened and yielding, and admit of enormous prolongation and distension; otherwise lacera- tion would be a common accident. MUSCLES OF THE PERINEUM. 1, tuber ischia; 2, sphincter vaginae; 3, its origin from the base of the clitoris; 4, vaginal ring of the same muscle, which receives a part of the fibres of the levator ani; 5, intercrossing of the sphincter ani and sphincter vaginae at the perineal centre; 6, erector clitoridis; 7, clitoris; 8, transversus perinei; 9, sphincter ani; 10, levator ani; 11, gracilis; 12, adductor magnus; 13, posterior part of gluteus magnus. The extent of the perineum from the point of the coccyx to the anus is about an inch and three-quarters, and from the anus to the vulva about an inch and a quarter; making three inches in all in its ordinary condition. But at the instant of the passage of the child's head into the external world at full term, it becomes so distended and prolonged downward and forward as to measure about five inches and three-fourths. It must now be evident that the terminal outlet of the obstetric canal in the living subject is not represented by the symphysis pubis and the point of the coccyx, but rather by the symphysis and the anterior commissure of the perineum; and the plane of this outlet 40 THE PERINEUM. will be represented by a line drawn from the lower part of the sym- physis to the commissure. But, in the last moment of labor, as the head is emerging through the vulva, the perineum is prolonged in a forward direction to the extent of passing beyond the lower part of the symphysis pubis, and the plane of the outlet at this moment will be represented by a line drawn from the symphysis to the edge of the distended perineum. Fig. 8. POSITION OP THE PELVIS AND THE DIRECTION OF ITS AXIS IN THE DORSAL ATTITUDE ASSUMED BY THE FEMALE DURING LABOR. a b, total axis of the excavation, being a continuation of d b, the axis of the superior strait; c v, perineum as distended at the moment of the passage of the head ; r, anal orifice; e v, terminal plane of the obstetric canal. The direction taken by the foetal head in its passage through the excavation of the bony pelvis is indicated by the axes of the various planes representing the curvature of that osseous canal. Now, if another series of planes be made, commencing at the plane of the bony outlet, and extending from the symphysis to various points upon the curvature of the distended perineum—the final plane ex- tending from the symphysis to the anterior perineal commissure—and the axes of these planes be ascertained, and prolonged so as to form a complete axis continuous with that of the excavation of the bony pelvis, the line thus indicated will represent the axis of the entire obstetrical canal and the course traversed by the foetus from its en- trance into the superior strait until its final emergence at the vulva. This is well represented in Fig. 8. It will thus be seen that, in the recumbent posture of parturition, the foetus, in following the axis of the obstetric canal, takes a course EXTERNAL ORGANS OF GENERATION. 41 first downward and backward, then downward and forward, then al- most directly forward, and finally, at the moment of delivery, upward and forward. CHAPTER IV. THE ORGANS OF GENERATION. The External Organs and Vagina. THE genital organs of the female, when closely studied and com- pared, will be found to bear a very strong resemblance to those of the male. And in addition to this particular similarity in the struc- ture and functions of some of the parts of the female to those of the male, there will be seen to be a universal and essential correspondence of all the sexual organs of the one sex to those of the other. For as all the sexual organs of the male are structurally and physiologically adapted and intended for giving, so all the sexual organs of the female are, in like manner, structurally and physiologically adapted and de- signed for receiving. Thus they bear to each other the relation of the two halves which are requisite to constitute one complete physiologi- cal whole—of two equally indispensable means for the accomplish- ment, physiologically, of the final end of reproduction. This dis- tinction of structural difference and similarity and of physiological correspondence is the type of the adaptation of the man to the woman in the married state; the highest condition of human life.* And this distinction should be steadily borne in mind in all our study of the genital organs and reproductive system of the female. These genital organs, which as well in structure as in function are much more complicated in the female than in the male, may be divided into external parts, or those without the pelvis, and internal organs, or those situated within the pelvis. The former are the mons veneris, the perineum and the vulva with its appendages. The latter are the vagina, the uterus, the Fallopian tubes and the ovaries. We will proceed to study their anatomy and physiology in the order in which they have just been named. The Mons Veneris.—The mons veneris is situated at the lower margin of the abodmen, just on or above the centre of the svmphysis pubis. Its diameter is usually about three inches; it is half an inch thick at its centre, and tapers off to a thin edge at its circumference. 42 THE MONS VENERIS. It is principally composed of dense cellular or adipose tissue, covered by thick elastic integument, and abundantly supplied with sebaceous follicles. The hair, which makes its appearance at puberty as one of its characteristic signs, is said to diminish in quantity, in many cases, on the cessation of the menses. The growth of the hair varies remark- Fig. 9. EXTERNAL GENITALS. A, mons veneris ; B, labia majora ; C, clitoris; D, labia minora; E, orifice of urethra; F, orifice of vagina ; I, posterior commissure of the vulva; H, perineum ; J, anus. ably in different individuals; and in some cases, where it is very white and scanty, it is supposed to indicate sterility. The excessive growTth of the hair is sometimes accompanied by pruritus, and in those who are subject to the plica polonica this disgusting disease attacks also the hair on the mons veneris, which becomes agglutinated and attains an enormous length. The mons veneris may become the seat of in- flammation and abscess, which should be treated promptly in the same manner that would be appropriate to similar conditions elsewhere. The perineum has already been described in connection with the soft parts of the pelvis. From its peculiar structural formation it ad- mits of very great distension during labor, but is prompt to resume its usual condition when the pressure of the child has been removed. When the last expulsive pains of labor are very violent and the perin- eum is from some cause or other unyielding, or when the woman in the throes of these last expulsive pains straightens herself out instead of remaining in a semi-flexed condition, the perineum may undergo lace- ration. The treatment to be adopted when such an accident occurs will be indicated hereafter. THE VULVA AND ITS APPENDAGES. 43 The Vulva and its Appendages.—The vulva or pudendum is the longitudinal opening between the projecting parts of the exter- Fig. 10. Fig. 11. Fig. 10. Hymen in the form of a crescent.—A, clitoris; B, labia externa; C, labia in- terna ; D, orifice of the urethra; E, hymen; F, orifice of the vagina; G, posterior commissure of the vulva; H, perineum. Fig. 11. This figure exhibits the Hymen in the form of a circle.—E, the hymen ; F, the central opening somewhat enlarged. nal organs of generation, which, situated immediately beneath the mons veneris, is bounded laterally by the labia majora and terminated posteriorly by the perineum. It constitutes the external opening com- mon to the vagina and to the urinary bladder. A more particular description of the vulva will be involved in that of its appendages. These are the labia majora, the labia minora or nymphae, the clitoris, hymen, caruneulse myrtiformes, fossa navicularis, fourchette, vestibule and urethra. The labia majora or labia externa are two prominent folds consisting externally of integument and internally of mucous membrane, which, commencing immediately beneath the mons veneris, diverge from each other, extending downward and backward to again converge and terminate at the perineum. Their junction at the mons is termed the anterior commissure, and that at the perineum the posterior commissure. Between the integument which constitutes the outer surface of these folds, and the mucous membrane which forms their inner lining, will be found a large quantity of areolar tissue, fat, glands, an interlacement of vessels and nerves, and a peculiar tissue which resembles the dartos of the scrotum in appearance and general 44 THE VULVA AND ITS APPENDAGES. * construction. The skin of the labia majora is usually soft and deli- cate, and is studded with hair after puberty. The mucous lining is continuous with the mucous lining of the genito-urinary apparatus. It is moist and smooth and of a rose-color in young women, and well supplied with sebaceous glands and mucous follicles. These glands secrete an oleaginous fluid which serves to moisten the parts and protect them from injury by the motion of the adjacent parts; while the mucous follicles likewise provide abundantly their peculiar secretion—stimulated and increased by exercise—which serves to guard these delicate surfaces, which are not only in apposition but in more or less constant movement upon each other, from the irritating effects of friction and from subsequent adhesions. But although these glands usually pour out a healthful and bland fluid, yet under the influence of some morbid conditions of the system their secretions may be exceedingly acrid and irritating, to the extent of causing severe excoriations and unbearable pruritus; and this acrid secretion, when occurring in a married woman, may produce in her husband a disease analogous to gonorrhoea; a circumstance which should be borne in mind. The arteries of the labia majora are derived from the perineal artery, which is usually a branch of the internal pudic. The veins, which are numerous and often become enlarged during pregnancy, generally accompany the arteries. The nerves proceed from branches of the lumbar plexus. The areolar tissue, or cellular structure of the labia majora, is more loose and spongy than in other parts of the body. Thus the labia frequently become the seat of serous infiltration by which they are enormously tumefied. Sanguineous and purulent engorgements, hernial protrusions, varicose veins, and other abnormal conditions may likewise occur in these parts. In girls and unmarried women the external labia are rounded, thicker above than below, and their inner surfaces are closely approximated; but in married women, and especially in those who have borne children, they are more widely- separated, irregular, pale and flaccid. The labia majora are usually regarded as analogous to the scrotum of the male. And, indeed, by careful comparison this is readily appreciable. The existence of a tissue in the labia bearing a marked resemblance to the dartos of the scrotum; the termination of the fibrils of the round ligament within its tissues—as the spermatic cord enters within the scrotum—the presence within the labia of a pouch or cul-de-sac between the dartos- like tissue and the inner surface of the labial integument, which ad- mits the passage of hernial protrusions or serous infiltrations resem- bling scrotal hernia or hydrocele, together with numerous other points THE VULVA AND ITS APPENDAGES. 45 of resemblance which might be cited, all go to prove the striking similarity between the labia majora and the scrotum. The fourchette is a small, transverse fold of mucous membrane found just within the posterior commissure of the vulva. It is usually ruptured in the first labor. The small space lying .between the fourchette and the posterior commissure is termed the fossa navicularis. Its distinctive presence is usually lost by the rupture of the fourchette. The labia minora, labia interna, or nymphce, are two lateral folds of mucous membrane, interior and parallel to the labia majora, by which they are concealed in the virgin. They are continuous externally with the mucous lining of the labia majora; internally with that of the vagina. Superiorly they commence at the clitoris, and extending from thence downward and outward on each side of the orifice of the vagina, are gradually lost. As each labium converges toward the clitoris to join its fellow, it is divided into two folds, the anterior of which unite and pass in front of or superior to the clitoris, forming a minute fold which has been termed praeputium clitoridis, while the posterior divisions unite with the clitoris itself and constitute, as it were, its fnenum. The nymphse are composed of mucous membrane having a thin epithelial layer, beneath which are numerous sensitive papillae. They are likewise supplied with blood-vessels and nerves, and a large number of mucous follicles which secrete an abundance of sebaceous matter. They are very extensive, and after frequent labor are generally found to project beyond the labia externa. Their use appears to be, chiefly, to enfold and protect the clitoris, meatus uri- narius and superior part of the vaginal orifice. The clitoris arises from the union beneath the pubic arch of two cavernous bodies which spring from the ischio-pubic rami; and its free extremity appears at the superior part of the vulva, a little beneath the anterior commissure of the labia majora. In its internal structure and erectile nature it resembles the corpora cavernosa of the male penis, to which organ it corresponds in sensational and passional function. At its anterior extremity, almost entirely covered and concealed by the prepuce formed by the folds of the nymphae, appears a minute gland which is analogous in texture and use to the glans penis. The clitoris is supplied with blood from the perineal artery, and with nerves from the perineal branch of the internal pudic nerve. Like the male penis, the clitoris has a suspensory liga- ment and an erector muscle. Occasionally it becomes greatly elongated, to the extent, in some instances, of four or five inches, and it then bears 46 THE VULVA AND ITS APPENDAGES. a very marked remcmblance to the penis of the male. Most of the cases of so-called hermaphroditism are referable to an extraordinary growth of this organ. The vestibule is a triangular smooth surface situated at the upper part of the vulva. It is bounded laterally by the labia interna, and extends from the clitoris backward to the orifice of the vagina. The meatus urinarius, or orifice of the urethra, is situated at the back part of the vestibule, just above the orifice of the vagina and about an inch below the clitoris. It is surrounded by a prominent elevation of the mucous membrane. The determination by touch alone of the exact location of the urethral orifice is important as enabling the physician to introduce the catheter in the most delicate manner where this operation is required. It may be effected in this way: the patient being placed upon her back, the point of the forefinger of the right hand should be placed just within the orifice of the vagina, the palmar surface looking upward and resting against the anterior vaginal wall. In this position the finger serves as a guide, along the palmar surface of which the catheter should be slidden until it reaches the tubercle formed by the mucous membrane and which marks the entrance to the urethra; then, by slightly depressing the shaft of the instrument, it may readily be made to pass over the elevation at which it has been arrested and to enter the urethra. Another and very satisfactory method of cathetcrizing the female is, to find the clitoris with the point of the forefinger, and then to pass the finger from this point downward over the surface of the vestibule until an elevation is met with, which is the urethral orifice, into which the instrument may without difficulty be inserted. It may sometimes happen that where great difficulty is experienced in passing the female catheter the use of the male catheter may be successful. The finger having been introduced as before directed, the instrument, with its concave surface upward, should be slidden along the finger, when the desired object will be accomplished by the point of the instrument dropping, as it were, into the orifice of the canal. Where cystocele exists this is the only method that can be crowned with success; it must be remembered, however, that in these cases as the instrument enters within the orifice it must be turned with its convex surface upward. Sometimes in women who have borne many children, or where <>reat tumefaction of the adjacent parts exists, it is impossible to find the urinary meatus by the sense of touch alone; and in such cases it becomes absolutely necessary to expose the vulva and introduce the catheter guided by sight as well as touch. THE VULVA AND ITS APPENDAGES. 47 The urethra itself is larger than its orifice, and may be described as a membranous canal about an inch and a half in length, slightly curved, with its concavity looking upward, passing obliquely upward and backward beneath the symphysis pubis, to which it is attached by loose cellular tissue. More interiorly it passes between the crura of the clitoris and just beneath their junction. It is susceptible of very great dilatation, and opens interiorly into the urinary bladder. It is composed of three tunics—a muscular coat continuous with that of the bladder and composed of circular fibres; a thin layer of erectile tissue intermixed with numerous elastic fibres; and a mucous coat, which is continuous externally with the vulva and internally with that of the bladder. It is surrounded also by the muscular fibres of the compressor urethra?, which assist in controlling the flow of the urine. In the various displacements of the uterus, the urethra, by reason of its structural connection with the vagina, is liable to be changed from its natural direction. This should be especially borne in mind if called upon to perform catheterism to relieve retention of urine caused by such uterine displacements. It is very distensible, in some cases becoming greatly enlarged. Calculi have been' removed from the bladder through the urethra, and large-sized pessaries have been passed through it into the bladder. Orifice of the Vagina.—Immediately below the meatus urinarius is found the much larger and irregularly shaped opening which constitutes the orifice of the vagina. The extent of this opening varies greatly according to the sexual condition of the female. In those who are virgins, and in some exceptional cases in persons who are not, the orifice of the vagina is very small, oval, or crescent-shaped, as repre- sented in Figs. 10 and 11. It is more or less closed in the virgin by a membranous fold called the hymen. The hymen is the delicate membranous structure which covers the greater portion of the orifice of the vagina, and which is usually ruptured at the first successful attempt at sexual intercourse. The rupture of this structure ordinarily occasions a slight flow of blood, and sometimes leads to no inconsiderable haemorrhage. The minute reddish tubercles found near the orifice of the vagina, and called carunculai myrtiformes, are regarded as the remains of the ruptured hymen. Sometimes this membrane, instead of being thin and easily broken, is dense and firm, requiring to be opened Avith an instrument before coition can be accomplished. In other instances the hymen is found entirely imperforate in childhood. And in these cases, unless the abnormal condition has been attended to in childhood, when the 48 THE VULVA AND ITS APPENDAGES. period of puberty is reached it may become necessary to resort to operative interference in order to allow of the escape of the menstrual discharge. When it is suspected that the hymen is imperforate and menstrual fluid is retained behind it, an examination should be made, which may be conducted in the following manner: Place the female upon her back, with the shoulders elevated at an angle of 30°, and the thighs flexed and separated. Then, with the index finger well lubricated, carefully explore the vulva. If no entrance into the vagina can be effected with the finger, a very small blunt probe may be substituted and the exploration very carefully continued. If, on this latter attempt, no orifice can be found, and an accumulation of menstrual fluid be suspected, hold the palmar surface of the index finger against the centre of the hymen with gentle force, and Avith the left hand make sudden and forcible downward pressure upon the abdomen immediately over the region of the Avomb, and if fluid be present within the vagina, it will be made appreciable to the index finger applied against the hymen. If the presence of the menstrual fluid should be made out, operate at once. But if the patient be un- married and not in good general health, an effort should be made to restore the general health by careful medical treatment. This done, if the hymen still remains imperforate, and the menses consequently do not floAV,* an operation should be resorted to in the folloAving manner: The patient should lie on her back, Avith the loAver limbs well flexed and separated, care being taken that as little of the person is exposed as possible. Then, Avith the index finger and thumb of the left hand, separate the external labia, and Avith a bistoury or scalpel make an incision in the mesial line, extending from about one- fourth of an inch below the meatus urinarius doAvmvard for about three-fourths of an inch. A suitable vessel should be at hand for receiving the flow Avhich will folloAV the incision of the hymen and the consequent separation of the vaginal Avails. The hymen is usually crescentic in shape, the concavity looking anteriorly. It occasionally presents a central perforation, or there may be a number of minute holes through it, like those through the top of a pepper-box. It is usually a thin and fragile membrane, and is readily ruptured, as before remarked, during first coition. Sometimes * I once examined a young unmarried lady, whose hymen was found perfectly im- perforate, but the presence of menstrual fluid could not be detected. She was in bad ' health, and her symptoms called for the exhibition of silicia, a single dose of which was given in a very high potency. This was followed by a rapid recovery of her general health, and about two months after the administration of the dose of silicia she menstruated freely and regularly. THE FOLLICULAR AND GLANDULAR SYSTEM. 49 however, it is dense and thick, and when this occurs and there is an opening through its anterior part immediately posterior to the meatus urinarius, a grooved director should be introduced through this orifice, and carried doAvn behind the hymen to the posterior wall of the vagina; then a probe-pointed bistoury should be carefully introduced until its blunt point lies Avithin the groove of the director, and a careful divis- ion of the hymen by cutting doAvnward and outward should follow. Sometimes the hymen lies high up in the vagina. If it be found imperforate in this situation, and section has to be resorted to, the speculum must be used and the cutting instrument introduced through it. When a division of the hymen is necessitated by the presence of menstrual fluid Avithin the vagina, the fluid should be allowed to run off gradually, for fear of shock to the system and subsequent irritative fever. The section of the hymen can be completed when the whole quantity has been evacuated. The presence of the hymen is commonly regarded as the evidence of virginity, but it is well known that the membrane has been found intact by the accoucheur at the setting in of labor, and, on the other hand, that its absence may be attributable to a variety of causes other than coition. Bough nurses, may de- stroy the delicate membrane in the babe, while washing the external genitals. The follicular and glandular system of the external organs of generation require particular attention. They may be divided into two classes: the first consisting of the piliferous bulbs, sudoriparous glands, sebaceous glands, and muciparous glands and follicles; the second including the vulvo-vaginal glands or glands of Bartholine. The piliferous bulbs nourish and support the hair Avhich appears more or less abundantly upon the mons Areneris and labia majora. The sudoripetrous glands are quite numerous upon the labia majora. They are mingled Avith the sebaceous glands and surround the pilifer- ous follicles. The sebaceous glands are more numerous than the rest, and in some situations, as on the mons veneris for instance, are of remarkably large size. They are found on the mons veneris, the external and internal labia, the fourchette, and the glans of the clitoris, but have not been discovered in the vestibule or around the urethral orifice. They se- crete an unctuous substance, thinner than that from sebaceous glands situated elseAvhere, Avhich shields the delicate organs from cold, keeps them moist and supple, and prevents them from being injured by the perspiration, urine, or vaginal or uterine secretions. The muciparous organs are placed at different situations on the 4 50 THE FOLLICULAR AND GLANDULAR SYSTEM. external parts, and are divided into isolated or agminated follicles and the vulvo-vaginal glands. The isolated follicles appear at several different points about the orifice of the vagina, and are variously named according to their Fig. 1~2. situation. The vestibular follicles, some six or eight in number, are found in the vestibule. (Fig. 12, A.) These are very minute; and their small and rounded openings are so oblique to the plane of the mucous membrane as to give them the appearance of being covered by a thin valve. The urethral follicles are situated in the cellulo-vascular tissue of the urethra. They are placed beneath the mucous membrane in a line parallel to the canal of the urethra, and discharge upon the inner margin of its orifice. (Fig. 12, B.) Their function is evidently to prevent the orifice of the urethra from becoming dry, and from being irritated by the streams of hot urine Avhich pass over it. The lateral urethral follicles appear on either side, and at some little distance from the orifice of the urethra. They have a common opening at the mouth of a peculiar conical depression. They are not always to be found, and are small and shallow. (Fig. 12, C.) The lateral follicles of the orifice of the vagina (Fig. 12, D, E), three or four in number and comparatively large, are found usually upon the lateral parts of the vaginal orifice immediately below the hymen or carunculse myrtiformes. They are irregular in their number situa- tion and arrangement, and are not to be found in all females. The vulvo-vaginal glands or glands of Bartholine, one on each side are true conglomerate glands, having a bulbous body and an excretory THE FOLLICULAR AND GLANDULAR SYSTEM. 51 duct. They are situated at about the lower third of the orifice of the vagina, just inside its lateral margins. The bulb (D) and excretory Fig. 13. VTTI.VO-VAGIN'AX GLAND. A A, section of the labia majora and of the nymphse, showing the excretory duct and its orifice; B, the gland ; C, excretory duct; I>, its glandular extremity ; E, its vul- var extremity and orifice; F, bulb of the vagina; G, ascending ramus of the ischium. duct (C), in size and exact position, are on one side, Avell represented in Fig. 13. These glands are comparatively small, acquiring full development only at puberty; are often unequal in size on the tAvo sides; as sympathizing with the ovary, the larger one is found on that side in which the ovary may be more voluminous. The diameter of these glands, Avhen largest, is from four-eighths to five-eighths of an inch. Their secretion is intended principally to lubricate the parts during sexual intercourse, and they are especially active at such times and under the influence of lascivious emotions. During coition the muscles of the perineum and vulva are excited, and the secretion of their glands is discharged in jets. There is a coincidence of action between them and the other muciparous follicles; and the secretion Avhich so abun- dantly supplies the vulva and vagina, especially during sexual inter- course, is the joint production of both glands and follicles. The Vagina. The vagina is the membranous canal Avhich leads from the vulva to the uterus. When distended it is cylindrical in shape, and it is i 52 THE VAGINA. curved in its natural position, with the concavity looking toward the symphysis pubis. Extending from the vulva, or outlet of the in- ferior strait, to the superior strait, the direction of its curvature is the same as that of the general axis of the pelvis. It is capable of great Fig. U. VERTICAL SECTION OF PELVIS, WITH OKGANS IN SITU. dilatation, but ordinarily its anterior and posterior walls remain in apposition. Anteriorly, the vagina is in relation Avith the base of the bladder and the urethra, with Avhich it is connected by condensed cellular tissue. Posteriorly, it is in relation Avith the rectum, to which it is attached by a considerable thickness of looser cellular membrane for the loAver three-fourths of its extent, its upper fourth being separated from the rectum by the recto-uterine fold of peritoneum. Thus, in displacements of the uterus, Avhich necessarily affect the vagina, the rectum is seldom involved, Avhile the bladder, being more firmly bound to the vagina, is ahvays disturbed by such changes in the posi- THE INTERNAL ORGANS OF GENERATION. 53 tion of the uterus. Hence the incessant calls to pass Avater, with pain- ful micturition or more or less complete retention of urine, so often seen in cases of anteversion or prolapsus uteri. The length of the vagina differs in different persons, and in differ- ent states of the same person. It is much longer posteriorly than anteriorly, and may be stated to be from four to five inches long on its anterior wall, and from five to six inches long on its posterior Avail. It is very elastic, and is capable of being distended longitudi- nally, as Avell as of being laterally dilated. In some instances it ap- pears very much shorter than the natural standard. This shortening of the vagina may be accidental, merely the result of partial prolapsus of the uterus, or it may be congenital and permanent. In the former case the womb may be pressed upAvard and restored to its natural position, Avhen the shortening of the vagina will at the same time dis- appear. But in the latter case the uterus cannot be thus pushed up by the finger, and this circumstance conclusively determines the nature of the difficulty. Extreme shortness of the vagina has been put doAvn by some authors amongst the causes of sterility; but it cannot be regarded as necessarily a cause, inasmuch as there is abundance of testimony to prove that conception has taken place from the semen coming into contact with the mucus lining of the vulva and orifice of the vagina. The vagina is narroAvest at its orifice, most capacious midAvay in its course, and again contracted at its uterine extremity. In these re- spects it resembles the superior strait, cavity and outlet of the pelvis. In Avomen who have borne many children its midway capacity is Arery great; its ordinary circumference is about three inches. The parietes of the vagina consist of an external or muscular coat, an internal mucous lining, and an intervening layer of erectile tissue enclosed between two layers of fibrous membrane. The muscular layer is composed of longitudinal muscular fibres, Avhich are continu- ous with the superficial muscular fibres of the uterus. These surround the vagina, and are more abundantly and poAverfully developed in some females than in others. The erectile tissue, Avhich appears to be com- posed mainly of several superposed layers of venous network, is more abundant at the lower than at the upper part of the vagina. The in- ternal or mucous coat is continuous above Avith the mucous lining of the uterus, and beloAV Avith that of the vestibule and vulva. This mucous coat of the vagina is thrown into numerous transverse or oblique folds, called rugos, which are more frequent and distinct near the orifice of the vagina, particularly in women avIio have not borne 54 THE UTERUS. children. These folds evidently constitute a provision for the dilata- tion of the vagina, to alloAV the passage of the fcetal head. The mucous membrane is covered with conical and filiform papillae and numerous glands. These latter, which are especially numerous at the upper part of the vagina and around the cervix uteri, pour out a profuse secretion more abundant during coition, and still more in par- turition. The vagina is abundantly supplied Avith blood-vessels, absorbents and nerves. The arteries are derived from the hypogastric; the veins, which are very numerous and plexiform, communicate with the vesi- cal plexus in front and the hemorrhoidal plexus behind, and its nerve plexus, Avhich contains a large proportion of spinal nerve fibres, arises from the inferior hypogastric or pelvic plexus. The superior portion of the vagina enfolds the neck of the uterus in a manner similar to the attachment of the Zouave pants to the legs, forming an anterior and a posterior cul-de-sac, of which the latter is much the deeper. In its use the vagina constitutes the chief copulative organ of the female, affords an outlet for the escape of the menstrual fluid, and be- comes the channel through Avhich the foetus passes from the uterus through the cavity of the pelvis into the external world. After par- turition it very speedily decreases in calibre and nearly resumes its natural size. The Uterus, The uterus is the organ of gestation in which the fecundated ovum is received, nourished, and supported till the proper period of its ex- pulsion at parturition. In its virgin state the uterus, under the influ- ence of the ovaries, constitutes the pivot around which play all the physical and nervous energies of the female organism; and its func- tional perfection exercises a powerfully controlling influence upon the physical health and social and moral happiness. The generative or- gans constitute the grand centre of the female economy. All the other organisms and functions of the woman are more or less in sym- pathy Avith these. And from the full, healthy, and harmonious de- velopment of the sexual system come the ruddy cheek, the elastic step, the buoyant, Avomanly spirit, and all that constancy of love and affec- tion Avhich so pre-eminently characterize, beautify and ennoble the female sex. And the impregnated uterus becomes at once one of the largest and certainly the most important organ in the body of the female in her highest state of physical development, it being then the THE UTERUS. 55 true physiological centre of the most excited vital activity—the repro- ductive seat of life within life. This distinction of the virgin from the impregnated uterus not only underlies the whole character and constitution and function of the organ, but affects also the entire physiological, social, moral, and even spiritual, nature and condition of the female herself. Both the organ and the individual in the one case are totally different in structure, function and being from the organ and individual in the other. The virgin or unimpregnated uterus has a structure and functions and dis- orders peculiar to itself. The impregnated uterus also has structure, functions, disorders, difficulties and dangers peculiar to it. We give then, in the first instance, an account of the virgin uterus, describing its shape, size, structure, position, relations, appendages and functions, and aftenvard pursue a similar course with reference to the gravid or impregnated uterus. Subsequently, and in the appro- priate place, Ave will detail the various dangers and disturbances to which the uterus—impregnated and unimpregnated—is liable, to- gether Avith the chief characteristic indications for the principal reme- dies required in their treatment. The virgin uterus is a holloAV, pear-shaped conoid organ, Avith its base or larger part turned upAvard and forward, and its apex or smaller extremity looking doAviiAvard and backward. The great im- portance of this organ, and the consequent minuteness of description requisite for its thorough study, have caused it to be divided, nomi- nally and externally at least, into five parts. Of these, the base or upper third is called the fundus ; the middle portion or that part be- tween the fundus and the cervix is called the body ; the loAver third is called the cervix or neck ; the lower extremity of the cervix is called the apex ; and the orifice or opening of the cervix is called the os ex- ternum, os uteri, or mouth of the womb. It has also, externally, an anterior and a posterior face; the anterior being more flat and looking toward the bladder and symphysis pubis, while the posterior face is more extensively covered by the peritoneum, more convex, and looks toward the rectum and promontory of the sacrum. There are also three borders or margins—one superior border, Avhich bounds the summit of the fundus, and one right and one left lateral border. To the two latter are attached the broad and round ligaments of the corresponding sides. Finally, the cervix and body of the Avomb have also an internal surface lined with mucous membrane, which is supplied with numerous follicles and glands. The fundus or base of the Avomb is convex, looking upAvard and 56 THE UTERUS. forward, ordinarily inclining toAvard the arch of the pubis, its summit never rising above the margin of the superior strait, Avhile the supe- rior two-thirds of its anterior and the Avhole of its posterior surface is covered by the reflected folds of the peritoneum. Its superior sur- face is in apposition with the convolutions of the small intestines. Fig. 15. THE INTERNAL GENITAL ORGANS. A, the uterus, seen on its anterior face; B, the intra-vaginal portion of the neck of the uterus; C C, the Fallopian tubes; D, the pavilion or fimbriated extremity of the tube; E E, the ovaries; F, the ligament of the ovary; G G, the round liga- ments ; H, the vagina laid open. On the right, the fimbriated extremity of the tube is seen applied to the ovary. The body of the uterus gradually narrows from above doAvmvard to terminate in the cervix. At the points on either side AA7hich mark the junction of the body with the fundus an angle is formed, Avhich indi- cates the positions of the two Fallopian tubes. A third angle is formed at the junction of the body with the cervix, and hence the uterus has been described as being of triangular shape. The anterior surface of the body is somewhat flattened, and is covered by peritoneum in its upper three-fourths, Avhile its loAver fourth is connected with the bas fond of the bladder by areolar tissue. This connection of the uterus with the bladder accounts in a great degree for the derangements of the urinary functions almost always attendant on displacements of the uterus; as well as for the change in position of the urethra Avhich attends the enlargement and elevation of the uterus during the pro- gress of pregnancy. Between the upper portion of the body and the bladder some coils of the small intestines are interposed. Posteriorly the body of the uterus is convex, separated from the rectum by portions THE UTERUS. 57 of the small intestines, and covered throughout by peritoneum. Its lateral borders are slightly concave, and give attachment to the Fal- lopian tubes and the broad and round ligaments. The cervix is about one inch in length, and is slightly constricted at its point of union with the body of the uterus. At this point take place the flexions which sometimes occur in connection with change of position of the body and fundus of the Avomb. Thus, in cases of anteflexion, retroflexion and lateroflexion the body of the uterus forms nearly a right angle with the neck. The usual position of the virgin uterus is with the fundus inclined toAvard the symphysis pubis. This causes the cervix to incline toward the superior portion of the coccyx (see Fig. 14), and the os uteri to look posteriorly toward the rectum, instead of looking directly downward in the direction of the axis of the inferior strait. The vagina embraces the cervix at its upper third, and hence divides it into two portions—an upper or uterine, which lies above the point of junction of the vagina, and a loAver or vaginal portion, Avhich pro- jects into the vagina as a free extremity of the Avomb. The anterior face of this free extremity is someAvhat shorter than the posterior face, on account of the oblique manner in Avhich the vagina surrounds the cervix. Before puberty the cervix is small, dense and conical in shape, while at puberty there is a considerable increase in its size and a dimi- nution of its density. Pregnancy and parturition still further and very markedly modify the conditions of the cervix in all particulars. From a description of the outer surface of the uterus we naturally come to a description of its cavity and internal surface. And first the cavity of the cervix engages our attention as the entrance to the greater cavity of the body of the womb. The entrance to the cavity or canal of the cervix is termed the os uteri, or, from a fancied resem- blance to the mouth of a tench, the os tineas. In the fully-developed virgin uterus the os uteri presents two lips, separated by a transverse fissure. These two lips are of nearly the same length, although the anterior is the thicker and descends a little lower than the other. In young girls the os is quite small, and sometimes almost undiscoverable. But where it thus seems Avanting or imperforate, gentle pressure of the finger will detect a slight depression which will indicate its exact situation. In women who have borne children, on the contrary, the os uteri is sufficiently open to admit the point of the finger, while the lips of the os are unequal in size and present a number of irregular depressions or notches. The canal of the cervix is from three-fourths of an inch to an inch 58 THE UTERUS. long, extending from the os externum to the os internum which marks the entrance into the cavity proper of the uterus. In its course from the external to the internal os, it first widens and then grows narrower as it merges itself with the os internum, which latter is in a measure a strait or intermediate portion connecting the canal of the cervix Avith the cavity of the body of the womb. The mucous membrane lining the canal of the cervix is arranged in radiating folds, or rugce, on either side; the united radiations of both sides, having an appearance resembling somewhat the arrangement of the branches of a cedar tree, have been called arbor vitm. (See Fig. 16, C, and Fig. 18, A.) The cavity of the body of the Avonih, into which that of the cervix Fig. 16. G CAVITY OF THE UTERUS AND THE FALLOPIAN TUBES. A, superior border or fundus of the womb; B, cavity of the womb; C, cavity of the neck of the womb; D, the canal of the Fallopian tube cut open ; E, the fimbri- ated extremity or pavilion, likewise laid open ; F F, the ovaries, one-half of which has been removed so as to bring into view several of the Graafian vesicles ; G, the cavity of the vagina; H H, the ligaments of the ovaries; G G, the round ligaments. leads, and with which it is continuous, is covered Avith mucous mem- brane, and abundantly supplied Avith muciparous follicles, although these are far less numerous in the body than in the cervix. In the virgin Avomb the Avails are nearly in apposition, there being ordinarily but little cavity in the empty womb. At the same time the walls are much more vascular than the parietes of the canal of the cervix. Still, the cavity of the womb, such as it is (Fig. 16, B), is triangular in shape, its inferior angle corresponding to the os internum, the two superior and lateral angles being situated at the orifices of the Fallo- pian tubes. In Fig. 17 appears a profile view, which conveys a more correct idea of the manner in which the walls of the virgin uterus are approximated in their ordinary condition. At the times of the menstrual excitement they are somewhat more distended. The external dimensions of the uterus vary in different persons—be- THE UTERUS. 59 ing larger or smaller, to correspond with the totality of their physical constitution. We give Avhat may be considered the average admea- surements of the fully-developed uterus at puberty. The entire length Fig. 17. This profile view gives an exact idea of the dimensions of the cavity of the body and of the neck of the womb in a state of vacuity. A, mucous membrane; B, tissue proper; C, cavity of the body; D, cavity of the neck. of the uterus, from the inferior margin of the cervix to the superior border of the fundus, is about three inches, its greatest breadth is about tAvo inches, and its thickness from the anterior to the posterior face is one inch. As the uterus increases in size from childhood to puberty, so from the cessation of the menses it begins to diminish in volume till it becomes more or less atrophied in the second childhood of advanced age. And as in the impregnated condition the womb becomes very greatly and permanently enlarged—that is, during the continuance of pregnancy—so at the accession of each of the monthly periods, in many females, it becomes temporarily enlarged. The Aveight of the virgin uterus may be set down as about an ounce to an ounce and a half, but after child-bearing it remains two or three times as heavy. The structure of the uterus forms a very important element in study- ing its nature and functions. Three distinct tissues, coats or tunics —each possessing a different constitution and performing totally dif- ferent functions—make up this complicated structure. These are the external or peritoneal coat, the middle or muscular coat, and the in- ternal or mucous coat. The external or peritoneal coat.—This membrane is reflected from the posterior surface of the bladder upon the anterior face of the uterus, extends upward, and, covering the fundus, is continued down 60 THE UTERUS. upon the vagina a short distance beloAV the cervix, and is then finally reflected upon the rectum. The peritoneal membrane or serous tissue is thus seen to be identical and continuous Avith the common lining membrane of the abdomen. The fold of peritoneum reflected from the bladder to the uterus is termed the vesico-uterine or anterior ligament, and that which passes from the posterior surface of the uterus to the rectum is termed the recto-uterine or posterior ligament. These, however, are mere subdivisions made for the sake of descrip- tion, of the broad ligaments of the uterus, which are formed by pro- longations on either side of the folds of peritoneum Avhich pass from the bladder to the anterior uterine wall, across the fundus and doAvn the posterior wall, and from thence to the rectum. These prolonga- tions are reflected from each lateral border of the uterus to the corre- sponding side of the pelvis, in the direction of the sacro-iliac symphy- sis. Taken as a whole, they form what are called the broad ligaments of the uterus, and contain the Fallopian tubes, the ovaries and the round ligaments. The middle or muscular coat forms the principal part of the sub- stance of the uterus. This tissue is dense, firm, and grayish in color. It is thickest upon the middle of the body and fundus, thinnest at the orifices of the Fallopian tubes. It consists of bundles of unstriped muscular fibres, disposed in three layers, intermingled Avith areolar tissue, blood-vessels, lymphatics and nerves. The external layer ap- pears principally upon the anterior and posterior surface; its fibres, converging at each superior angle of the uterus, are continued upon the Fallopian tubes, the round ligament and ligaments of the ovary__ some few running backward from the cervix uteri to eonnect Avith the recto-uterine ligaments. The middle layer of this coat is composed of longitudinal, oblique and transverse muscular fibres. The internal layer consists of circular fibres arranged in the form of holloAV cones Avhose apices surround the orifices of the Fallopian tubes, their bases meeting and intermingling at the middle of the body of the uterus. The fibres of this layer are disposed transversely or circularly in the cervix uteri. The womb is a muscular organ of very great power, and a thorough knowledge of the nature and arrangement of its muscular fibres in the cervix, and especially in the fundus, and of their relation to the broad and other ligaments, is essential to a correct understand- ing of its Avonderful action in parturition. The mucous coat of the uterus is so closely adherent to the subjacent tissue that, from the difficulty of separating and demonstrating it its existence has been denied by many authors. But by the aid of'the THE UTERUS. 61 microscope this mucous coat has not only been clearly distinguished, but shoAvn also to consist of epithelium, basement membrane, fibrous tissue, blood-vessels and nerves, like other mucous membranes. This Fig. is. This figure represents the arrangement of the mucous membrane, and of the tissue proper of the uterus, as also their relative dimensions. A, cavity of the neck and arbor vitse ; B, cavity of the body; C, mucous membrane; D, intervening membrane ; E represents the marked thinning ofF of the mucous membrane toward the neck. internal mucous coat of the uterus is continuous with that of the vagina, and also Avith the peritoneum above, through the fimbriated extremity of the Fallopian tubes. It abounds in follicles, whose secretion lubricates the interior surface of the uterus. And the abnor- mal, catarrhal and leucorrhoeal secretions and other morbid products, to be subsequently considered as disorders of the cervix and even of the fundus, conclusively show the mucous character of this innermost tissue of the uterus. Numerous follicles, glands and papilla? appear in the mucous lining membrane of the cervix, the secretions from Avhich serve to maintain the mouth of the virgin uterus in a healthy condition. Much the larger portion of the mucous secretion from the Avomb is in reality the product of the innumerable glands of the cer- vix. This secretion in its normal state is Avhitish, very viscid, almost transparent, and gives an alkaline reaction. It adheres to the crypts and rugse of the cervix, and occupies its canal. The blood-vessels of the Avomb are numerous, and largely developed in comparison Avith the size of the organ. This has reference not only 62 THE UTERUS. to the nutrition of the womb in its ordinary condition, and to its con- gested state at the periods of menstrual excitement, but is provisional also for the necessities of that impregnated condition for Avhich it is designed. The arteries Avhich supply the Avomb form tAvo distinct systems, according to the sources from which they are derived and the parts to Avhich they are finally distributed. The first, or superior system, is composed of the ovarian arteries, Avhich correspond Avith the spermatic arteries of the male, arise from the aorta, and descending along the sides of the womb in a serpentine course are distributed to its upper part, to the Fallopian tubes and to the ovaries. The second, or inferior system, is composed of the uterine arteries, which are de- rived from the internal iliac arteries. These also pass along the sides of the womb, to be finally distributed to the cervix and upper part of the vagina. These arteries pursue a remarkably tortuous course in the substance of the uterus; thus provision is made for their great elongation without danger of rupture in the advanced stages of preg nancy. The numerous branches of these two systems freely anasto- mose with each other. The veins of the virgin uterus are of large size, possess no valves, correspond in name with the arteries, and folloAV their course. The right spermatic vein terminates in the inferior ATena cava, the left in the renal vein; the uterine veins empty into the internal iliacs. They are capable of very great increase in pregnancy, and are then known as uterine sinuses. The lymphatic vessels of the uterus, invested by delicate coverings of peritoneum, are distributed upon all the external surfaces of that organ. They are very numerous, and,, in the virgin'uterus, very small. Some of these ascend, in a serpentine course, from the cervix to the body and fundus of the uterus. Others pass less tortuously, in vari- ous directions, over both these surfaces, communicating with branches ascending from the vagina and with those from the Fallopian tubes and ovaries. The internal as well as the external surfaces of the uterus, Fallopian tubes and ovaries are abundantly supplied with these absorbent vessels. Those of the former, from the interior struc- ture of these organs, communicate with the lumbar ganglia; those of the latter, from their external surfaces, communicate Avith the pelvic or inguinal ganglia. This latter circumstance is important to be borne in mind, since this anatomical and physiological connection is fre- quently the index to pathological appearances. In addition to the general division of the lymphatics of these organs to correspond to their external and their internal surfaces, the mode in Avhich they are THE UTERUS. 63 originally distributed to follow the course of the arteries, arranges them all in two distinct systems of lymphatic circulation. With the exception of the proper menstrual secretion, there is no discharge from the interior of the female organs of generation in their normal condi- tion, the lymphatics sufficing to reabsorb the natural secretions of their internal surfaces, so that no accumulation occurs. The nerves of the uterus and its connecting structures of the gene- rative system are derived, either directly or indirectly, from all three of the great nervous centres of the body, and by their union and concentration serve to render the sexual system of the female the great physiological centre of her entire organism. The nerves which are distributed to the uterus are, in part, derived from the great sympathetic, and in part from the spinal nervous, system. But these latter, as branches of the third and fourth sacral nerves given off from the cerebro-spinal axis, are, indirectly at least, derived also from the cerebral nervous centre, as Avell as from the spinal, although they are not under the immediate control of the will. The nerves Avhich are distributed to- the uterus from the sympathetic system are derived from the aortic and from the hypogastric plexus. The former—variously named as the renal, the spermatic or ovarian plexuses, according to their more immediate relations—are all derived from the great solar or epigastric plexus, and are intimately connected with all the other pelvic, abdominal and thoracic nervous centres. Hence the powerful sympathy Avhich exists between the womb itself and all the other great organs of the female. Hence, too, the intense pain felt at the pit of the stomach in cases of uterine neuralgia, and the nausea and vomiting which are so often associated with peculiar conditions of the impregnated Avomb. The nerves which are distributed to the uterus from the hypogas- tric plexus come directly from the pelvic portion of the sympathetic, and have associated with themselves the filaments from the third and fourth sacral nerves, Avhich connect the womb Avith the general mus- cular apparatus of the body—the former class of nerves having espe- cial relation to the two great functions of nutrition and reproduction, as in the growth of the womb itself and of the ovum Avhich it may contain in the impregnated state; the latter having relation to those muscular powers of the womb by which it is enabled to exert itself so Avonderfully to expel the product of conception at full term, and to combine with its own efforts the muscular powers of all other parts of the body. Unlike other muscular structures, the nervous filaments penetrate 64 THE UTERUS. into the substance of the womb, and during the period of utero- gestation all the uterine nerves are very greatly enlarged. The uterus appears as if supported or suspended in the midst of the pelvis, and is sustained in this position by certain ligaments, which are processes given off from its own substance or from the enveloping peritoneum, and by the peritoneum itself. The ligaments are arranged in four pairs, and are knoAvn as the anterior, the posterior, the round and the broad ligaments. The anterior and posterior, to- gether Avith the broad ligaments of Avhich they are a part, have already been described. Stretching laterally from the sides of the uterus to those of the pelvis, they form a partition wall or septum in the caAdty of the pelvis, Avhich divides it into an anterior portion, containing the bladder, urethra and vagina, and a posterior portion, containing the rectum. The round, ligaments, continuous with the proper tissue of the Avomb, are produced from the anterior and superior part of its body. They are four or five inches long, situated between the layers of the broad ligament, and attached to the superior angles of the uterus, one on each side, a little in front of the Fallopian tube. (Fig. 16, G.) From this point the ligament proceeds outward and forward to pass through the inguinal canal toward the symphysis pubis, Avhere its expanded fibres are distributed to the subcutaneous cellular tissue of the groin, mons veneris and dartoid pouch of the labia. The tubular process in this ligament, called the canal of Nuclc, is analogous to the peritoneal pouch Avhich accompanies the descent of the testes in the male. The womb is apparently maintained in its oblique position by the co-operative agency of all its ligaments, assisted by the support fur- nished by the vagina and the pressure of the intestines. But when Ave come to consider the subject carefully, it undoubtedly appears that it is to the folds of peritoneum the maintenance of the uterus, in its position between the pubes and the sacrum in the ever-varyino- move- ments of the Avoman, is mainly if not wholly due. For, if Ave consider that nearly all the viscera Avithin the abdominal cavity are invested and supported in position by the peritoneum, and that this membrane, reflected from the bladder, covers the entire upper and anterior three- fourths of the uterus, and is thence reflected over its fundus and doAvn- Avard upon its entire posterior length, it will be seen that the organ is invested by, and lies between, as it were, tAvo layers of peritoneum riding upon the anterior and inferior layer, and covered in and held doAvn by the posterior superior layer, the Avhole being anchored in situ to the sides of the pelvis by the reflected broad ligaments. Thus THE UTERUS. 65 while the broad ligaments, the round ligaments, the vaginal walls and the superimposed intestines contribute to keep the uterus in its oblique antero-posterior position, its main support is derived from the investing layers of peritoneal tissue, which almost entirely cover it. These supports of the uterus are not merely extensible, but possess contractile poAver, due to the presence of muscular fibres. Thus a large degree of motion is allowed the womb, particularly in an antero- posterior direction. If the bladder be distended, the uterus will be pushed backward toward the rectum, and if, on the contrary, the bladder be empty and the rectum distended, the viscus will be cor- respondingly pushed forAvard, the contractile power of its ligaments serving to replace the organ when its normal position has been dis- turbed. When these circumstances are borne in mind, and it is like- wise remembered that displacements of the uterus must frequently occur in consequence of the relaxation of these supporting processes of peritoneum resulting from some constitutional disordered con- dition, the rationale of their cure by medication alone becomes per- fectly obvious. " During and after menstruation the uterus is enlarged and more vas- cular, its surfaces rounder; the os externum is rounded, its labia SAvollen, and the lining membrane of the body thickened, softer and of a darker color. " During pregnancy it increases in weight from one pound and a half to three pounds. It becomes enormously enlarged, and projects into the hypogastric and lower part of the umbilical regions. This enlargement, which continues up to the sixth month of gestation, is partially due to increased development of pre-existing and new-formed muscular tissue. The round ligaments are enlarged, and the broad ligaments become encroached upon by the uterus making its Avay between their laminse. The mucous membrane becomes more vascu- lar, its mucous follicles and glands enlarged; the rugae and folds in the canal of the cervix become obliterated; the blood-vessels and lym- phatics, as well as the nerves, according to the researches of Dr. Lee, become greatly enlarged. u After parturition the uterus nearly regains its natural size, weigh- ing from two to three ounces, but its cavity is larger than in the virgin state; the external orifice is more marked and assumes a transverse direction; its edges present a fissured surface; its vessels are tortu- ous, and its muscular layers are more defined. " In old age the uterus becomes atrophied and paler and denser in texture; a more distinct constriction separates the body and cervix. 5 66 THE OVARIES. The ostium internum, and occasionally the vaginal orifice, often be- comes obliterated, and its labia almost entirely disappear."—Gray. The Fallopian Tubes. The Fallopian tubes are the oviducts through which the ovum is conveyed from the ovary to the uterus. They are two in number, one on each side, about four inches in length, and extend from the superior lateral angles of the uterus, lying in the free margin of the broad ligament, outward toward the sides of the pelvis, where they terminate in fringed borders or fimbriated extremities. The canal of these tubes is exceedingly minute. The internal orifice, that within the cavity of the uterus, is termed the ostium internum, or uterinum, and is so small as scarcely to admit the introduction of a fine bristle. From this orifice the tube widens until it is finally developed into a trumpet-shaped extremity, the pavilion. At the base of the pavilion a contracted circle, the ostium abdominale, forms the termination of the tube proper, and from this circle radiate the fringes which com- pose the pavilion or fimbriated extremity itself. The Fallopian tubes are composed of three distinct coats or tunics. The outer coat is derived from the peritoneum. The middle coat is muscular, and consists of two layers of fibres, an outer or longitudinal, and an inner or circular layer, both of which are continuous with the muscular fibres of the uterus. The inner coat consists of mucous membrane, which is continuous at the inner extremity of the tube Avith the mucous lining of the uterus, and at its fimbriated extremity with the peritoneum. Toward the outer extremity of the tube the mucous coat is thrown into folds, which indicates its adaptability for dilatation. It is covered with columnar-ciliated epithelium; the cilia? being arranged in such a way as to facilitate the passage of ova from the ovary to the uterus. The ovules discharged at the menstrual periods pass through the tubes to the uterus. The Ovaries. It is only in a practical or obstetric point of view that the uterus can be regarded as the most important of the generative organs. The ovary, though constituting but a small part, anatomically considered, of these organs, is really the part to which all others are subservient^ inasmuch as it furnishes the element which is essential to the repro- ductive act. And not only can it be claimed for the ovary that it is the essential part of the reproductive system, but that in a very great degree it regulates the growth of the whole female organism—as the the ovaries. 67 testes do in the male—and determines the distinctive characteristics of the sex. " It is the organ upon the presence of which depends the sexual passion and the function of menstruation, whose congenital deficiency is indicated by the absence externally of all signs of a secondary sexual character, whose artificial removal entirely unsexes the individual, and the decline of Avhose functional activity, as age ad- vances, is the cause of the generate faculty being lost in the female long before the ordinary term of life has expired, and at a much earlier period than that at which the power of procreation ceases in the other sex." * In a physiological sense, therefore, the uterus, as well as every other part of the generative apparatus, must be regarded as an ap- pendage of the ovary, and the common formula, " Uterus and its Ap- pendages," might be superseded most appropriately by the title, " Ovaries and their Appendages." The ovaries are the analogues in the female of the testes in the male. They are two in number, lying deeply in the lateral and posterior part of the cavity of the true pelvis, one on each side of the uterus, with which they are so intimately connected as necessarily to take part in all changes of position of that organ, whether normal or abnormal. They lie within the folds of the broad ligament, or, more accurately, within a fold of peritoneum derived from the pos- terior lamina of the broad ligament, and each ovary is in part covered by the Fallopian tube of the same side. In addition to its connection with the uterus by means of the broad ligament, each ovary has an- other and more direct attachment to that organ by means of its OAvn proper ligament of the ovary, Avhich serves as a cord to bind it more securely to the uterus. It is likewise attached by a cord-like process to the fimbriae of the Fallopian tube. In shape, the ovaries are oval, elongated and flattened from above downward. Each ovary is about an inch and a half in length, three-quarters of an inch in width, and about a third of an inch in thickness. They are not usually fully developed until some time after the establishment of puberty, but vary in size, weight and situation in different conditions of the system, increasing in volume at the monthly periods, and in most instances becoming more or less atrophied after the final cessation of the menses. The ovary is composed of protecting parts or tunics, of proper secreting structures containing the ova, imbedded in a parenchyma or stroma, and of vessels and nerves. The tunics of the ovary correspond with those of the testicle, and consist of the peritoneal * Todd's Cyclopaedia of Anatomy and Physiology, vol. v. 68 THE OVARIES. covering derived from the posterior lamina of the broad ligament, and the tunica propria or special covering of the ovary. The peritoneal covering of the ovary is intimately connected with the gland, except at its base. It does not in any way differ from the peritoneal covering of the viscera generally. The tunica albuginea or tunica propria is the covering proper of the ovary, and serves to give it form, as Avell as to protect the stroma and ova from injury. This tunic, which is very tough, forms a complete investment for the ovary except at its lower border, where the fibres are either few or altogether wanting, leaving a longitudinal space or fissure—the hilum—through Avhich the vessels and nerves are admitted to the gland. The parenchyma or stroma of the ovary lies immediately beneath the tunica albuginea, with which it is in contact, and fills up all the intermediate space between the ovisacs, thus giving form to the ovary. It acts as a soft bed for the ovisacs, protects the ova from injury, and serves as a vehicle for the conveyance of the minute blood- vessels to the ova. It is of a pale-pink or bright-red color, owing to the numerous blood-vessels by which it is permeated. The Graafian vesicles, or ovisacs, are numerous small, round, trans- parent vesicles, in various stages of development, imbedded in the stroma, and themselves containing the ova. The number of well- developed vesicles contained within each ovary, and visible to the naked eye, varies in different subjects. They are usually computed to be from twelve to tAventy, and it Avas commonly supposed that when these were exhausted by repeated conceptions the poAver of procreation of necessity ceased. But a more careful and accurate examination of the contents of the stroma has shoAvn that the number of these vesicles greatly exceeds the above computation. During the early development of the ovary the Graafian vesicles are small, and are deeply seated Avithin the substance of the stroma, but as develop- ment progresses they enlarge and approach nearer to the surface; and finally, Avhen mature, they form projections on the surface of the ovary beneath the peritoneal covering. Each Graafian vesicle consists of an external coat, which is fibro-vascular, and which is in connection with the surrounding stroma by means of a vascular network, and an in- ternal tunic, the ovi capsule, which is lined by a very delicate mem- brane, the membrana granulosa. Within these walls is contained a transparent albuminous fluid, in which is suspended the ovum. The human ovum is exceedingly minute, measuring from the T}7 to -j-i^ of an inch, and is made up as follows: an external transparent capsule or envelope, the vitelline membrane, within which, and in con- OVULATION AND MENSTRUATION. 69 tact with it, is the vitellus or yelk, and lying in the substance of the yelk is a small vesicular body, the germinal vesicle, which contains the germinal spot. The vitelline membrane is thick, colorless and transparent, and corresponds to the chorion of the impregnated ovum. The vitellus consists of granules of various sizes lying in a more or less viscid fluid. The germinal vesicle is about yts °f an incn in diameter, and consists of a delicate transparent membrane containing a watery fluid. The germinal spot is opaque, of a yelloAV color, and granular in struc- ture, measuring from ^^ to ^ of an inch. The ovary derives its supply of blood chiefly from the ovarian, but in part also from the uterine arteries, between Avhich vessels there is a very complete and free anastomosis. The veins are very numerous, and form immediately outside the ovary, and between folds of the broad ligament, a plexus termed the pampiniform plexus. The nerves are derived from the spermatic plexus, and enter the ovary through the hilum, along Avith the blood-vessels. CHAPTER V. OVULATION AND MENSTRUATION. THROUGHOUT the entire scale of creation the ovaries form the ultima ratio of generation. The uterus derives its stimulus from the excitation of the external organs of generation, but the^wa^ cause, the true physiological and vital reason of its existence and action, is to be found in the ovaries. It has been amply shown by the success- ful experiments of modern observers that the ovaria are the essential organs of reproduction, and that in them originate the greater propor- tion of those sympathies which have been so long generalized as uterine; and furthermore, that the development of the pelvis, of the uterine system and of the mamma?, the function of menstruation and all the peculiarities of the human female, depend upon the ovaries. These supply the ova Avhich, through the stimulus of the life-impart- ing principle contained in the semen of the male, may be developed into an indiAridual similar to its progenitors. In fulfilling their appro- priate and primary function of ovulation the ovaries determine also that of menstruation, Avhich is secondary and consequent. The ovaries have already been described as containing at puberty 70 OA'ULATION AND MENSTRUATION. the germinal vesicles in different states of development. But these ova are discoverable long before the accession of the period of puberty. They may be seen in the ovaries of the new-born babe, and even in those of the foetus in utero. They form, therefore, an integral part of the ovarian tissue. The ante-pubertal life of the female is one of preparation, of groAvth in stature and in strength, Avith especial refer- ence to the perfect fulfillment of the function of the ovaries. Many of the lower orders of the animal creation arrive at maturity much earlier than man. The human female is longer in arriving at the full measure of her development, as her being and destiny are higher. And the same general principle of greater length of preparation and greater results is seen in the more particular instances of those indi- viduals who commence to menstruate at a period later than the aver- age. Those later in assuming the evidences of maturity are said to be more steadfastly regular in menstruation, and to continue it longer. And the converse is still more evidently true. For, as in general all those Avhose precocious growth, even of the intellectual faculties, at- tracts so much attention, are seen to become exhausted almost before they enter upon the race of life, so in the particular instance under consideration of premature development of the sexual system, the earlier young people arrive at puberty so much the earlier do they grow old. And this is as manifestly true of nations as of individuals. Those races in which, like the Hindoo, the Avomen arrive at sexual maturity at the earlier periods, as in the twelfth year, are effete, emas- culate and doomed to be conquered by those in which the period of puberty is longer delayed. And this is true independently of those influences of climate or temperature Avhich may apparently seem to have conduced to such premature development. Thus the female, after a preparatory period of constitutional incuba- tion, becomes so highly developed in her entire system in general, especially in her sexual organization, and more particularly still in her ovaries, that these minute seminal vesicles, these ova or eggs, ma- ture and begin to burst through the outer covering of the ovary itself. Previous to the final accession of the period of puberty the ova have been but imperfectly developed, and have in consequence remained comparatively dormant. But at this time a new life and vigor spring up in the ovaries, Avhich rapidly develop the external form of the female herself in general, and all the organs of her sexual system in particular. For, as the soul animates the body, so by the interior vital chang«, and new life and vigor of the ovaries, the lank and lean aAvkward and boyish form of the school-girl is transformed into that OVULATION AND MENSTRUATION. 71 full development of neck and bust, that rounded contour of the hips and loveliness of the features which the poet exalts as "beautiful exceedingly." The period of the accession of puberty varies, according to climate and race and hereditary and social circumstances, from the thirteenth to the sixteenth year. But if Ave take the fourteenth year for the average, as is probably the case in this country, half as many more years must be spent before the young woman's constitution and sexual organization will have acquired its fullest development—that is, be- come capable of bearing the most healthy children in the easiest and most healthy manner. Some young women indeed arrive earlier at their highest maturity, as some also do at a still later period ; but in general the average age of the first ovulation being at fourteen, Ave may assume the period of the most perfect and complete development of this function to be at about the twenty-first year. Ovulation, or the functional action of the ovaries, consists in the maturation of the ova and in their extrusion through the ovarian sur- faces. This functional activity occurs in the normal state at regularly recurring periods, usually once in twenty-eight days. And in many women this period returns with great exactness at the same day of the Aveek, or even in some instances at the same time of the day. This increased activity of the ovaries is not far removed from a congestion of these organs, and in many cases the entire system sympathizes in this disturbance of the ordinary sanguineous and nervous circulations. The manner in Avhich the process of ovulation takes place is so ad- mirably described by Dalton* that we quote it in full, and copy the accompanying very elegant illustrations. " In the earlier periods of life, in man and the higher animals, the egg is contained in a Graafian follicle Avhich closely embraces its ex- terior, and is consequently hardly larger than the egg itself. As puberty approaches, those follicles Avhich are situated near the free surface of the ovary become enlarged by the accumulation of a color- less, serous fluid in their cavity. We then find that the ovary, Avhen cut open, shows a considerable number of globular, transparent vesi- cles, readily perceptible by the eye, the smaller of which are deep- seated, but which increase in size as they approach the free surface of the organ. These vesicles are the Graafian follicles, Avhich, in conse- quence of the advancing maturity of the eggs contained in them, gradually enlarge as the period of generation approaches. " The Graafian follicle at this time consists of a closed globular sac * Physiology, p. 567. 72 OVULATION AND MENSTRUATION. or vesicle, the external Avail of which, though quite translucent, has a fibrous texture under the microscope, and is Avell supplied Avith blood-vessels. This fibrous and vascular Avail is distinguished by the name of the ' membrane of the vesicle.' It is not very firm in texture, and if roughly handled is easily ruptured. " The membrane of the vesicle is lined throughout by a thin layer of minute granular cells, A\rhich form for it a kind of epithelium, similar to the epithelium of the pleura, pericardium and other serous membranes. This layer is termed the membrana granulosa. It ad- heres but slightly to the membrane of the vesicle, and may easily be detached by careless manipulation before the vesicle is opened, being then mingled, in the form of light flakes and shreds, with the serous fluid contained in the vesicle. " At the most superficial part of the Graafian follicle, or that which is nearest the surface of the ovary, the membrana granulosa is thicker than elsewhere. Its cells are here accumulated in a kind of mound or 1 heap,' which has received the name cumulus proligerus. It is some- Fig. 19. GRAAFIAN FOLLICLE NEAR THE PERIOD OF RUPTURE. a, membrane of the vesicle; b, membrana granulosa; c, cavity of follicle; d, egg; e, peritoneum; /, tunica albuginea; gg, tissue of the ovary. times called the discus proligerus, because the thickened mass, Avhen vieAved from above, has a somewhat circular or disk-like form. In the centre of this thickened portion of the membrana granulosa the egg is embedded. It is accordingly always situated at the most superficial portion of the follicle, and advances in this way toward the surface of the ovary. " As the period approaches at which the egg is destined to be dis- charged, the Graafian follicle becomes more vascular, and enlarges by an increased exudation of serum into its cavity. It then begins to project from the surface of the ovary, still covered by the albu- gineous tunic and the peritoneum. The constant accumulation of OVULATION AND MENSTRUATION. 73 fluid, however, in the follicle, exerts such a steady and increasing pressure from within outward, that the albugineous tunic and the peritoneum successively yield before it, until the Graafian follicle protrudes from the ovary as a tense, rounded translucent vesicle, in which the sense of fluctuation can be readily perceived on applying the fingers to its surface. Finally, the process of effusion and disten- sion still going on, the Avail of the vesicle yields at its most prominent portion, and the contained fluid is driven out Avith a gush by the re- action and elasticity of the neighboring ovarian tissues, carrying with it the egg, still entangled in the cells of the proligerous disk." OVARY WITH GRAAFIAN FOLLICLE RUPTURED. At a, egg just discharged, with a portion of membrana granulosa. During the earlier life of the female, the ova, or rather their rudimentary and incompletely-developed germs, are formed in the ovaries. But at the full constitutional and sexual development called puberty, with each return of the menstrual period, or ovarian nisus, one or more of the complete ovules bursts through the enveloping membranes of each ovary in the manner just described, and is received into the upper portion of one of the oviducts, called the Fallopian tubes. The fimbriated extremities of these tubes are applied to the ovaries—not, as is supposed by some, under the stimulus of sexual intercourse, but under the wonderful reflex influence of the process of ovulation itself—by which these extremities are led to apply them- selves firmly over the exact portion of the ovaries from which the ova are about making their appearance. This must necessarily be the case, since the ova are conveyed to the uterus whether impregnated or not. At each menstrual period, it is believed that at least one ovum is transmitted through the Fallopian tubes, Avhich passes off and is lost. At the same time those remaining in the ovaries are advanced in their 74 OVULATION AND MENSTRUATION. development. Of the particular manner and time of the transmission of the impregnated ova we shall speak in treating of conception. Suffice it to say here, in general, that the ripening and discharge of the ovum in menstruation is called cestruation. Menstruation requires to be particularly studied in this connec- tion, since it usually forms an important attendant and consequent portion of the process of ovulation, although it is not alA\rays present, even in apparently perfect health. Ovulation we have found to consist in the maturation of the ova, and in their extrusion from the ovaries. By the Fallopian tubes these ova are taken up and transmitted to the womb. The uterus becomes then immediately and directly connected with the ovarian nisus, and at the same time it partakes in a most remarkable manner in the ovarian congestion. And, in fact, all the other parts of the generative apparatus, the vagina and the external organs, and eAren the entire sanguineous and nervous circulations, sympathize in this congestion and excitement. But although thus involving the Avhole system, the menstrual orgasm is entirely dependent upon the ovarian nisus. Where there are no ovaries, there are neither sexual desires nor menstrual periods. And in a remarkable case, in which both ovaries Avere extirpated in removing a painful tumor from each groin, a Avoman Avho before had ahvays menstruated Avith great regularity, immediately and permanently ceased to menstruate; while in some other cases in which the womb Avas either Avanting naturally or had been removed on account of disease, the mammary development and sexual desires remained unabated, and the menstrual discharges took place from the vagina. As long as the ovaries remain intact the Avoman is a Avoman still in external form and inward desires, although, from absence of the uterus or vagina, she may be incapable of conception or even of sexual intercourse. But let the ovaries be removed, and the woman loses at once all the distinguishing traits of the female character; her breasts diminish in size, and she becomes masculine in features, form and voice. Relation of Menstruation to Ovulation.—Thus far we have shown that menstruation is essentially dependent upon the functional action of the ovaries; that it is not an original action of the uterus, since it ahvays fails where the ovaries are Avanting, but does not necessarily fail AA'here the uterus is absent; and that, although there can be no menstruation except in connection Avith ovulation, there may be ovula- tion without menstruation. This latter fact may be, and probably is in consequence of the menstrual fluid being reabsorbed, instead of OVULATION AND MENSTRUATION. 75 passing off as ordinary ovulation occurs and the usual and consequent congestion ensues, but for some occult cause the fluid is again taken up, and this Avithout detriment to the general health. Cases are re- corded of women who have conceived and borne children without ever having menstruated. Let us now examine the physiological relation Avhich menstruation or the quasi function of the Avomb bears to ovulation or the primary function of the ovaries. The orgasm of the ovaries at the period of the maturation and ex- trusion of the ova, and the consequent congestion of the Avomb and other dependent parts of the sexual apparatus, have already been described as very intense and as involving the entire system. This intense orgasm having accomplished its primary purpose in the ma- turation and extrusion of the riper ova, and having at the same time also advanced others to a proportionate degree of development, requires a larger basis for its OAvn critical ultimation. The intense congestion of the blood-vessels and the no less intense excitement of the nervous centres must be relieved, and this relief is obtained through the men- strual discharge, Avhich is simply the excessive blood congested in the uterus and in its mucous membrane, and which oozes from the free surface of the membrane and passes doAvn through the canal of the cervix in greater or lesser quantities into the vagina, and finally through the vulva. And not only does the congestion consequent upon ovula- tion fill the uterine vessels with blood in excess, but the Fallopian tubes likewise partake of the orgasm, in consequence of which their fimbriated extremities approach and are accurately applied over the ovaries, upon that part of the ovarian surface from which the ripened ovules are extruded, and thus receive the ovules, Avhich pass through the Fallopian canals and are discharged into the cavity of the uterus. The first menstruation usually takes place about the fourteenth year. In some individual cases it comes earlier, and in others much later. Delicate and luxurious habits of living, especially in large cities, tend to render the menstrual period earlier in its first occurrence, but less constant and regular in its subsequent appearance. Hereditary consti- tution exerts a poAverful influence in determining the time of the first menstruation. For, while in Calcutta, India, the native females usually begin to menstruate between the twelfth and thirteenth years, the children of British residents, although born in the city, average about the sixteenth year. And different conditions in life, and resi- dence in the country rather than in the city, exert an important influ- ence in determining the period of first menstruation. Thus, in Den- 7G OVULATION AND MENSTRUATION. mark, in the Avomen born in the country, the average period of first menstruation Avill be found to be at sixteen years and five months; those in the larger towns, fifteen years and four months; those in Copenhagen, the largest city, fifteen years and seven months. So in Russia, in fifty-three cases of the noble and rich the average was found by De Boismont to be thirteen years and eight months. In one hun- dred and thirty-five women of the well-to-do classes the average Avas fourteen years and five months. And in one hundred and seventy- one of the poor the average was set down at fourteen years and ten months. In London, of sixty-seven women of the opulent class the average was thirteen years and about six months, while in seven hun- dred and seventy-five Avomen of the Avell-to-do working class the average was fourteen years and four months. The cessation of the menses usually takes place between the fortieth and the fiftieth years, about forty-five being considered to be the aver- age time of the change of life. But this may and often does vary in individual cases to a considerable extent. Some Avomen cease to men- struate soon after thirty, especially those Avho began early, Avhile others have borne children after they Avere fifty years of age, and regularly menstruated to their sixty-second year. Others again cease to men- struate at the usual period, but experience a return of the periodic floAV after some years. In some instances this protracted menstrua- tion or return of the flow may be dependent upon ulceration or other disease of the womb. But in most cases late menstruation, especially if unattended Avith much suffering or other morbid symptoms, may usually be regarded as evidence of remarkable constitutional strength and longevity; since, in general, life is longest and the health most assured in those females who commence to menstruate later, and Avho continue in the exercise of this function later than the ordinary term. In many cases the cessation of the menses does not occur at once, but is arrived at gradually through from one to three or even more years of menstrual irregularities, called by some, " the dodging-time." And the cessation may be by a gradual diminution of the Aoav, by alternate copious and scanty menstruation, or by changes in the character of the discharge itself. The general average duration of the function of menstruation may be stated at about thirty-two years. Symptoms.—"The menstrual discharge consists of an abundant secretion of mucus mingled with blood. When the expected period is about to come on, the female is affected with a certain degree of discomfort and lassitude, and sense of Aveight in the pelvis and more or less disinclination to society." In some instances these symn- OVULATION AND MENSTRUATION. 77 toms are but slightly pronounced, while in others they are more de- cided. If the individual be in a state of perfect general health, there will be, most likely, no premonitory symptoms Avhatever, and but slight derangement during the continuance of the period; but when the general organism is in an unsound condition, the premonitory and the concurrent symptoms of menstruation may be very severe, and to these may be superadded the suffering arising from obstruction of the canal of the uterine cervix or other abnormality of the uterus. " An unusual discharge of vaginal mucus then begins to take place, Avhich soon becomes yellowish or nearly broAvn in color, from the ad- mixture of a certain proportion of blood, and by the second or third day the discharge has the appearance of nearly pure blood. The un- pleasant sensations which Avere at first manifested then usually sub- side, and the discharge, after continuing for a certain period, begins to grow more scanty. Its color changes from a pure red to a brownish or rusty tinge, until it finally disappears altogether, and the female returns to her ordinary condition."—Dalton. The original menstrual flux, as it issues from the uterus, is nearly pure blood; but in its passage through the vagina it becomes mingled with the acid mucous secretion from the vaginal surface, Avhich changes its quality and appearance. The menstrual discharge returns Avith great regularity in perfectly healthy Avomen, but varies in quan- tity in different individuals, being quite free in some and scanty in others. Each menstrual period occupies from two or three to five or six days, and the whole amount of the Aoav may vary from three ounces to eight, according to the temperament and idiosyncrasy of the individual; some plethoric persons having a very scanty flow, Avhile in others, who seem to have no blood to spare, the discharge is much more free; and in some exceptional cases of persons apparently en- joying good health the catamenia may differ from the normal stand- ard in eA^ery respect. Those irregularities Avhich are properly termed morbid will be considered in a separate chapter. During utero-gesta- tion and lactation the menses are usually wanting; there are, however, exceptions, some Avomen menstruating with their usual regularity while enceinte and while nursing; in many others the menses return after the first few months of lactation. The causes of menstruation must be identical with those of ovula- tion, from the intimate connection of these two functions, and from the essential dependence of the former upon the latter. The causes of ovulation must be found in the nerves which supply the ovaries. These form part of the ganglionic system, and are immediately de- 78 OVULATION AND MENSTRUATION. rived from the solar plexus, which is the great centre of vegetative life. All the actions of the human body may be considered as voluntary, as involuntary, or as partaking of the nature of both these conditions. Thus the bodily actions may be distinctly referred either to the cere- bral or voluntary nervous system, to the ganglionic or involuntary nervous system, or to the spinal nervous centre, which is more or less influenced and controlled by each of the others. The involuntary functions, Avith Avhich alone we are at present concerned, may all be classified as belonging either to the nutrition of the individual or to the reproduction of the species. Thus the ante-pubertal period is almost exclusively devoted to the nutrition of the individual, but not without reference to future reproduction, as is seen in the existence and even extrusion of the premature ova during all this period. Dur- ing the child-bearing period the nutrition of the individual is rendered unusually active and vigorous in order that it may subserve the repro- duction of the species, and when both cannot be at the same time provided for, it is the former which gives way to the latter. This is seen in cases of consumptive women who become enceinte; the child flourishes at the expense of the mother and is born comparatively healthy, Avhile the mother dies from inanition. Thus menstruation, as dependent upon the action of the ovaries, must find its immediate cause in the ganglionic nerves which supply these organs. And as forming, with ovulation, one of the important processes preparatory to conception, menstruation must find its final cause in that grand function of reproduction of the species, to the per- fect accomplishment of Avhich all the energies of the individual life are devoted. The above engraving represents the union of the extremes of the sexes. The male, in all respects, is created for giving, even from the very inmost; the female, for receiv- ing, even into her inmost. Hence the fecundating principle, secreted in the testicle from the bosom of his blood is transmitted,—as shown by the dotted line,—to her ovary; where it is received into the ovule, and becomes conjoined with that which is secreted from the bosom of her blood. Thus the extremes meet in the ovule, within the ovary; and thus conjointly united, the male and th« female principle become at once and forever a new creation, a new human being. U.—The Uterus. T.—The Testicle and Appendages. O O.—The Ovaries. L L.—The Ovarian Ligaments. V.—The Vagina. The dotted line represents the passage of the fecundating principle, from the testicle, through the vagina, uterine walls and ovarian ligaments, to the ovaries. REPRODUCTION. 79 CHAPTEK VI. REPRODUCTION REPRODUCTION forms one of the three most general divisions of the functions of organic life, nutrition and innervation con- stituting the others. It includes therefore the aggregate of the more particular functions which concur in organized beings to the repro- duction of their kind. Provision is made in the constitution of the individuals of the human race, as in other orders of the animate crea- tion, for the perpetuation of the species. This is effected by means of generation, Avhich results from the union of the male and female sexes. The act by which this union is effected is termed copulation. The two sexes are differently constituted in the various characteristics of their mental and moral being, and this difference of interior con- stitution becomes the foundation of corresponding differences in ex- ternal form and in sexual organization. The respective mental and moral characteristics of the male and of the female are so constituted as to correspond to each other, so that from the conjunction of man with woman in the married state there results a perfect union, a complete man. Apart, each represents an incomplete moiety—together, they form a whole. In like manner, the sexual organs of the man and of the woman are adapted to each other, and through their conjunction the spiritual and affectional union of man with Avoman is confirmed and consummated. And through this conjunction, in the holy state of matrimony, is accomplished the procreation of off- spring, the perpetuation of the race. In their mutual adaptation to each other, in general and in par- ticular, the male is formed for giving and the female for receiving. Thus the male and the female are seen to correspond, to be adapted and yet opposite to each other. During the act of copulation the male deposits the semen in the vagina of the female, whence the fecundating principle arises, and, entering certain ducts specially arranged for that purpose, passes up through the walls of the uterus, out through the ovarian ligament to the ovary. Here it enters and impregnates an ovule on that side. In the plate opposite this page the semen is represented as passing from the testicle through the penis into the vagina, and from thence the fecundating principle may be traced upward through the uterine parietes and ovarian ligaments to the ovary of either side. 80 REPRODUCTION. It Avill here be observed that it is claimed that the vitalizing principle of the male semen finds its Avay to the ovary of the female through the uterine Avails and ovarian ligaments—a route not generally acknoAvledged as the true one by physiologists; and that impregnation of the ovule occurs within the ovary, which is a point yet in dispute, and by no means agreed to even by a majority of writers. Having prepared an article on the subject of reproduction, as an elaboration of vieAvs concisely set forth in the first edition of this Avork, and which was published in the Hahnemannian Monthly, December, 1868, I take occasion to transfer from that article such arguments as were in it adduced as evidence of the truth of both of the above propositions: " Many years ago Jean Bohn published a Avork on physiology, in Avhich he defended De Graaf. He was decidedly of opinion that the aura seminalis transmitted through the porous structure of the uterus reached the ovary and fertilized the ovum, Avhich then descended through the Fallopian tube..... " Another position assumed by De Graaf, Avhich had been main- tained previously by Warton, and afterward supported by Haller and almost all preceding physiologists, Avas that impregnation was accomplished always in the ovaries.* " Under the head of ' Impregnation of the Ovum while still in the Ovary,' J. Muller says: ' This is the place of impregnation, at all events in man and mammiferous animals. In all cases of extra- uterine pregnancy, in which the ovum is developed in the ovary itself, or escaping into the abdominal cavity is developed there, it cannot be doubted that the ovum was in these instances impregnated in the ovary.' f " A constriction (of a Fallopian tube) may prevent the arrival of the fecundated ovule into the uterus, and may thus give rise to a pregnancy of the tube.J " Haller found it possible to produce artificially an extra-uterine gestation, by tying the corona of the Avomb of a mammalian animal three days after conception. The result of this operation was that tAvo foetuses were discovered in the tube betAveen the uterus and the ovary.§ " Cazeaux, referring to the experiments of Nuck and Hoighton, and * Ritchie's Ovarian Physiology and Pathology, pp. 4, 97 ; London, 1865. f Muller's Elements of Physiology, London, 1842, Vol. II., p. 1491. X Scanzoni, Diseases of Females, New York, 1868, p. 370. § Ritchie, Op. cit., p. 165. REPRODUCTION. 81 the later observations of Bischoff, says: (Such results evidently prove that fecundation sometimes takes place in the ovary.' * "Ritchie—already quoted—mentions cases of ovarian pregnancy. Mr. Stanley has published an account of a case of ovarian pregnancy [British Med. Trans., Vol. VI., Art. 16]; and Dr. Granville a more extraordinary example, the foetus being perfect and four months old [Phil. Trans., 1820]. The celebrated Tyler Smith says: ' Of the occa- sional occurrence of ovarian pregnancy, there can be no doubt.' . . . In the admitted cases the entire foetus has been found within the (ovarian) sac, or escaped from a perforation of the ovarian cyst.f "The instances adduced from these authorities amply prove the fact of the occasional occurrence of true ovarian conception. Now, Avhile no cases can be brought forward to show that conception ever occurs in any other place than in the ovary, I offer the following reasons, among others, for believing that it never does occur any- where else. "I. Extra-uterine pregnancies, Avhether ovarian, tubal, or inter- stitial, all show that the ovule must have been impregnated Avithin the ovary, but failed to be transmitted by the Fallopian tube to the uterus. " II. No embryologist has ever yet found either the germinal spot or the germinal vesicle in an impregnated ovule, even at its first entrance into the Fallopian tube. Both must have been obliterated, as the effects of impregnation, before leaving the ovary; while its gradual and progressive course down through the tube is always marked by a corresponding development looking toAvard the pro- duction of a new human being. "III. The length of time occurring after conception before the ovule can be found in the uterus becomes a still more convincing proof. ' In the present record of our science,' says Cazeaux, (there is no one conclusive fact that proves the ovule to have ever been seen in the Avomb of a woman prior to the tenth or twelfth day after her conception.' " IV. The preparation made in the uterus itself, in the shape of the decidua, for the reception of the impregnated ovule, becomes additional proof when considered from the true physiological point of \Tiew. In accordance Avith the most beautiful economy of nature, this preparation commences immediately and only upon the com- pletion of the impregnation in conception, and occupies the entire time consumed by the product of conception in passing from the * Midwifery, Philadelphia, 1857, p. 97. f Lectures on Obstetrics, Am. ed., p. 343. 6 82 REPRODUCTION'. ovary to the uterus. Thus the impregnated ovule is preparing for the decidua, and at the same time the decidua for the impregnated ovule, each vital process being influenced by the other. "V. It is well known at the present day [see Cazeaux, third American edition, foot-note, p. 98] that the ovule Avhich causes the menstrual flux is never impregnated. After the cessation of the menses, at any time prior to the succeeding nisus, impregnation of an ovule noAV lying Avithin the stroma of the ovary may be effected. This is proven from the preparation made Avithin the uterine cavity, as stated in IV. This preparation could not be effected otherwise than by the evolution of the impregnated ovule. The attendant physiological process proves the event, and the Avhole is confirmed Avhen we consider the length of time occupied by the ovule in passing from the ovary to the uterus after effective coitus. " These considerations will, perhaps, suffice to convince the un- biased mind that the ovary is the seat of conception. " An answer is now demanded to the second question—viz.: What is the course of the semen in its passage to the ovary ? " I am aware that, according to the opinion commonly entertained and supported by the greater weight of authority, this course is through the Fallopian tubes. But while the positive determination of this question is at once impossible, yet, as I have felt entirely dissatisfied with the solutions of the vexed question already offered in obstetrical authorities, I have been led to believe, as above stated, that the semen passes through the Avails of the uterus and out through the ovarian ligament to the ovary. And if the following reasons for this belief appear less convincing to others than to myself, it should be remembered that the whole question is still a matter of opinion rather than of actual demonstration. "I. In numerous cases of extra-uterine pregnancy the cause of the non-transmission of the impregnated ovule into the uterus has been found to be an imperforate condition of the Fallopian tubes. In these cases there could be discovered no sign of an opening ever haying existed through Avhich the semen might have passed to the ovary. The only natural channel Avhich othenvise appears is that through the ovarian ligament. "II. Normal uterine pregnancies have been found where the os uteri was entirely Avanting,* and where not the slightest trace of its ever having existed could be detected. In these instances, as well as * The records of obstetric science furnish several cases of complete absence or occlusion of the os (congenital). The following paragraph, from a source readily REPRODUCTION. 83 in those of an imperforate condition of the tubes, the semen certainly could not pass up to impregnate the ovum through the Fallopian tubes. " III. This modified doctrine of absorption is descriptive of the most simple process that nature could adopt for conveying the semen to the ovary; and while it is true that the assertion that semen is con- veyed ' through the walls of the uterus and out through the ovarian ligament to the ovary' is not predicated upon any anatomical dis- coveries of ducts or passages that I have made in the human uterus, such ducts or passages have been found in the elephant, and, by Dr. Gartner of Copenhagen, in the cow and soav.* " IV. The correspondence of the general affection of the Avhole female organism to that of the male requires that, even as the semen is given from the inmost of the male, so it shall be received into the inmost of the female, even into the OAraries, and there perform its vitalizing function. And here I Avish to remark, that while it is admitted that the actual reception of some portion of the semen into the ovule is necessary in order to impregnate it, still this portion need be no more than the minutest particle, Avhich in organized bodies corresponds to the elementary or primary atom of the inorganic Avorld; and that, in addition to this, the old doctrine of the universal im- pregnation of the blood of the female by means of the seminal aura of the male seems to be confirmed rather than refuted by the later discoveries of modern physiological science. The entire system of the female is influenced most poAverfully, and in a direction highly favorable to reproduction, both by the general magnetic sphere of the male, and by that richly-endoAved secretion Avhich is given off as the representative of his energetic vitality. " V. It is to be remembered that the ovaries are encompassed by, first, the serous peritoneum, and secondly, by the tunica albuginea, a highly-organized and dense fibrous tissue, impervious in a much greater degree than the comparatively porous textures of the uterine accessible to all [Churchill, Theory and Practice of Midwifery, Philadelphia, 1851, p. 256], places beyond cavil the existence of such instances. " Lastly, a few cases are on record of total absence of the os uteri, as in a case which came under the care of my friend, Dr. Ashwell, and which he has described in Guy's Hospital Reports: 'it was found necessary to make an artificial opening with the knife; the labor terminated favorably.' A single well-authenticated instance of pregnancy occurring with an ab.=ent or occluded os entirely uproots the theory of the passage of the semen to the ovary via the Fallopian tube. * See Ryan's Compendium of Gynecology and Paidonosology; also, Cazeaux, Mid- wifery, Philadelphia. 84 REPRODUCTION. Avails and the ovarian ligaments. Thus, though it may be true, as is claimed, that spermatozoa have been observed on the ovary, it does not folloAV that impregnation of the contained ovule is effected through the passage of these spermatozoa through the Fallopian tube. The ovules are within the ovary, at one end of an uninterrupted porous chain, and it is reasonable to argue that the vivifying principle is conducted to the ovule by that way. " Again, it is to be remembered that the Fallopian tubes (oviducts), being lined by ciliated epithelium, have the cilise in a direction to aid movement from the ovary and toward the uterus, and to retard move- ment in the opposite direction." The semen of the male is principally and in the first instance secreted by the testes. In its passage it is commingled Avith the secretions of the corpus Highmorianum, the epididymis and vasa def- erentia. To this are superadded the secretions of the prostate, of Cowper's glands and of the vesiculse seminales. The latter additions appear to protect, and perhaps modify, the original product of the testes. In its mature condition, semen principally consists of an extremely small quantity of a viscid fluid, and of innumerable minute linear corpuscles having a peculiar movement, Avhich are termed the sper- matic filaments, or spermatozoa. As the semen is found in the vas deferens—that is, before admixture with the secretions of the above- mentioned glands and follicles, Avhich give it its peculiar odor—it is whitish, viscid and inodorous, and consists almost entirely of sper- matozoa and connective fluid. In the pure semen these spermatozoa exhibit no movements, or scarcely any Avhen it is concentrated. A peculiar lashing motion of the tail of the spermatozoa is visible in the semen found in the vesiculse seminales. But these bodies, once deemed essential to the procreative function of semen, are now be- lieved to be the products of the formative action of the organs in which they are found, and cannot therefore be ranked in the same category Avith animalcules. The semen, as finally imparted to the female in copulation, consists, then, of three distinct portions: first, the original vital secretion of the superior portion of the testes; secondly, of the delicate fluids which are associated Avith this secretion as it passes through the sec- ondary structures of the epididymis and vasa deferentia; and thirdly, of the more voluminous mucous secretions of the subsequent glands and follicles, which envelop the Avhole as with a natural body. These three diverse and yet harmonizing elements are essential to REPRODUCTION. 85 the healthy condition of the semen; for neither the spermatozoa nor the delicate secretions of the vas deferens, nor the grosser products of the various glands, can accomplish fecundation of the ovum sepa- rately. Nor is it to be regarded that the semen, vieAved according to its physical qualities or chemical constituents as a liquor seminis, can, as such, effect fecundation and the primitive organization of a distinct and vitalized being. But it is upon the vital essence or spirit, so to speak, of the semen that its power to impart life depends. The gross liquor carries Avith it a part of the essential life of its giver, which, meeting a similar vital essence of the female organism in the ovum of the o\rary, the conjunction of these two vital essences or principles is the process of fecundation by and through which a new being results Avhich partakes of the life of the man and Avoman, and which is in that instant made a living soul. The three constituent elements of the semen correspond to the body, soul and spirit. Within the inmost of each seminal nucleus is contained the very highest soul and life of the parent; the deli- cate fluids which immediately surround it are inspired by the animal spirits, Avhile the more gross and exterior mucous envelopments cor- respond to the animal body. This organization of the seminal globule, which makes it correspond to a representative of the body, soul and spirit of the parent, finds in the female ova a corresponding threefold organization, equally repre- sentative of the female constitution. And the semen of the male therefore unites and combines with the ovum of the female, in each one of these three constituent and representative forms, in more or less perfect harmony, according to the more or less perfect adaptability of the male parent to the female. And as in the mingling of different races the stronger takes the lead and predominates in the offspring, so in the union of the seed of the different individuals, the stronger predominates in the moral, mental and physical characteristics im- pressed upon the child. Thus as the lower, more gross and material portion of the male semen meets its counterpart in the grosser organi- zation of the ovum, with Avhich it unites and Avhich it vitalizes Avith its degree of life, so each of the other constituent forms of the semen necessarily unite with and inspire the corresponding representative organization of the ovum. The ovum then receives, cherishes and nourishes the vitality imparted to it by the male semen, and the living form Avhich is the result of such reception partakes of the qualities of the ovum on the one part and of the semen on the other, even as these are but faithful representatives of the various qualities, Avhether 86 REPRODUCTION. orderly or disorderly, of the male and female individuals from Avhich they spring. And even as it was stated in general at the beginning of this chap- ter, that all the sexual organs of the male were for giving and all those of the female Avere for receiving, so here now it is particularly seen hoAV the female ovum becomes receptive of the semen of the male. And at the moment of this vital reception the entire female organism feels its influence, and prepares forth Avith to provide for the protection, sustenance, growth and development of the new creation. This impregnation and fecundation of the ovum is called Conception. And this product of conception usually remains quiet Avithin the ovary for about the space of five days. During this time the first initial stages of subtle and mysterious vital organization and growth are taking place—processes too minutely recondite for successful ex- ploration by the eye of man. Wonderful arcana of nature ! in Avhich, after all our profoundest scrutiny into the mystery of life, we can discern only the means and the ends, but not the manner. We see the minute representative forms of two lives combined to produce a third, in which shall appear, during all the possible threescore years and ten of its subsequent life, the general characteristics of the human race as distinguished from those of other forms of animate nature; the general characteristics of the nation or tribe to Avhich its progenitors belong; the characteristics of the family as distinguished from those of other families in the vicinity; and lastly the personal peculiarities of each of the immediate parents,—all of Avhich are impressed upon the embryonic germ, grow with its groAvth and strengthen Avith its strength. During this time, in which the fecundated ovum remains quiet in the ovary, the interior surface of the uterus is being prepared for its reception. Under the influence of the impetus imparted to the entire system by this event of conception, the mucous lining membrane of the uterus becomes deeply congested, as in spontaneous ovulation. This congested uterine condition is due to the natural evolution of the fecundated ovule, and while the physio-pathological concrestive condition is similar to that occurring with spontaneous ovulation, yet a different evolvement is now to be effected, and, instead of the con- gestion being relieved or carried off in the form of a menstrual flux the decidua is formed as a step in the process of prospective utero- gestation. Very rarely indeed does the congestion after fecundation result in the discharge of the menstrual blood. Thus, by the time the fecundated ovum bursts through its original REPRODUCTION. 87 seat in the ovary and reaches the uterus, it finds prepared for it a thick, rich, soft, vascular and velvety lining, quite different from that Avhich is to be found in the unimpregnated uterus. This hyper- trophied development of the mucous coat of the uterus forms a sort of bed, into Avhich the impregnated ovule is received immediately upon its escape from the Fallopian tube. This, Avhich is the original mucous lining membrane of the uterus, forms Avhat is termed the decidua vera, Avhile the subsequent extension of the same growth, which completely envelopes the ovum, is called the decidua reflexa. The decidua thus constituted and developed form a sort of nidus or nutritious nest, in Avhich the villi of the ovum take root, and from Avhich the development of the ovum itself, already quite advanced, now progresses still more rapidly. Here, then, Avill appear the contrast betAveen spontaneous ovulation and that Avhich occurs in connection with impregnation. In the former instance the disengaged ovum passes from the ovary through the Fallopian tube, only to be swept away by the menstrual flood, which forms the crisis of the menstrual molimen. In the latter instance the fecundated ovum, reposing for a few days in its original bed in the ovary, emerges at length from the ovary, and passes into the uterus, to find, as the result of the uterine congestion attendant upon its fecundation, the beautiful provision already described for its reception under the name of decidua vera. Under the influence of this same congestion the Fallopian tubes become erect, and fix their fimbriated extremities upon the exact portion of the ovaries from which the ova are about to issue. The stimulus which arouses these tubes to their almost instinctive action is to be found not in the orgasm of copulation, as is alleged by many authors, but in the reflex action of the emergence and escape of the ovum itself. The same reflex action of the first birth of the ovum, of its escape from the ovary, causes the exact and timely application of the fimbria? of the Fallopian tubes to the ovaries; and in the case of spontaneous ovulation results only in the critical discharge of the menses, which relieves the uterine congestion; Avhile in the case of impregnated ovulation, conception, it ultimates itself in that congestion of the mucous membrane of the uterus Avhich forms the alma mater of the descending ovum. Hitherto we have attempted to explain the nature of generation, or the reproduction of the species; the nature of the semen of the male and of the ova of the female; their representative character; the mode of their union in copulation; the results of that union in con- 88 REPRODUCTION. ception; and the natural history of the product of conception from its first development and brief stay in the ovary to its arrival at its more permanent but still temporary resting-place in the uterus. There will be seen an analogy between the repose and primary growth of the impregnated ovum in the ovary and its much longer residence and final development in the uterus. The first is the era of concep- tion, the latter is the period of gestation or utero-gestation, to Avhich Ave noAV invite your attention. Gestation, the act of bearing the product of conception, strictly speaking, begins at the moment of conception. As already explained, during a very small portion of this period the fecundated ovum is still retained Avithin the ovary. But after a few days consumed in the vital organization of the ovum itself and in preparing the uterus for its reception, the ovum usually descends into the uterus through the Fallopian tube of that side. From this moment the general term gestation is replaced by the more particular one of utero-gestation. The cases of the so-called extra-uterine pregnancy occur from the failure of the impregnated ova to be properly transmitted through the Fallopian tubes to the uterus. In such cases the ovum may increase in size and development, being nourished in a manner to be subsequently described, Avherever it may finally be deposited, whether in the Fallopian tube, in the adjacent folds of the peri- toneum, or even in the ovary itself. The more general term of gestation Avill, however, continue to be used here, since it is more convenient, and more applicable in some respects, such as in speaking of its period, Avhich, reckoning from its commencement at the moment of conception to its close at partu- rition, is two hundred and seventy days, or nine solar months. This period is, hoAvever, by no means invariable. For, not to speak in this place of those abortions, miscarriages and premature deliveries which are the results of accident or of disease more or less palpably developed, there are many instances recorded of persons Avho from some individual peculiarity have much prolonged this period; while in other instances there seems to have been a disposition to shorten it, independent of any apparent morbid condition. Generally speak- ing, the shorter the period of gestation the less viability has the child after birth. As already explained, conception always takes place Avithin the ovary; and where the embryo, the product of conception, descends regularly into the uterus and there becomes developed, it constitutes what is termed a good, normal or uterine pregnancy. But when it REPRODUCTION. 89 does not thus descend and become developed in the Avomb, if it remain and is developed in the ovary, if it fall into the cavity of the peritoneum, stop in the Fallopian tube, or become engaged in the substance of the womb itself, it forms a bad, extraordinary or extra- uterine pregnancy. Uterine Pregnancy may be simple when the uterus contains but a single ovum; double, triple, quadruple or compound, according as there are two, three, four or more foetuses; and complicated where, in addition to the foetus, there is also found a tumor, polypus, dropsy or other pathological formation in the abdomen. Extra-Uterine Pregnancy may consist of one or the other of the four folloAving varieties, according to the location of the fecun- dated ovum: 1. Ovarian, Avhere the ovum continues its growth in the ovary itself; 2. Peritoneal, Avhere the ovum fails to be received by the fimbria of the Fallopian tube, and thus becomes lodged in the folds of the surrounding peritoneum; 3. Tubal, where the ovum is arrested in its passage through the Fallopian tube, and is there developed; 4. Interstitial, AAThere the ovum penetrates the parietes of the uterus instead of attaching itself to its interior surface. In either of these varieties extra-uterine pregnancy must sooner or later terminate disastrously, unless relieved by the Caesarean section, since normal parturition is impossible, except perhaps in the last. What, by some authors, is termed false pregnancy, consists in an enlargement of the abdomen from the presence of hydatids or other tumors, when in reality no living foetus is present. Simple Uterine Pregnancy.—Upon the occurrence of preg- nancy Ave have to do with two different living beings, which although still united, the one within the other, present two different subjects for our consideration and two different classes of phenomena for our study. The woman, the prospective mother, represents one of these, and the embryo, the future child, represents the other. We will first study the influence of pregnancy upon the woman, and observe the various changes which it introduces into the entire economy. The manner in Avhich the anatomical structure, the physiological func- tions and the intellectual and moral states and sensibilities are affected by this neAv condition of pregnancy must be carefully explained. This account of the natural history of pregnancy will be succeeded, in a subsequent chapter, by a description of the dis- orders incident to pregnancy, and a detail of the principal remedies required for their successful treatment. 90 pregnancy. CHAPTER VII. PREGNANCY. Physiological and Anatomical Changes. HEN fecundation follows copulation, the congestion and tumes- cence of the uterus and Fallopian tubes become continuous, and numerous physiological and anatomical changes are established. Some of these are local, some more general; some are transient, Avhile others en- dure throughout the Avhole period of gestation; some affect the physical economy only, others in a remarkable degree disturb the mental states and moral sensibilities; and finally, some of these changes are purely healthy and normal. These Ave shall consider in the present chapter, while others, being accidental morbid conditions, or the developments of inherent morbid predispositions, will be subsequently described. The Uterus becomes the seat of the most remarkable and first apparent of these changes, in Avhich both the cervix and fundus par- take. Those which occur in the neck are separate from, although simultaneous Avith, those occurring in the body; the former also resulting from the latter. Thus, the ceiwix softens and enlarges from beloAV upAvard, as the body softens and enlarges from aboA^e down- Avard, during almost the entire period of pregnancy. And the altera- tions affect this organ in eA^ery respect—principally in its volume, form, situation, structure and functions. Let us first examine the changes in the body of the uterus. As explained in a previous chapter, the congestion attendant upon a menstrual crisis produces a temporary increase in the uterine parietes. A similar and more permanent result attends fecundation; the congestion attendant on the evolution of the ovum in that case is in some measure perpetuated, and a permanently hypertrophied con- dition of the uterine walls becomes established. Volume, Size.—The mucous lining membrane becomes congested and almost double in thickness; and in consequence of this develop- ment of its vessels, as described by Cazeaux, and especially of the minute glands of Avhich it is partly composed, it has its thickness so much increased in proportion to the size of the uterine cavity as to be throAvn, in a great many subjects, into soft, projecting folds or cir- cumvolutions, Avhich are so .pressed together as to leave no vacant place in the cavity of the uterus. This, as Avill be subsequently ex- plained, constitutes the decidua or enveloping membrane into which the fecundated ovule is received upon its entrance into the uterus w pregnancy. 91 from the Fallopian tube of the side corresponding to that of its ovarian birthplace. Immediately upon its reception of the embryo, the uterus com- mences to increase in size—not uniformly, but in a ratio proportioned to the larger development of the foetus—that is, the larger the foetus the more rapid the enlargement of the uterus. This growth of the uterus takes place in e\^ery direction, and is not a mere mechan- ical distension, as if arising from the outward pressure of the in- creasing ovum, but it is proved to be a true physiological develop- ment, in Avhich both ovum and uterus partake simultaneously and in unison. Form.—The uterus, instead of remaining flattened on its two sur- faces, becomes rounded and then pyriform in the earlier stages of pregnancy, while in the later months it becomes spheroidal, and finally assumes the form of an ovoid which is slightly flattened from before backward, and has its point looking doAvnward. " Of dimen- sions nearly equal in every direction, about the fifth or sixth month the uterus exhibits the figure of a spheroidal vase terminated by a very short neck; it might be compared to a hog's bladder, Avith the urethral extremity surrounded Avith thread for an inch or two; sup- posing some one should umvind the thread by degrees, from aboATe downward, while another blows into the bladder from the fundus, so as to distend it, Ave should acquire a pretty clear idea of the gradual effacement of the cervix of the Avomb."—Velpeau. In the latter months of utero-gestation the shape of the uterus is modified by the exact relatiA^e position of the foetus. That side of the fundus Avhich is occupied by one of its extremities is sometimes more elevated than the other. And since in the most usual presentations the trunk of the foetus is found to incline to the right side, this por- tion of the fundus of the Avomb yvill often be found most elevated. These general statements as to the shape of the gravid uterus are, however, liable to exceptions, Avhich may arise from the number of the foetuses, or from the varieties in the original shape of the uterus itself. In its situation the gravid uterus is subject to important changes. These changes arise in the first instance from the change in size of the organ itself. Remaining in the pelvic cavity during the first three months of gestation, the uterus sometimes becomes at first slightly depressed, so that its cervix approaches nearer to the vulva. This is especially the case in those in Avhom the pelvis is large. Still, this depression of the uterus, when it does occur, is but temporary, and at 92 PREGNANCY. three months the position is in all respects almost exactly the same as before impregnation. From the third and a half to the fourth month, the uterus, finding itself more and more incommoded as it increases in size, gradually forces itself upward from the excavation of the pelvis, rises above the superior strait, then to the level of the umbilicus, and toAvard the close of pregnancy it reaches the epigastric region. But during the last tAvo weeks of gestation the uterus commences to sink doAvn some- what; and this, which is regarded as one of the earliest signs of approaching parturition, is in fact almost the commencement of this process, since in most instances it results from the approximation of the foetal head toAvard the cavity of the pelvis, and in some cases from its actual entrance into the cavity itself. Direction.—The changes in the direction of the womb in pregnancy are no less remarkable than those of size and form. While still re- maining Avithin the pelvic cavity, the uterus, from the greater Aveight of the posterior portion of the fundus or upper portion, inclines back- Avard, as in partial retroversion, and the os uteri looks forAvard toAvard the pubic arch. But this is not ahvays the case in the earlier or first three months of gestation. In many such cases the fundus will be found inclining forAvard more in its natural position, Avhile the os tincse will be reached only by the farthest extension of the finger toA\rard the hollow of the sacrum. As the uterus in the fourth and fifth months rises above the level of the superior strait, two remarkable directions are assumed and maintained, usually till the close of gestation. These are—the in- clination forward, as if leaning over the arch of the pubes, and the inclination to one side, usually the right side. The forAvard inclina- tion of the graArid uterus is the necessary result of the hard, unyield- ing nature of the lumbar vertebra? behind, and of the less rigid structure of the abdominal parietes in front, in combination Avith the constant pressure from above of the contents of the abdomen itself. The line of motion Avhich alone is possible for the gravid uterus on emerging from the pelvic ca\rity being the axis of the superior strait, as guided by the projecting promontory of the sacrum, Avill even from the first have given it a decided inclination forAvard. The lateral inclination to one side or the other is the necessary result of the pro- jecting ridge of the lumbar vertebrae, as it would be little less than impossible to balance Jhe uterus on this high-raised median line. The proportion of cases in Avhich the uterus is found inclining to the right side is stated by various authorities to be as high as eight out PREGNANCY. 93 of ten. But there is less unanimity of opinion as to the causes Avhich produce such a result. Among the various causes proposed to account for this general tendency, no one seems entirely sufficient, nor do many of them unite with any degree of constancy in a given number of cases. Thus, if the inclination is to be attributed to the greater Aveight from the attachment of the placenta, it is found that the placenta is far from being always on the side toAvard which the uterus is inclined. The same is true of the relation of the colon loaded with fecal matter—of the position of the female Avhile at rest on the right or left side. For the present, the most plausible opinion appears to be that of Madame Boivin—that the round ligament of the right side is shorter, stronger and contains more muscular fibres than that of the left, and that to the more poAverful action of this ligament is to be attributed the usual inclination of the uterus to the right side. Still, there is no doubt that the more active physiological influences do much to determine this matter of the lateral inclination of the gravid uterus; and in confirmation of Avhat is here implied it may be sufficient to state that, according to the observations of some authors, the uterus inclines to the left in women who are left-handed. The thickness and density of the uterine parietes form two of the most remarkable changes of pregnancy. The non-gravid uterus has already been described as having Arery thick Avails. After fecundation these walls maintain usually the same relative thickness, although, as the uterus itself increases in size, its parietes become less dense, and instead of being hard and fibrous, are said by Cazeaux to have a clammy softness closely resembling that of caoutchouc softened by ebullition, or that of an cedematous limb. " It is now knoAvn that the Avomb preserves nearly the same thickness during the Avhole course of pregnancy as it had Avhen unimpregnated. This thickness, which is greater at the insertion of the placenta, generally diminishes from the fundus toward the cervix, where it is frequently found to be not more than two or three lines or even less. It increases a little in all parts of the organ at the same time, until the third or fourth month, and then remains rather beloAV its primitive limits, to exceed them again in the last stages of pregnancy, except the cervix, which at that period especially grows thinner." Structure.—The immense enlargement of the Avomb, from its non- gravid size up to that capable of enclosing one foetus or even more at full term, can only be the result of a very great increase in its entire mass. But this great development in substance—in which the weight of the uterus comes to be reckoned by pounds instead of by ounces— 94 PREGNANCY. is accompanied Avith a corresponding development of its proper organization. In its non-gravid condition the uterus exhibits only the type of the Avonderful deA^elopment which it acquires in pregnancy, and Avhich is essential to the proper performance of the important functions with Avhich it then becomes charged. "Its fibres, which were pale, dense and inextricably tangled, soften, become redder and soon represent layers and bundles easy to detect and to follow. The cellular tissue, Avhich was before so firm, dense and elastic, relaxes, becomes supple, and indeed resembles the common cellular tissue, and in this A\ray permits the other elements which it held in bondage, as it Avere, to folloAV the impulse that animates the whole womb. The arterial branches, folded upon each other like the vas deferens, and bridled in this condition by dense elastic laminae, yield to the general relaxation, and gradually become lengthened; their angles, at first so sharp, Avith their doublings, grow blunter, enlarge, and at last exhibit only certain zigzags of greater or less depth—tortuosities which do not impede the circulation. " The veins undergo the same metamorphosis : already in the natural state larger and less tortuous, they are enlarged and developed still more rapidly than the arteries; afterward they are observed to furrow the fleshy layer in eArery direction, and form a network which in some measure separates it into two planes. They are large enough to admit a goose-quill, and in some instances the end of the little finger; near the mucous membrane they dilate so as to constitute cones with inverted bases, Avhich were first termed uterine sinuses, but Avhich are noAV called venous sinuses."—Velpeau. The lymphatic vessels and the nerves are also enlarged in a cor- responding manner in pregnancy. The great change in the texture of the mucous lining membrane of the uterus has already been re- ferred to in describing the formation of the decidua. All the com- ponent tissues of the body of the uterus receiA^e accessions both in structure, size and physiological activity, to correspond Avith the new and most important functions which this organ is called upon to discharge in pregnancy and gestation. The Cervix Uteri is also subject to certain changes during the period of gestation. These occur simultaneously Avith those already described as affecting the body of the Avomb, and are the results of the physiological action by Avhich the entire uterus becomes adapted to its neAv functions. In the consistence of its tissue, in its volume form, situation and direction, the cervix uteri becomes chano-ed in a remarkable manner; and these changes, so far as they are appreciable PREGNANCY. 95 afford valuable indications for determining the fact and the stage of pregnancy. Softening of the tissue constitutes the principal modification of the actual structure of the cervix uteri. The change from a firm, fibrous structure to that of a soft, fungus-like substance begins at the loAver border of the interior surface of the os tincae in the first month of pregnancy, and increases from within outward, and from below up- Avard, till at the sixth month this softening embraces the whole thick- ness of the lips of the os tincse and the lower half of the sub-vaginal portion of the cervix. This softening of the tissue is ahvays from beloAV upward, and proceeds also pari passu with the development of the fundus. And so exactly is this proportion maintained that an experienced examiner can always determine with very great accuracy the advancement of the pregnancy by noting the extent of this upward softening in the ceiwix uteri. It must be borne in mind, hoAvever, that in those Avho have had several children the sub-vaginal portion of the neck of the uterus loses a considerable portion of its length; otherwise the briefer extent of the softening in such cases might mis- lead the examiner to conclude that the pregnancy was less far advanced than it really was. So also in cases of first pregnancy, since this softening of the cervix uteri is less strongly marked and more sIoav in its deArelopment, and therefore more difficult of detection, these circumstances should ahvays be taken into consideration in forming a conclusion in such cases. The increase in volume of the cervix uteri goes on in equal ratio with the decrease in the density of its substance. But the cervix does not shorten: the description given from Velpeau, on a previous page, of the development of the fundus at the expense of the cervix, is applicable only to the last fortnight of utero-gestation. On the contrary, the length of the cervix may begin to increase a little after the commencement of the fifth month; and this elongation, Avhich previously had been rather apparent than real, is continued till the final absorption of the cervix itself in the fortnight immediately pre- ceding parturition. At this period the Avhole neck, having become softened and thickened, becomes more easily distensible, and the development of the body of the uterus from above downward meets the softening and development of the neck from below upAvard at this juncture, which is at the os internum, and the complete fusion of the fundus with the cervix takes place, and the cavity of the womb is one from the fundus to the os tincae or os externum. This fusion causes the sinking down of the fundus from the pit of the stomach 96 PREGNANCY. so often observed in the last weeks of gestation; the fundus must sink as the walls and loAver segment of the uterus are expanded. And upon the occurrence of this depression the female breathes freer and feels better in all respects. The form of the cervix uteri differs in the multiparae from what is observed in the primiparae; this difference is principally to be noted in the varying size and shape of the os tincae and of the cavity of the cervix itself. In the primiparae the os tincae changes from a simple transverse fissure to a circular depression. The cavity, from being conical, becomes spindle-shaped, and the softening of the externally constricted os will not alloAV the finger to penetrate into the cavity. The os tincae never having been ruptured by parturition, its mucous lining membrane rounds it off very nicely, and none of the in- equalities, fissures or puckerings so common in the multiparae are to be found here. Fig. 21. A section showing the neck of the uterus; the anterior and posterior lips are seen in situ, being separated from each other by the fusiform cavity in the neck. In the multiparae the numerous cicatrices and indentations render the os tincae more originally patulous; and the most noticeable effect of the pregnancy upon the orifice in such cases is to cause it to be more easily dilatable. And as the gestation progresses this dilata- bility of the os tincae becomes an actual spreading out of the inferior portion of the cervix, until it reaches the middle part of the cervix uteri about the seventh month, and nearly gains the internal orifice by the ninth month. The cavity of the cervix goes on enlarging simultaneously with the softening of its walls and the advance of pregnancy, and the opening and cavity become thimble-shaped, admitting the finger farther and farther into it as the pregnancy advances. The gradual change in the opening of the os tincae and dilatation of the cavity of the cervix may be seen in the accompanying cuts upon the next page. In the preceding account of the changes in the neck of the uterus incidental to pregnancy we have principally PREGNANCY. 9? followed the very excellent and in some respects entirely original account given by Cazeaux; and for the following summary of these changes we are indebted to the same author. Summary.—From the statements made in the preceding sections we may draw the following conclusions: I. The tissue of the neck begins to soften at the very commence- ment of pregnancy, and the softening, although not very apparent in the early months, and limited to the most inferior part, gradually ascends, so as to invade successively the whole neck from below up- ward, though it is much less marked and less rapid in its progress in primiparae than in other women. II. The cavity of the neck dilates simultaneously Avith the soften- ing of its walls; and, further, this enlargement causes it to be spin- dle-shaped in primiparae, and in Avomen who have already borne children to resemble a thimble, the finger of a glove, or a funnel with its base below. III. The external orifice remains either closed, or else very slightly open, in primiparae up to the very term of pregnancy, whilst in others it is widely open, and constitutes the base of the funnel. IV. The whole length of the neck disappears in the last fortnight, being lost in the cavity of the body. V. Contrary to the opinions hitherto generally adopted, the neck preserves its whole length until the last fortnight; it does not shorten from above doAvnAvard during the last four months, but the fusion of the neck Avith the body takes place only Avithin the last few weeks of gestation. Fig. 22. Fig. 23. Fig. 24. These three figures give an idea of the gradual dilatation which the cavity of the neck undergoes at various periods of pregnancy. This final fusion of the cervix with the body of the uterus causes or is accompanied by a manifest sinking downward of the uterine tumor from the epigastric region, and a corresponding expansion laterally of the abdomen; which phenomena are usually accompanied 7 98 PREGNANCY. with greater freedom of respiration and other evidences of relief from pressure upon the stomach, diaphragm and thoracic contents. The Texture and Properties of the Uterus are also greatly modified by the condition of pregnancy. These changes affect the different tissues and structures of which the uterus is composed. The serous coat or peritoneum, Avhich constitutes the external tissue of the uterus, like the entire substance of the uterine walls, is ex- tended without being diminished in thickness. Just as the uterus itself grows \vith the growth of the ovum it contains, so its perito- neal covering absolutely grows, and in proportion to the whole groAvth of the uterus which it envelops. The mucous coat of the uterus, as already stated in speaking of the formation of the decidua, becomes much more highly developed in pregnancy, and this development belongs to the glands as well as to the mucous tissue itself. This is also the case with the mucous glands of the cervix; these secrete a peculiar dense, semi-transparent, almost insoluble mass of mucus, which fills and closes the entire cavity of the neck during pregnancy. The muscular coat of the uterus also becomes developed in a cor- responding manner during pregnancy; so that the various layers of muscular fibres are much more easily demonstrable at this time than in the unimpregnated condition, and the actual muscular character of this middle coat of the uterus is positively ascertained. The various muscular fibres are noAV seen to cross and intercross in such a man- ner as to secure the greatest possible amount of strength; and the arrangement of the layers and fibres is such that at every orderly con- traction they all act upon one common centre, the centre of the womb itself. The vascular apparatus of the uterus also undergoes very important changes in connection with the advance of pregnancy. These consist in augmented development, which embraces the arteries as Avell as the veins. Through these vessels the blood flows into and through the uterus in greatly increased quantities, and this blood supplies the nutrition for the growth of the uterine walls, and of the'foetus Avhich they enclose. "The augmentation in the size of the arteries only becomes con- siderable as they approach the uterus. Whilst advancing between the peritoneum and the external face of the organ, and before giving off their first divisions, they dilate and swell up, and then they furnish branches to the anterior and lateral parts, Avhich ramify ad infinitum; they are not situated immediately below the peritoneum, but are sepa- PREGNANCY. 99 rated from it by a delicate layer of muscular tissue. All these rami- fications anastomose freely, and penetrate through to the internal sur- face, Avhere they generally terminate; but a large number of those corresponding to the placental insertion traverse the mucous mem- brane and enter the placental deciduous membrane."—Jacquemier. Through these enlarged arteries is conveyed the blood requisite for the growth of the uterine parietes and appendages, and for the supply of the placenta, and consequently of the foetus. The arterial branches become lengthened with the increasing size of the uterus, but do not lose their original tortuosities, Avhich, however, do not appear to impede the circulation through them. The veins undergo similar and no less extensive changes. This will be evident from examining them as they emerge from the uterus; the ovarian veins are nearly as large as the external iliacs, and the uterine veins are but little less in size. In the original state, before pregnancy, they are larger and less tortuous than the arteries; during gestation they become enlarged and de- veloped still more rapidly; and at term they furrow the muscular tissue in every direction, and form a network which lies intermediate between its external and internal face. This muscular tissue or coat of the uterus is traATersed by a great number of venous branches run- ning in every direction, Avhich anastomose and form large sinuses at their junction. Some of the canals of this plexus or network are large enough to admit a goose-quill, or in some instances even the end of the little finger. This is particularly the case at that part of the interior surface of the uterus to Avhich the placenta becomes adherent. Opposite the insertion of the placenta these venous trunks are largest, and they diminish in size as they recede from this vicinity; and in the sub- stance of the mucous membrane, immediately beneath which the placenta is situated, these vessels form, through an enormous dilata- tion of their branches, the long sinuses Avhich exist at the adherent surface of the placenta. These sinuses communicate freely with each other, so as to form a reservoir of blood divided and kept in place by numerous partitions. At intervals may be found a small number of orifices through Avhich this mass of blood communicates Avith cor- responding sinuses in the muscular Avails of the uterus. The veins as well as the arteries are lengthened, growing thus with the growth of the uterus, since even in their greatest extent, in the last months of pregnancy, they still maintain their tortuosities. The areolar tissue which envelops the uterine arteries is not found on the veins, these latter being placed in immediate relation with the muscular tissue 100 PREGNANCY. through which they pass. Neither are there any valves to be found in these veins; probably their numerous convolutions and sinuosities may serve to ansAver the purposes secured by the valves in other venous trunks. The lymphatic vessels of the uterus also acquire an extraordinary development in pregnancy and gestation. These vessels form several distinct layers or planes in the uterine Avails, the superficial being the most fully developed; and, as previously described, they belong to two distinct groups, those of the cervix communicating Avith the pelvic ganglia, and those of the body of the womb terminating in the lumbar ganglia. The lymphatic system forms, with the arteries and veins, a third and no less indispensable set of vessels; and the neces- sities of the circulation, of the nutrition (reparation and growth) of the uterine tissues and their contents, require that the augmentation of the lymphatic vessels should be in some proportion to the increase of those of the arterial and venous systems. The nerves of the uterus during the period of gestation necessarily partake of the same increased activity as the other uterine structures, and it was once supposed that they received also a corresponding augmentation in development. But the more recent researches of physiologists haA^e shown that the proper nerA^e-tissue itself remained unaltered during pregnancy, and that the apparent increase in size of the nerves is due to the augmentation of the tissue composing the neurilemma—a tissue which is almost entirely fibrous, and exhibits no structure specially nervous, its office being to support, protect and bind together the nerve-tubules and ganglionic nerve-corpuscles. Those arising from the ovarian plexus are distributed to the angles of the fundus; those arising from the hypogastric plexus are dis- tributed to the cervix and lower portion of the body, these, by branches from the third and fourth sacral ner\res, being connected Avith the spinal nerves; and finally, those arising from the great sympa- thetic accompany the uterine arteries, and are lost upon the neck and lateral parts of the womb. . Thus the entire structure of the uterus is sure to be supplied with nerves from the nervous system of organic life, a portion only of the nervous filaments distributed to the cervix being in immediate relation Avith the spinal nervous system. The complicated arrangement of the various tissues and organized structures which make up the substance of the Avomb renders it ex- ceedingly difficult to demonstrate the full development of the nervous system of this organ. But there can be no doubt of the fact that the uterus is so abundantly supplied with nervous substance in itself and PREGNANCY. 101 so intimately connected with the great ganglia in its vicinity, that it is endowed, especially in the gravid state, with a vitality peculiarly its OAvn, through Avhich it is enabled not only to support the nutrition of the embryo, but also to exert a controlling influence upon the entire economy of the Avoman herself. These changes in the structures composing the uterus must occasion corresponding changes in the physiological and sensitive conditions of this organ. The physiological properties of the gravid uterus, as to sensibility, irritability and contractility, are very different from those exhibited in the non-gravid condition. The common sensibility of the uterus in the non-gravid state is but slight, but in consequence of the more active development of the nerves of organic life and of their connec- tion, in the cervix, Avith the spinal nerves, this sensibility is much in- creased during pregnancy. And yet in many individuals the uterus shows in this respect a most astonishing power of endurance—a Avon- derful tenacity which enables it to retain and preserve the embryo in the midst of the greatest dangers. Near akin to this increased sensi- bility appears the peculiar irritability of the uterus. This may be defined as a certain morbid sensibility, or a sensibility attended Avith weakness rather than with strength. In the former instance the woman can bear Avith impunity the active movements of the foetus in utero; in the latter, these movements induce the most poignant anguish, or may even threaten a premature delivery. Contractility is but a still farther advance in the direction of sensi- bility and irritability, or, rather, the former is the crisis or reaction Avhich results from the latter. The most important function of con- tractility is, of course, peculiar to the gravid as contrasted with the non-gravid uterus. It belongs to the increased muscular development of the uterine parietes, nourished as they are by the augmented blood- vessels, and inspired by the more active influences of the nerves. This contractility may be excited by the reflex action, from irritation, of the cervix; thus, a common cause of abortion is to be found in repeated and violent coition, and in other disturbances of the os and cervix uteri. The menstrual molimen, in the unimpregnated condition, seems to have the poAver of exciting all the contractility of which the womb is then capable. And even in the impregnated state the same influence is still to be traced in the remarkable tendency to abort at menstrual periods, especially at the third. And it is thus that many drugs Avhich are capable of so irritating the uterus or the adjacent sympathizing structures as to produce a congestion Avhich may simu- 102 PREGNANCY. late that of menstruation, are also capable of directly producing abor- tion. But the grand physiological functional contractility of the gravid uterus is seen only at full term. Then this organ arises in its might in the fullness of time, spontaneously casts off in the most vio- lent manner, even at the blind risk of destroying the mother a\ here deformity may be present, the ovum which it has cherished, protected, nourished and vivified through nine long months. And to the accom- plishment of this contractility the nerves of the uterus summon not only all the various curiously-arranged and poAAerful muscular tissues pertaining to that organ, but through their connections Avith the cere- brospinal nervous system they compel the co-operation of all the inA'oluntary and voluntary muscular apparatus of the entire body, and of all the determined energies of the mind. The efforts of the will, co-operating Avith the involuntary muscular contractions, exert no small influence in maintaining the labor-pain. In some rare instances the contrary has been obseiwed. Mrs. C, living five miles from the city, at a time Avhen the traveling was very bad, was taken in labor, and felt as if she Avould be confined before her physician could reach her. Her pains Avere frequent and vigor- ous, but by a determined effort of her will she had entirely sup- pressed them, and her physician was obliged, after Avaiting in A'ain for some time, to restore them by exhibiting the appropriate remedies. This Avas not a case of fear, but the lady said she exerted herself all she could to suppress the pains. The favorable influence of good hope of a speedy delivery is so well known that the physician instinct- ively encourages his patient all he possibly can. In the state of nature in animals and among the savage tribes this function of con- tractility, even at its final result in the expulsion of the foetus at full term, is attended with little or no pain. But this is very far from being the case usually in civilized life. That function of the uterine tissues by Avhich the Avomb, after being thus emptied, is restored to its original state, is by some authors con- sidered to be distinct from contractility, and termed elasticity. But this seems nothing more than a continuation, into the minute struc- ture, of the same contraction which, in the first instance, had affected the entire organ. In the latter instance, the minutest filaments of the muscular and other tissues seem affected, as in the former the entire muscles and muscular parietes. This identity of contractility Avith Avhat is termed elasticity will be more certainly demonstrated by the consideration of the very similar effects of the same physical and even moral agents in producing or in PREGNANCY. 103 arresting their development. Thus, ergot, Avhich is one of the most efficient agents in producing powerful contraction of the muscular parietes, is no less active in arresting the hemorrhage subsequent to parturition which arises in consequence of a Avant of the proper inter- stitial contractility or elasticity which should close the open mouths of the blood-vessels. In the same manner, fright, from being told there was " something wrong" about the presentation, has been known instantly to arrest the labor-pains and change the labor itself from a natural to an instrumental one. So fear has been seen to stop the normal contraction of the uterus after child-birth, and thus admit alarming hemorrhage. The reflex stimulus of friction to the abdo- men may indifferently produce the pains of labor, or those after- pains by which the continued contraction and final restoration of the Avomb to near its original size are secured. The uterus may be so Avorn out in the actual labor, even if its involuntary contractions have not already ceased before delivery, that it has no longer any tone, and, like an overstretched piece of india-rubber, appears incapable of re- suming its natural form. Such also may easily be imagined to be the case in those in Avhom, whether from failure of the vital forces in general or from organic exhaustion, the foetus has to be removed by force. Nor is it unknown for the last, most violent and successful expulsive efforts of the Avomb to be followed by entire paralysis of the organ. • But, in general, the interstitial contraction would seem to keep pace with the organic, and as the fundus closes in upon the foetus as the head emerges from the os uteri, so the minute interstitial contractility (elasticity) of the tissues already follows on and aids the organic con- tractility in separating and expelling the placenta. Position.—The changes in position of the gravid uterus have already been referred to under the head of direction. But it will not be amiss to again refer to them here, and it will be interesting to note in what Avay the addition of so large a body as the uterus to the already occupied abdomen is provided for, without any of the viscera suffering inju- rious pressure, and without that impediment to the circulatory and respiratory systems, which, in the absence of such a provision, must inevitably take place. " The oblique direction of the uterus upward and forward is deter- mined, firstly, by the corresponding obliquity of the pelvis, the plane of whose brim forms Avith the horizon an angle of 60°. But as the fundus gradually, after three months, emerges from the pelvic cavity, the oblique direction of the uterus is maintained by the symphysis 104 PREGNANCY. pubis in front and the sacral promontory behind. Between these, the superior portion of the uterus continues to ascend, supported most by the abdominal Avails anteriorly and the spine posteriorly. The intes- tines, being bound doAvn by the mesentery, cannot be displaced, and will therefore occupy a position midAvay between the spinal column and the posterior uterine Avail. The pressure of the sacral promontory and of the lumbar vertebrae will still give to the uterus a forward tendency, which, on the other hand, will be prevented from becoming excessive by the elasticity of the front walls of the abdomen. If these have not been previously much distended, the fundus glides upAvard, and ultimately fills the epigastric holloAv; but if the abdominal Avails have been much relaxed, as by frequent child-bearing, or if the pelvis is much deformed, the fundus uteri is usually turned directly forAvard, or even dowmvard. " At the end of pregnancy the whole of the fore part of the abdo- men is occupied by the uterus; on either side lie the ascending and descending colon; the transverse arch, together with the omentum and stomach, fill the space between the fundus of the uterus and the diaphragm, Avhile the rest of the abdominal viscera lie laterally and posteriorly to its hinder wall. " Thus it results that in pregnancy, and especially in its last stages, no injurious pressure is exercised either upon the great vessels, the aorta and vena cava, or upon the intestines, liver or stomach, Avhilst the descent of the diaphragm, and consequently the act of respiration, is not materially impeded, and space is left for the bladder and rec- tum to perform their appropriate acts."—Dr. Farre, in Todd's Cyclo- paedia. Changes in the Uterine Appendages and Adjacent Organs. —Next to the changes which are induced by pregnancy in the neck and body of the uterus, those Avhich are wrought in the uterine appendages and adjacent organs need to be considered. The vagina, Fallopian tubes, round and broad ligaments, the bladder, the rectum, various parts of the trunk, and, finally, the mammae, are all more or less affected in structure or in development during the period of utero-gestation. The vagina becomes shortened with the descent of the uterus in the earlier stages of pregnancy, and lengthened as the uterus subsequently arises above the superior strait. The veins of the vagina experience an enlargement somewhat corresponding, although less in extent, Avith the dilatation of the uterine veins; and these Areins sometimes become varicose. Toward the end of pregnancy the finger will often encounter PREGNANCY. 105 these varicose enlargements, and certain nodosities described by French authors under the name of thrombus. On the superior portion of the vagina, and especially on the infra-vaginal part of the uterus, arterial pulsations may also be detected. This Araginal pulse has been con- sidered an important diagnostic sign of pregnancy. The mucous mem- « brane of the vagina also experiences an extraordinary development Fig. 25. POSITION OF THE UTERUS AT THE END OF PREGNANCY (AFTER MAYGRIER). in pregnancy, analogous to the hypertrophy of the mucous lining membrane of the uterus. This is shown by the innumerable granules or enlargements of the mucous follicles, Avhich about the seventh or eighth month are found covering the interior surface of the vagina, and Avhich are also to be found upon the exterior and interior surface 106 PREGNANCY. of the ceiwix uteri. An increased mucous secretion accompanies this follicular development. This increased secretion of mucus is the nor- mal condition in pregnancy, especially in its advanced stages; and it should never be suppressed by injections. In such cases even cold water injection does harm, since, from the suppression of these vaginal mucosities, the labor is rendered more lingering and severe; Avhat is called dry labor may result. The Fallopian tubes and ovaries are draAvn nearer to the body of the uterus; the former, instead of being on a level with the fundus, now correspond to the upper fourth, or even to the middle, of the uterus. This results from the ascent of the Avomb above the pelvis, by Avhich the folds of the peritoneum, called the broad ligaments, prolonged into the pelvic cavity to reach and support the uterus, are shortened and caused to disappear. The round ligaments are carried forward by the greater development of the anterior than of the posterior wall of the uterus, so that their insertions, instead of being at the sides of the womb, are iioav found at the point of union of the anterior fifth Avith the posterior four-fifths of the antero-posterior diameter. The bladder, during the early months of pregnancy, is gradually pushed above the superior strait; the urethra is elongated, and its orifice concealed behind the border of the symphysis pubis. The anterior projection of the bladder renders the line of the urethra much more curved; so that its course will be more readily followed by the male catheter, with its convex surface backAvard and its con- cave surface forward, than with the nearly straight one ordinarily used for females. The gravid uterus rests doAvn upon the posterior surface of the urethra, and by compressing it against the arch of the pubis often causes an obstruction in its circulation. This may be knoAvn by the tumor to be found in such cases behind the sym- physis, and by the severe and painfully distressing tenesmus, and even strangury, which not unfrequently arise from such compression and irritation of the meatus urinarius. In some of these cases the catheter is requisite in order to afford temporary relief, until, from quiet and rest in the horizontal position, the cause may be removed long enough to alloAV the irritation to sub- side or the proper medicines to be applied for its relief. As pregnancy advances, and the bladder is gradually encroached and pressed upon by the increasing gravid uterus, it becomes more and more flattened, and its capacity for containing the urine is con- siderably lessened; hence the more frequent and more urgent calls to urinate. PREGNANCY. 107 The rectum is pressed upon in a similar manner posteriorly; hence, in part from the mechanical obstruction, there results the constipation so common in pregnancy. A similar obstruction of the blood-vessels and lymphatics in some cases tends to develop hemorrhoids and oedema of the vulva and of the lower extremities. These deviations, partaking of a pathological nature, will be more particularly consid- ered, with the other morbid conditions of pregnancy, in a succeeding chapter. The relaxation of the various pelvic symphyses, especially that of the pubes, Avhich during pregnancy occurs in some peculiar constitu- tions, and which renders locomotion difficult, if not impossible, also results from a morbid condition subsequently to be considered. The abdomen becomes very much enlarged as pregnancy advances, its parietes being thinned, and on the inferior portion often marked by broad or bluish streaks, which form parallel curved lines, Avith the convexity toward the pubes. On the median line, from the pubes to the umbilicus, may be observed a brownish streak, Avhich in primi- parae has been deemed a certain sign of pregnancy; a similar dark- colored line has been seen, however, in non-gravid females and in males. After delivery an oblong tumor is sometimes seen on the median line, especially during any severe exertion. This results from the projection of the boAvels Avhere the abdominal parietes have been permanently thinned and Aveakened by the separation of the aponeu- rotic fibres. With each subsequent pregnancy this enlargement be- comes greater, until, in some instances, it becomes necessary to band- age it. The thorax, with the upward ascent of the large volume of the gravid uterus, experiences important changes. Its base is enlarged, the diaphragm is pressed upward and distended by the stomach and contents of the abdomen; sometimes the croAvding together obstructs the circulation of the heart and great vessels, respiration is visibly affected in such cases, and sometimes the irritability of the distended diaphragm occasions a more or less constant cough. The mammae, both from original sympathy Avith the genital organs and in preparation for the performance of their oavii future function, exhibit remarkable changes during gestation, Avhich may also become diagnostic of the pregnancy itself. These changes are of two kinds— those relating to increase in size, and those which affect the color of the areola surrounding the nipple. Very soon after the commence- ment of pregnancy in many women, the breasts become more full and somewhat tender; they have evidently assumed a more vigorous 108 PREGNANCY. physiological activity. This increase in the volume of the mammae will sometimes diminish toAvard the fourth or fifth month, but to re- turn again and become still greater toAvard the close of gestation. The nipples also become turgid and more prominent; the same in- creased activity already mentioned as apparent in the mammae in general is particularly evident in the nipples; their erectile tissue be- comes more permanently developed, as if in sympathy Avith the corre- sponding hypertrophy of the mucous coat of the uterus. The areola around the nipples becomes much darker. And in the centre of the areola, immediately surrounding the base of the nipple, may be seen quite a number of minute glands, from Avhich may be squeezed a serous, and in the advanced stages of pregnancy a sero- lactescent, liquid. These changes in the size of the nipples, in the color of the areola and in the development of the glandules make their appearance in the course of the third month. About the same time with these, blue veins begin to make their appearance over the surface of the bosom, from Avhich numerous branches are given off to the areola. In connection with these venous trunks may sometimes be seen certain shining silvery lines, linea cdbicantes; both the enlarged veins and the silvery streaks are more prominent in the breasts of primiparae. The change of the areola from the delicate pink tinge of the virgin to a more or less darker shade in the first pregnancy remains permanent thereafter, the color becoming darker at the accession of each subsequent pregnancy. But a more particular statement of the changes in the structure and ap- pearance of the mammae will be given when we come to study them in the chapter on the Diagnosis of Pregnancy. Generally speaking, these changes in the external form of the Avoman in pregnancy but partially disappear after parturition. Where the abdomen has been so greatly distended, certain folds or Avrinkles will still remain as consequences. So the hernia-like protrusion of the boAA^els along the median line below the umbilicus, Avhich has been mentioned as resulting from the separation of the fibres of the aponeurosis on that line, unless remedied by appropriate treatment, Avill tend to increase rather than to diminish. Neither does the dis- coloration of the areola ever entirely fade away; it always remains as evidence that pregnancy has existed; and yet not as of itself affording conclusiA^e eA'idence, for this discoloration may be the result of uterine irritation in Avomen Avho have never been enceinte, just as the breasts may enlarge from sympathy Avith enlargements of the uterus which are caused by the development of tumors or other morbid groAvths. THE DIAGNOSIS OF PREGNANCY. 109 CHAPTER VIII. THE DIAGNOSIS OF PREGNANCY. rnHE determination of pregnancy at the earliest possible period JL forms one of the most frequent, difficult and important problems in the practice of medicine. The physician will often be called upon to decide this question where strong feelings are aAvakened and great interests are at stake of the most opposite character. " The honor, and therefore the happiness, of a female may depend upon his decis- ion ; the peace of families may rest upon it, and the inheritance of property be controlled by it." For some to be enceinte is the grati- fication of their highest hopes and most ardent desires; by others it is regarded as a most serious inconvenience—as something to be dreaded on account of health, or, in the unmarried, as threatening a disgrace- ful exposure of their want of chastity. All these different states of mind and various social relations must always be considered in esti- mating the value of evidence for or against a supposed pregnancy, since those earnestly desirous of children Avill naturally magnify eA^ery new sensation, Avhile in some other cases there may be a disposition to suppress or overlook the signs of an actual pregnancy. " In all such eases the physician must remember that he may not merely be re- quested to investigate a case of doubtful pregnancy Avhere no shame is involved, but that he may be consulted in cases Avhere pregnancy is concealed by unmarried women, or by married Avomen under certain circumstances, to avoid disgrace, and on the other hand, Avhere it is pretended in order to secure an inheritance, to extort money or to delay punishment." And the very circumstances Avhich tend to ren- der the question more difficult to decide, at the same time seriously increase the responsibility attached to such decision. Hence, the physician can neATer be too cautious or too discreet in these matters, especially where the question relates to the unmarried; his acknoAV- ledging himself to have been mistaken Avill afford but a poor repara- tion for shocking the feelings and insulting the \rirtue of the pure- minded and the innocent. Such a blunder were Avorse than a crime, and its consequences might be irreparable as Avell for the physician himself as for his patient. The signs of pregnancy may be divided into two classes—those earliest observed, which are called rational or presumptive signs, and those subsequently appreciable, which are termed sensible or positive 110 THE DIAGNOSIS OF PREGNANCY. signs. From one or more of the first class a presumption of preg- nancy may arise, and from all that the case affords in its early stages a rational conclusion may be draAvn; but this is not positive know- ledge: this can be derived from the positive or sensible sighs alone, and of all these there is but a single one that is entirely incapable of being mistaken, and that is the beating of the foetal heart. The signs of pregnancy increase in number and become accumulative in value as the case advances. Thus, the diagnosis Avhich in the first instance had been possible pregnancy becomes presumptive, probable, and, finally, certain or demonstrable pregnancy. We will study, therefore, these signs as they arise in order of succession, proceeding from the rational to the sensible. Rational Signs are derived from the circumstantial history of the case, from the related experience and sensations of the Avoman, and from our own observations of such changes as may appear. Among these may be classed the general effects observed in the female econ- omy—such as greater rapidity of pulse and of respiration ; greater activity of the circulation and secretions, especially those of the genital organs; greater sensibility of the nervous system. But from indica- tions so general as these no rational inference can be draAvn; they are only important Avhen taken in connection with other more particular signs. Suspension of the catamenia is generally the first indication which leads the Avoman in Avhom impregnation has been possible, to con- sider herself enceinte. But the importance of this symptom will very greatly depend upon the attendant circumstances: if the woman has been very regular, and if the cessation of the menses promptly occur after some particular sexual intercourse, the presumption of preg- nancy Avill be ATery strong indeed. But if she has always been very irregular, the mere fact of the menses failing to make their appearance at a particular monthly period will carry with it but little weight. Where the entire absence of the menses for two or three months occurs from no other assignable cause, and Avhere this suspension is attended with good health and appetite, and some perceptible increase in the size of the abdomen, the rational conclusion of pregnancy may be considered to be Avell founded. And yet even these circumstances are far from affording infallible evidences of pregnancy, since thev haAre been knoAvn to arise in this combination from other causes. In newly-married Avomen the catamenia are sometimes suspended from irritation of the sexual organs where no conception has taken place • and at the same time there may be an increase in the size of the THE DIAGNOSIS OF PREGNANCY. Ill abdomen and in the sensibility of the breasts; so that even this very strong combination of symptoms cannot be positively relied upon. The attendant circumstances must be borne in mind in other re- spects ; for Avhile conception may take place in women who have never apparently menstruated, so the catamenia may still continue even after conception and through all the months of utero-gestation. Cases have been recorded in which menstruation appeared only during pregnancy; but such cases are anomalous. Thus while the cessation of the menses, under favorable circumstances, becomes the first and one of the most important signs of pregnancy, it is by no means decisive, since on the one hand the catamenia may be suspended without preg- nancy, and on the other pregnancy may occur without the suspension of the catamenia. The general rule Avill be all the more valuable, if Ave constantly bear in mind the possibility of the exceptions Avhich, though far from being common, may occur in any given case. Morning sickness forms in very many women the next sign of pregnancy. As its name indicates, it is a morbid symptom, but on that account none the less valuable as a diagnostic sign. It arises from sympathy of the cceliac or solar plexus with the organic nervous system of the uterus. This morbid irritability may commence im- mediately after conception, but it generally sets in about the fifth or sixth Aveek, and ceases soon after the third month. It may become in individuals a positive indication of their being pregnant, since these persons learn by experience that these symptoms occur with certainty and regularity at a particular time after conception. Thus in different persons the presence or absence of morning sickness "will have a very different diagnostic value. In those who have had it in former pregnancies, its non-appearance will be tolerably conclusive evidence against the existence of pregnancy; while in primiparae its non-appearance Avould scarcely be considered worth noticing as an evidence that they were not enceinte. Still, where morning sickness makes its appearance persistently attended by suppression of the cata- menia, and in circumstances where there is a liability to impregnation, it can scarcely be attributed to any other more probable cause than pregnancy. And this indication will be strengthened by the character of the sickness itself. The appetite improves and is good through the day, in spite of the nausea, vomiting of a peculiar watery fluid and sinking at the pit of the stomach, which occur and continue for a short time only on first rising in the morning. The sickness and the fluids Aromited up are different from those accompanying any other disorder, such as gastric or bilious fevers, for example. While morn- 112 THE DIAGNOSIS OF PREGNANCY. ing sickness, from its peculiar character, brief daily appearance, usual temporary continuance and final sudden and perhaps unexpected dis- appearance, becomes, Avhere it occurs, a valuable indication of preg- nancy, its absence is hardly to be regarded as a negative sign, as functional or organic disturbances of the uterus apart from pregnancy may occasion it, and it sometimes follows suppression of the monthly flux from other causes than conception. The morning sickness which exists during the earlier months of pregnancy is a physiological occur- rence, Avhereas that Avhich occurs during the latter months is due to mechanical causes. Certain other derangements of the digestive organs, such as eructa- tions, heartburn, remarkable longings for some particular article of food or other substances not used as food, and corresponding aversion to some one or more of the common varieties of food, which occur separately or in connection with morning sickness, or even subse- quently to it, may also be regarded as among the rational signs of pregnancy. The same may be said of salivation, which occurs in some Avomen about the fourth or sixth Aveek; in such cases the frequent spitting will be equally diagnostic Avhether the quantity be large or small. This salivation, differing from that which results from mercurial influences by the absence of the fetid breath, sore gums, and great prostration, becomes truly characteristic of pregnancy, just as the morning sickness above described does, by reason of its being a sympathetic rather than a primary and idiopathic affection. Spitting of " feathers" or " fippenny bits" is with some Avomen a marked signal of the existence of pregnancy, and with such women is of course of greater diagnostic \ralue than with others. There is in some cases an irresistible impulse to spit at any time and under any circumstances when pregnancy is advancing. The abdomen, by its changes in size and form, affords some rational signs of pregnancy even in the early stages. The enlargement of the abdomen may indeed occur from many other causes; but no other cause can simulate the shape and manner of development of the enlargement of pregnancy. A careful study of all the successive appearances of the abdomen in pregnancy will therefore enable the practitioner to estimate at their proper value the changes Avhich may present in any given case. Sometimes even in the first month the abdomen will seem larger than it does in the second, which arises from the co-operation of two distinct causes. First the abdomen seems larger because it is rendered tympanitic by the reflex influence THE DIAGNOSIS OF PREGNANCY. 113 of the newly-begun pregnancy itself. After three or four weeks this tympanitic condition passes off, and the abdomen loses its apparent increase in size. In cases in which this tympanitic condition has disappeared, as well as in those in Avhich it had not occurred, the abdomen becomes flattened. This flattening of the abdomen is usually •attended Avith a draAving inAvard and doAvnAvard of the umbilicus. These appearances, the very opposite to what might naturally be expected, are due to the sinking of the uterus a little loAver down in the pelvis, as described in the preceding chapter. And in connection Avith these changes there may be more frequent calls to urinate. But after the second month the uterus begins to rise Avithin the cavity of the pelvis, and the abdomen soon recovers from this depressed condition. About the third month the abdomen is seen to be visibly enlarged, and the enlargement steadily goes on till toward the close of pregnancy, the uterus still continuing to ascend Avithin the pelvis. After the third, fourth or fourth and a half month, according to the capacity of the pelvis to give it room, it rises above the superior strait, either suddenly or gradually, according as it has been more or less impacted in the pelvis. This rising out of the cavity of the pelvis into the abdominal cavity constitutes what is called quickening, and sometimes it occurs so sud- denly as to quite alarm the mother. It was at one time erroneously supposed that no life Avas present in the foetus till the occurrence of quickening, but it is now Avell known that at the very earliest mo- ment of conception a living human soul is there. Motion probably takes place at a much earlier period than it is perceptible to the mother, but it is not usually sensibly recognized till the uterus has finally risen from the smaller into the larger or abdominal pelvis. Usually after the beginning of the third month the enlargement begins to show itself just above and behind the symphysis pubis, being ahvays more considerable on the median line. After the commencement of the fourth month, if the woman be not too corpulent, by placing her upon her back with her thighs flexed upon the abdomen, the enlarged uterus can be felt like a half moon rising behind the symphysis pubis; and this ascent of the uterus goes on regularly, and usually at the rate of about tAvo fingers' breadth per month, until Avithin two weeks of the full term. But this enlargement is not always so regular in its development, since it may be varied by dropsical accumulations, multiple pregnancies, a greater or less projection of the spinal column, breadth of the pelvis or other individual peculiarities. An important means of distinguishing the enlargement of the abdo- 8 114 THE DIAGNOSIS OF PREGNANCY. men Avhich results from pregnancy from that caused by dropsies, tumors or other morbid conditions, will be found in observing the manner in Avhich this enlargement is developed, very nearly on the median line and always proceeding from below upward. Just above the symphysis pubis the tumefaction begins to show itself, at first being more considerable on the median line than elseAvhere; the sides' are flattened and the middle portion projects considerably. And the constant, steady and uniform enlargement of the abdomen, in the manner just described, and under favorable attendant circumstances as to health, appetite, etc., affords substantial ground for a conclusion in favor of the existence of pregnancy. The umbilicus also affords some indications of A^alue among the rational signs of pregnancy, since the changes which occur here are almost ahvays present and can ahvays be obserA^ed. During the first two months of pregnancy the depression of the umbilicus is greater than usual, OAving to the descent of the uterus into the pehTis and to its dragging doAvn the fundus of the bladder, by Avhich tension is made upon the urachus. This umbilical depression continues and gradually increases during the continuance of the descent of the uterus, and during this period the woman may be seen to walk stooping, in order to relieve the dragging sensation experienced by this strain upon the umbilicus. This descent of the uterus upon the bladder occasions frequent micturition, and the dragging upon the urachus sometimes gives rise to a distressing pain at the umbilicus, Avhich disappears, together with the too frequent urination, when the uterus commences its ascent. As soon as this sinking doAvnAvard is arrested, and the uterus begins to rise again, the umbilicus is gradually restored to its normal condition. It next begins to lose its depression, groAving decidedly superficial during the fifth and sixth months, becoming entirely flattened out in the seventh month and on a level Avith the surrounding integuments, and during the last two months the umbili- cus really pouts or protrudes beyond the general surface of the abdo- men. This course of changes in the umbilicus during pregnancy is the general rule; there may be some deviations, but usually the phenomena afforded by the umbilicus are regular and of great value. Tumors or ascites may cause appearances someAvhat similar, but these do not arise in the same regular order of time. When the three suc- cessive and Avell-defined stages of umbilical depression, restoration and projection occur as above described, they constitute a rational sio-n of pregnancy very easily observed and of very great value. The mammce, about two months after conception, begin to afford THE DIAGNOSIS OF PREGNANCY. 110 indications of much ATalue. Although from various causes some of these indications, except in primiparous Avomen, are less reliable in the early stages than many others, still, taken in connection with other signs, they cannot but haAre some Aveight. As described by Tyler Smith, these indications consist in a certain sense of fullness and Aveight and shooting pains in the breast; subsequently the circu- lation becomes more active, and there is an actual increase of volume; the gland becomes hard, knotty and tender to the touch, and large blue veins may be seen meandering over its surface just beneath the integument. About the end of the second month the nipple SAvells, becomes more erectile, sensitive and projecting; its color is also deeper. The surrounding skin assumes an emphysematous appear- ance, and becomes also a little darker. By the end of the fourth month a dark-broAvn areola is seen to surround the nipple in every direction, at a distance of three-quarters of an inch from its base. In blondes, or in feeble, delicate women, this appearance is not so well marked as in those Avho have black hair and eyes and in brunettes. "As pregnancy advances, especially if it be a first pregnancy, the de- posit of pigment in the areolae increases, the areolae themselves become moister, and the follicles studding their surface are prominent, dis- tended and bedeAved Avith transuded fluid. These follicles or little glandules which appear near the base of the nipple Avithin the areola attain an eleA^ation of one or two lines aboAre the surface of the skin. Each little gland has an excretory duct, and by pressing upon its base a little serous or sero-lactescent fluid is made to escape. In several instances I have seen this fluid flow in considerable quantities during lactation." Sometimes these glandules become very sore, Avhen Calendula Avill effect a speedy cure. About the fifth month a sort of shadoAV of the first areola makes its appearance outside the first, very pale, although quite similar to the first; and outside of these again, somewhat later, or about the seventh month, are often seen dark veins running across the breasts in various directions. Minute streaks, glistening like silver threads, are also observed running near these darker vessels. These appearances of the mammae, occurring in regular order, par- ticularly when taken in connection Avith other rational signs, afford almost conclusive evidence of the existence of pregnancy. But it should be borne in mind that the discoloration of the areolae, from never entirely disappearing when it has once taken place, is of little value as a sign of pregnancy except in primiparae, and also that both the enlargement of the mammae and the discoloration of the areolae 116 THE DIAGNOSIS OF PREGNANCY. may be occasioned by distension of the uterus from other causes than pregnancy. Quickening, Avhere it can be distinctly recognized, becomes of course a conclusive evidence of pregnancy; but it cannot be thus posi- tiA^ely determined except in those Avhose previous experience leads them to interpret aright the sensations which compose it. The term was originally applied to the supposed period at Avhich the foetus in utero first became possessed of the living principle, or Avas united to its physical soul, Avhich " quickening" of the foetus Avas believed to be the cause of the changes and unusual sensations experienced by the mother at that time; but not only is it true that from the moment of conception the embyro is " a living soul," but equally a fact that it may move within a feAV hours after the conception has taken place. It is curious to note hoAV the advance in physical science is equaled by that in psychical knoAvledge—hoAV physiology and psychology go hand in hand. Thirty years ago Davis wrote, in this connection, " It is now well knoAvn that the foetus in utero possesses some of the most important attributes of life from the earliest pulsations of the first speck of organization called the punctum saliens." By quickening, therefore, we merely understand those sensations which indicate the escape of the gravid uterus from the pelvic into the abdominal caATity. It is not the result, as formerly supposed, of movements of the foetus itself, but rather of the intrusion of the uterus itself among the other organs of the abdomen, and perhaps of the removal of the pressure hitherto exerted by the uterus upon the large vessels in the pelvis. " The sudden intrusion of the volume of the uterus among the abdominal viscera, organs of high sensibility, accompanied by a sudden removal of pressure from the iliac vessels, is quite equal to the production of the sensation called quickening. The sensation is felt in the transit at the moment Avhen the uterus, upon quitting its residence in the pelvis, enters the abdominal cavity." —Davis. This sensation, AArhich occurs at various periods in Ararious Avomen, is to be distinguished from those arising from the actual movements of the foetus in utero, Avhich are only subsequently experi- enced. Quickening may occur as early as the tenth Aveek, or it may not be observed till the sixteenth, the eighteenth or even the twenti- eth Aveek; the average period is probably about the sixteenth week. Changes in the Urine. Much valuable time and a great amount of labor have been spent in attempting to render the alterations of the urine useful as a rational sign of pregnancy; and A\*hile, for reasons subsequently to be stated, Ave attach e\ren less importance to these THE DIAGNOSIS OF PREGNANCY. 117 changes in the urine than do the Allopathic Avriters, we will briefly describe them, folloAving principally the account given by the cele- brated Dr. Elisha Kent Kane.* These changes consist briefly in the formation of a gelatino-albu- minous product in the urine of pregnant females subsequent to the first month of gestation, which is separated from the other elements of that fluid by rest alone, and to Avhich is given the name of Kiesteine. This consists of certain globules held in suspension in the urine Avhen secreted, and which rise to the surface and there form a pellicle which resembles in appearance the thin scum of fatty substance covering soup as it cools. When thick this pellicle is said to give off a strong cheesy odor. This pellicle usually makes its appearance upon the second day, or in the course of the third; though it is sometimes not observed till the urine has stood longer, even till the eighth day. The experiments of Dr. Kane and others prove that the Kiesteine is by no means peculiar to pregnancy, but that it has more especial rela- tion to lactation, either prospective or actually present; since it makes its appearance either where the milk is but imperfectly withdraAvn from the breasts, or in those cases in which, as in pregnancy, nature is pre- paring for the future function of lactation. Finally, Kiesteine can- not be regarded as an unerring diagnostic of pregnancy, since it may occur under other conditions of the system, and is not always observ- able where pregnancy actually exists; but its presence in the urine of an othenvise healthy woman is stated by Cazeaux to be an important rational sign. It remains noAV to state Avhy we attach little or no importance to this phenomenon as an indication of pregnancy in the homoeopathic practice; and this is from the fact that those changes of the urine Avhich ultimate in the formation of this peculiar pellicle, if not purely pathological, are at least but the consequences of the imperfectly per- formed physiological processes. These imperfections are also mani- fested in other more positive morbid symptoms, Avhich being cured by appropriate homoeopathic medication, the pellicle entirely fails to make its appearance. Still in cases of supposed pregnancy the experi- ment could easily be made as a matter of curiosity. Sensible Signs.—The sensible signs of pregnancy are observed through the medium of the senses of touch and hearing. By the touch Ave examine the condition and position of the uterus and its relations to the adjacent parts, externally, through the vagina, and, if necessary, through the rectum. By auscultation Ave ascertain the * See American Journal of the Medical Sciences, New Series, vol. iv., July, 1842. 118 THE DIAGNOSIS OF PREGNANCY. probable existence of pregnancy from hearing the bruit de souffle, or belloAVS murmur, and, at a little later period, its positive existence by detecting the pulsations of the fcetal heart. The term " towc/i" signifies the means wThereby knoAvledge is ob- tained of the condition of the woman as to health or disease, or whether she be pregnant or other Avise—by vaginal or anal examination Avith the finger, or by external examination Avith the hand, called palpa- tion. By vaginal touch we may be able to diagnose the stage of gestation, the stage of parturition, or Avhether the Avoman is in that state, the progress of labor, the presentation and position of the child; in fact all normal and abnormal conditions Avhich have ultimated themselves in material products. In order to be able to use the touch with certainty and advantage, the finger must be educated to recognize all the normal conditions, then it will be able to readily de- tect disease or any important change in material or structural mani- festations. The vaginal touch may be practiced Avith the woman standing, lying upon her back or upon either side. If she be standing the physician should place himself toAvard her left and upon his right knee, his left hand upon her abdomen exter- nally, and his right hand, the index finger being well lubricated Avith oil, should be carried under her clothes and directly between her limbs, —great care being taken not to touch her skin—the back of the hand upAvard, Avith all but the index finger closed. The index finger should be slightly flexed, and if carried directly between the limbs Avithout shocking her by touching the skin, the back of the finger will come directly in contact with the hairy portion of the vulva; now press Avith a little firmness and straighten the finger and its point Avill pass directly into the vagina. Noav drop the A\-rist and pass the finger upAvard and forAvard and it Avill exactly trace the canal of the vaoina, and by rotating the hand on the Avrist the interior cavity of the smaller pelvis can be explored and all the abnormities and deviations in that vicinity may be noted. If the Avoman be lying upon her left side, with her thighs flexed upon her abdomen, Avhich is the most usual position for the exami- nation, the physician will sit at her back and use his right hand. In this case also the thumb and all the fingers should be closed except the index, Avhich should be Avell lubricated and slightly curved, as before directed. The hand should be carried to the parts Avith great care to avoid touching the bare skin unnecessarily. As the back of the finger comes in contact with the A^ulva, press firmly thouo-h care- fully, straighten the finger and its point at once enters the A'ao-ina. THE DIAGNOSIS OF PREGNANCY. 119 Let the finger now be carried backward and upward and the canal of the vagina Avill be traced, and by rotating the hand as before, all parts of the canal can be well examined. If the patient be lying upon her right side, the physician will seat himself at her back as before, but Avill touch with the finger of the left hand. Anointing the finger with lard or oil, not only facilitates its introduction into the vagina, but serves to protect it from any disease that the woman may have. The physician should accustom himself to examine Avith both hands; since it may be necessary sometimes to use the left hand from the peculiar condition of the patient herself, or from experiencing a tem- porary injury to his right. In like manner it may be desirable to examine both in the erect and in the horizontal position. In the earlier months the recumbent position, Avith the extremities flexed and separated, will give a greater degree of relaxation of the abdominal muscles and render the uterus more completely accessible. In the standing position, ballottement may be more readily accomplished. But in all doubtful or difficult cases, the Avoman should be examined in both positions. When about to be examined standing, the patient should be placed Avith her back against the wall, a chair should be placed at each side to support her hands, and the upper part of her body should be a little bent over and forward. When it becomes necessary to make an examination per vaginam, all the parts of the perineum, vulva, vagina and cavity of the pelvis should be carefully exjflored, in order to detect any existing abnor- mities or diagnostic indications. If the patient be a supposed primi- para, the condition of the vagina as constricted and presenting the evidences of increased activity of the circulation will be carefully noted. The position and direction of the os uteri will then be ascertained. If in the early Aveeks of pregnancy, the uterus may be found some- what settled doAvn in the pelvis, and the os looking toward the holloAV of the sacrum. Or the supposed greater advance in the pregnancy will prepare him to find the uterus in its usual position Avhen unim- pregnated, or still higher, above the superior strait. Thus, on the one hand, the indications given by the rational signs will be either confirmed or invalidated by these sensible evidences; and on the other, the rational signs and history of the case Avill direct the physical exploration. The impregnated uterus is heavier than in the ordinary state; and its loAver segment, at about the third month, will be found so distended as to occupy nearly the whole cavity of the lesser pelvis. 120 THE DIAGNOSIS OF PREGNANCY. Its mobility is Arery slight; when, if unimpregnated, it Avould be very movable in every direction and much easier to raise on the point of the finger. One of the surest of the sensible signs of pregnancy at this stage consists in the softening of the extreme point of the neck. The sensation is that of a sort of velvety softness, only deeper, beyond Avhich may be felt a certain hardness, as of a board. No other state than pregnancy can either produce or simulate this feeling of softness. And this softening, as well as a corresponding dilatability of the neck, increases from beloAV upward, from month to month, in almost exact proportion to the development of the pregnancy. Palpation is a means of obtaining knowledge of the condition of the womb by placing the hands upon the > abdomen externally; and this method is much pleasanter to the woman than the former, although not so satisfactory. If the abdominal integuments are not too thick and fleshy, by placing the patient upon her back, Avith her head raised and her thighs flexed, and pressing the points of the fingers gently downward and backAvard above the pubes, a hard, round tumor will be found on the median line rising out of the pelvis. This can be felt as early as the third month, if the walls of the abdomen are not too thick. In two or four weeks later the increase is much more strongly marked and the true state of the case more certainly an- nounced. We must bear in mihd that, as pregnancy advances, the tumor loses more and more of its hardness and becomes more and more elastic, like a cyst filled Avith Avater. Percussion is also useful in deciding as to the existence of pregnancy. In such cases the uterine tumor Avill invariably afford a dull sound, unless a mass of intestines should intervene, Avhile all around may be distinguished the usual clear abdominal resonance. But, in pursuing this method of examination, care must be taken not to confuse all the indications by percussing over a full bladder. Tumors of the abdomen or womb would also give a similar dullness on percussion ; but such tumors are irregular as to the time of their development. In doubtful cases, Avhere decided enlargement of the abdomen is present, the exploration per vaginam becomes of very great import- ance, since the softening of the os uteri and even of the loAver end of the neck does not occur from any other cause than pregnancy. By the end of the sixth week this softening can be detected, like a piece of velvet drawn OATer a table. But Avhere tumors occur in the abdominal cavity, unconnected with pregnancy, they may be more easily detected by simultaneous palpation and vaginal touch. This THE DIAGNOSIS OF PREGNANCY. 121 is accomplished with the finger applied to the cervix uteri, and the other hand placed upon the abdomen externally, in order to find the fundus uteri. The finger may be brought in direct apposition with the lower portion of the uterus, Avhile the other hand presses down its upper portion, so that, Avith the exception of the abdominal walls, nothing but the uterus itself intervenes between the two hands. In this manner a judgment may be formed as to the size of the organ, as Avell as of its relations to the surrounding parts. And thus, any tumor Avhich may have occasioned the abdominal enlargement may be distinguished from the uterus. If unconnected with this organ, the tumor will remain stationary Avhen the uterus is moved; if it is attached to the uterus, moving the latter will, of course, be attended with corresponding movement of the former. And, in addition to any other tumor in the pelvis or rising above it, the actual size of the Avomb Avill also be ascertained, since the presence of any adven- titious groAvth in the pelvis, whether connected with the uterus or not, by no means precludes the possibility of pregnancy also. The greatest caution should be observed, as Avell in making the exami- nation as in giving a final opinion. It is not many years since the profession, in a certain city in New England, were greatly amused at the denouement of a case of uterine tumor in the wife of a Avell-knoAvn practitioner. The poor woman, Avho had sons groAvn up, and was supposed to have passed the change of life, during a course of several months endured all the severities of the most orthodox allopathic treatment at the hands of her anxious husband, assisted by a much older and more eminent practitioner than himself, in which injections of solution of nitrate of silver and large and frequent doses of the most powerful drugs performed an active part. The case advanced in spite of the treatment; and, the symptoms becoming more urgent, a third physician was called in consultation, who presently relieved the patient from her dangerous condition by delivering her of a full- grown child, Avhich had finally succumbed to the tours deforce of the latest injections. The patient had had no other disease than this tumor (pregnancy) ; but it required many months for her to recover from the effects of the protracted treatment she had undergone.* During: the first three or four months it is a difficult matter to de- termine the existence of pregnancy; up to this time the most certain * This statement is simple fact; the circumstances were well known at the time to the public, as well as to the profession, and are by no means forgotten now. The account is given here simply to show how men of the largest experience may not only be mistaken,but remain so. 122 THE DIAGNOSIS OF PREGNANCY. sign is the unmistakable softening of the cervix or os tincae. By taking into consideration, together, all the rational and sensible signs and the time of their appearance, Ave may in most cases be able to announce pretty confidently the existence of pregnancy by the third or fourth month, but not Avith absolute certainty. On the other hand, from being able to ascertain that the uterus still retains its natural size Ave can Avith much more positiA^eness determine that pregnancy does not exist in a given case. The uterus may, indeed, be enlarged or distended by some other cause than pregnancy; but if it is not found enlarged at what should be the third month, Ave may be sure there is no pregnancy. During the last five months the active and passive movements of the child reveal the fact of pregnancy Avith sufficient certainty. The active movements are felt by the Avoman at about four and a half months, sometimes earlier. In accordance Avith the strength of the child they are at first very slight and uncertain. We can easily imagine how delicate must be the sensations experienced by the woman from the motions of a foetus of four months, and trace them to the bounding and springing of a viable child of eight or nine months. It might be imagined that these sensations experienced by the mother would be quite infallible as indications of pregnancy. But other sen- sations, the result even of morbid changes in the abdomen, have been mistaken by women for those occasioned by a foetus in utero. In- stances are given by Avriters in Avhich the sensations produced by an incipient dropsy, in connection with the enlargement of the abdomen from the same cause, have been mistaken in this manner, to the seri- ous disappointment of all concerned. But the physician is not liable to such misinterpretation of sensations. By placing his open hand upon the abdomen the motions of the child may easily be perceived if the Avoman be pregnant, and these movements are unmistakable, since no pathological conditions can simulate them, although cases are recorded in which foetal movements Avere simulated by persons who had acquired complete control over the abdominal muscles. When from the inactivity of the child it becomes desirable to provoke its movement, this may be done by placing one hand upon one side of the abdomen and Avith the other hand gently striking the opposite side; the child will move quickly as if to get out of the way. By some Avomen the motions of the foetus are felt about the end of the third month, usually at about four months and a half. Some are conscious of these movements only after six, seven, or eight months, and some do not experience them at all. This, Avhich is OAving to the THE DIAGNOSIS OF PREGNANCY. 123 great passiveness of the child, is particularly apparent in Avomen of an inactive, sluggish temperament. After the motions have been dis- tinctly recognized for some days, if they then evidently become weaker and Aveaker, or entirely fail, the physician should at once understand that there is danger. All the mother's symptoms should be at once sought out, for some condition threatens the destruction of the life of the child. The proper remedy will remove this abnormal condition of the mother and restore the motions of the child. In plethoric women aconite will often do this, but we must be guided here, as else- Avhere, by the symptoms. The passive movement, or ballottement, is obtained by the manipula- tions of the examiner. The foetus swimming in the amniotic fluid is nearly of the same specific gravity; being a little heavier, it just swims in the fluid, touching the loAver internal surface of the amnion at inter- vals. Consequently, if Ave suddenly press upon the most dependent portion of the uterus, and then retain the finger steadily at that point, the foetus, having been forced to rise in the fluid by the sudden pres- sure, Avill soon return, and its Aveight will be felt as it again strikes the finger of the operator. The proper method of performing this operation by the vaginal touch is to place the woman either in the sitting or the erect posture, then Avith the finger upon the Avail of the uterus, either in front or behind the cenrix, curve the finger suddenly upward and forAvard, hold it there for a moment, Avhen the foetus, having been displaced and made to rise in the fluid, will rebound and impinge upon the finger Avhich displaced it. There results an unmis- takable dowiiAArard shock, and a sensation upon the finger Avhich no other condition of the Avoman can possibly produce. The same ex- periment Avith a stone in the bladder might seem to simulate this, but the sharp, strong bloAV which would be giA^en by a stone would con- vey a very different impression from that of the gentle, momentary touch of the foetus rebounding in the amniotic fluid. The accoucheur should be careful, in the effort to detect ballotte- ment, to press from below upward, and at the same time from behind forward. Pressure simply from beloAv upAvard may not be sufficient to cause the desired momentary ascent of the foetus, and the experi- ment may therefore fail. The force exerted upon the floating foetus in utero should be in the direction, as nearly as possible, of the axis of the uterine cavity. The same ballottement sensation may also be obtained by placing the woman upon her side, Avith the palmar surface of all the fingers applied to the most dependent part of the abdomen, forcibly flex them against 124 THE DIAGNOSIS OF PREGNANCY. the abdomen and hold them there; the foetus, thus suddenly displaced, will rebound from the upper side of the uterine cavity, where its movement may be felt against the other hand there applied, and settle doAvn again upon the fingers with a certain gentle, subdued, unmis- takable shock. The most favorable time for obtaining this sign of pregnancy is at any time after the period of quickening and before the first of the ninth month, for then the child becomes too large to be easily displaced or to descend upon the finger. At six months and a half or seA^en months is the most satisfactory time for making this diagnostic experiment. Where, from the presence of the hymen or the partial obliteration of the vagina, the examination per vaginam is inexpedient or impossi- ble, it may be made through the rectum. But the unpleasantness of the operation to the physician, as Avell as to the woman herself, Avould preA'ent resort to the rectal examination, except in cases Avhere no other method was available, or Avhere there existed an urgent necessity for a positively correct diagnosis, and the conjunction of all other means failed to afford a satisfactory result. Auscultation as applied to pregnancy consists in listening for the beating of the foetal heart. If the stethoscope be applied to the abdo- men Avith care at any time after the period of quickening, the heart of the foetus may be heard to beat nearly twice as fast as that of the mother, Avith a sound faint indeed, and muffled, but still unmistakable. These pulsations generally become perceptible in the course of the fourth or fifth month, and they range from one hundred and thirty to one hundred and sixty per minute. They are sometimes faster and sometimes sloAver Avithout any assignable cause, apparently not in the least influenced by the changes in the pulse of the mother. The foetal pulsations Avill be most distinctly perceptible in that region of the abdomen Avhich corresponds to the dorsal surface of the foetus. They are more frequently heard over the left iliac fossa than over the right, less frequently on the median line above the symphysis pubis. There is ahvays a point over Avhich these sounds are most distinct, and they diminish in intensity as Ave recede from this point. In their intensity these pulsations vary Avith the age of the foetus, increasing in strength usually up to the full term. But the number of the pul- sations is very much the same from the period of their being first distinguished up to the full term, except in some anomalous cases. When in the progress of labor the membranes are ruptured, the escape of the liquor amnii, by bringing the ear still nearer the foetus, renders the beating of the heart more distinct. The pulsations be- THE DIAGNOSIS OF PREGNANCY. 125 come less regular as the labor advances, and they are more sIoav and feeble during the contractions. Hence it becomes evident that the health of the child must ahvays be more or less seriously compromised during difficult and protracted labors. When the dorsal surface of the foetus is toward the abdomen of the mother, the pulsations are more distinctly heard; but after the sixth month they may be heard in any position of the foetus. There are two distinct sounds observable in the beating of the foetal heart, corresponding to those of the adult heart—a first and a second sound, of Avhich the first is more distinct. In those cases where at first but a single sound is heard, the other may often be distinguished by examining in some different position. As a sign of pregnancy the beating of the fatal heart is conclusive, since no other conditions can produce a similar sound. Aneurisms or other abnormal pulsations of the mother must be synchronous Avith the pulse at the Avrist, which is ne\Ter the case with the pulsations of the fcetal heart. Double or tAvin pregnancies may be detected by hearing the pul- sations of the foetal heart at two distinct parts of the abdomen, the sound becoming more and more distinct as you approach each part; while at the same time there is a perceptible Avant of harmony between the two sounds. Still, the apparent absence of the sounds of two hearts does not preclude the possibility of a tAvin pregnancy, since one foetus may be so directly behind the other as to mask its sounds. The position of the foetus in the uterus can be determined to a limited extent only by auscultation. The pulsations heard most dis- tinctly on the left of the median line, Ioav doAvn, just above the horizontal ramus of the pubis, indicate the first position. When they are heard in the same situation on the right side, they indicate the second position. The sounds being heard on either side on a leA^el with or even above the umbilicus indicate a breech presentation. If there be any truth at all in the statement that Pulsatilla, by reason of its action upon the muscular fibres of the uterus, can produce a change in the position of the foetus from an unfavorable to a favorable one, then the ascertaining of the position of the foetus by means of the stethescope becomes a matter of moment in all cases of pregnancy, as touching the welfare of both mother and child during parturition. A careful study of the sounds of the foetal heart, both during the continuance of utero-gestation and at its period in labor, enables us to determine the health of the child. Thus, after the sixth month, when Ave have had sufficient evidence of the existence of pregnancy, 126 THE DIAGNOSIS OF PREGNANCY. the absence of the sound produced by the pulsations of the foetal heart, ascertained by repeated examinations made at different times, will prove the death of the foetus. And during labor, if after the rupture of the membranes the pulsations of the foetal heart become irregular, more and more feeble and more and more rapid, Avith irregularity of rhythm, absence of the second stroke, complete cessation of the beats during the pains and sloAvness of their return after these have ceased, the life of the child is evidently threatened by further delay, and the labor should be terminated as promptly as possible. Still, it should be remembered that just in proportion as from auscultation Ave have reason to conclude that the child is no longer living or viable, we should give our principal attention to the mother and govern our conduct by indications derived from her condition. For in many cases of protracted labor, in Avhich the pulsations can still be distinguished at the moment of birth, the child has already suffered so much that respiration cannot be established. While the positive evidence of the death of the foetus in utero Avhich may be afforded by auscultation, leaves us at liberty to resort to craniotomy under circumstances in Avhich it might not be justifiable if the child Avere still living. The bellows murmur, bruit de souffle, although capable of being distinguished before any of the other intra-uterine sounds, before the beating of the foetal heart can be heard, is here mentioned in the second place, since it possesses little or no diagnostic value. This sound may generally be heard as soon as the uterus has risen out of the pelvic cavity—that is, a little earlier than the sound of the fcetal heart can be made out. From the supposition that it was produced in the utero- placental circulation, it has been called the placental murmur. From being supposed by others to be produced by pressure of the developed uterus upon the iliac arteries and aorta, in the posterior plane of the abdomen, it has been termed the abdominal souffle. From being sup- posed to originate in the enlarged vessels Avhich ramify in the walls of the uterus, it has received from others the name of uterine souffle. The fact that this sound has been distinctly heard for a short time after delivery is conclusive against the placental theory. The double fact that this sound is heard as distinctly in the same position, Avhen the pressure of the gravid uterus must be supposed to be removed from the posterior abdominal arteries, and that it disappears under pressure made upon the anterior of the uterus directly toAvard the spine, proves no less conclusively that it is not caused by obstruction of or pressure upon the iliacs and the aorta. There remains only the hypothesis of the uterine sinuses; and here the following circumstances THE DIAGNOSIS OF PREGNANCY. 127 may be considered as decisive of the question : the bruit is# heard in the earlier part of the second moiety of utero-gestation, nearer the pubes, and it gradually ascends Avith the upAvard advance of the uterus; it is most distinctly heard in that portion of the uterus where its A^essels are largest; and finally it may be heard through an instrument (the metroscope of M. Nauche) applied to the cervix uteri, Avhen it cannot be distinguished by the ordinary abdominal examination. The bruit de souffle, uterine murmur, then, is produced in the walls of the uterus itself and is synchronous with the radial pulse. It can be heard in chlorotic Avomen in whom no pregnancy exists, in cases of fibrous tumor and vascular tumor of the uterus, and in males. As a sign of pregnancy its value is A^ery differently estimated by different authors, some giATing it much more importance than others do. It can only serve to render probable the existence of pregnancy, since it may exist independently of pregnancy and does not always accompany it. No proof of the life or death or position of the child can be obtained from the uterine murmur, nor whether the uterus contains one or more than one foetus. Where Ave are certain the woman has no disease, the bruit de souffle becomes of some importance as a sign of pregnancy. In auscultating the abdomen for the purpose of discovering the signs of pregnancy, it should be remembered that the uterine murmur may be first distinguished at about the fourth or fifth month, or at Avhatever time the uterus rises out of the pelvic cavity, and that the beating of the foetal heart may be discerned in the course of the fifth month, so that in most cases the examiner may expect to meet Avith both classes of sounds. The bruit de souffle, coming first in order of time, may senre to render pregnancy probable, Avhile the clearly dis- tinguished beating of the foetal heart not only renders absolutely cer- tain the presence of a living foetus, but affords some indications as to its position in the Avomb and its healthy condition. Auscultation in the earlier months of pregnancy can only be ac- complished by placing the woman upon her back; later she may lie on her side, sit, or be examined standing. It is always best to use the stethoscope, Avhich should be placed at once, first on the left side, low down, then in the same region on the right side if necessary. Thus by applying directly to the place where the pulsations are most usually to be found, Ave escape annoying the woman by searching at random. It is important for the physician to avoid stooping too much, Avhich in many cases will cause such a pressure of blood in his head as to prevent him from hearing at all. By using the stethoscope the exam- 128 THE DIAGNOSIS OF PREGNANCY. iuer Avill avoid all danger of confusing the uterine sounds by the fric- tion of his ear upon the abdomen, and at the same time relieve his patient from the close personal contact Avhich to many Avomen is a very serious annoyance. In cases in which the mother has already recognized the foetal movements, the stethoscope should be applied exactly opposite to the side where these are most distinctly felt. For the upper and lower extremities of the foetus which cause the " mo- tions" being folded upon the abdomen, and the pulsations of the fcetal heart being most distinctly perceived from the back, it Avill be evi- dent that if the motions are felt in the left side of the abdomen of the mother, the sounds of the fcetal heart will be plainest on the right side, and Arice versa. Before the fifth month, however, the pulsations are usually most plainly discernible on the median line, from the pubes to the umbilicus. In addition to the uterine murmur, or uterine souffle, as, it is more properly termed, and the beating of the fcetal heart, certain " sounds of the displacement of the foetus" have been distinguished by auscul- tation, and at a period even prior to the uterine murmur. These sounds consist of shocks, sometimes quick, like a light tap, and at other times more like a heavy plunge, and there are also friction- sounds Avhich are evidently produced by the gliding of the surface ' of the foetus over the inner surface of the uterus. Some have even believed they could distinguish the pulsations over the funis itself— in cases where the parietes of the abdomen were extremely thin. But both these classes of sounds, Avhile they possess at the least very little of practical diagnostic value, require for their successful discovery more protracted opportunities for auscultating the particular case, and greater skill and more extended experience in auscultation in general, than usually fall to the lot of the young physician, at least in private practice. Statement of the Principal Signs in Pregnancy, Showing the time and order of their appearance; condensed from Cazeaux. First and Second Months.—Suppression of the menses, usually from the first of conception, some exceptions, which however are less numerous in the later months. Morning sickness, nausea and vomit- ing, and other gastric disturbances, sometimes flattening of the hypo- gastric region, depression of the umbilical ring. Enlargement and tenderness of the breasts, increase in the size of the uterus. It slightly descends and becomes less movable. Third and Fourth Months.—ToAvard the close of the third THE DIAGNOSIS OF PREGNANCY. 129 month the fundus uteri rises to the level of the superior strait. About the end of the fourth month it reaches midway in the space between the umbilicus and the pubes. Vomiting and other gastric derange- ments. A small protuberance in the hypogastric region. By abdom- inal palpation a round tumor may be detected of the size of a child's head. Less depression of the umbilical cicatrix. Increased enlarge- ment of the breasts; the nipple appears more prominent and the areola slightly discolored, especially in primiparae. In the fourth month the cervix uteri appears elevated and directed backward and to the left side. The orifice of the os tincae is more softened; in multiparae it is patulous, admitting the finger; in primiparae it is closed and rounded. Kiesteine in the urine. Fifth and Sixth Months.—ToAvard the close of the fifth month the fundus uteri is one finger's breadth below the umbilicus, and the" same distance above at the end of the sixth month. The gastric dis- turbances generally disappear. The sensation of " quickening" may be experienced about the sixteenth or eighteenth week—that is, about the beginning or middle of the fifth month. Then the movements of the foetus itself begin to be noticed. The abdomen becomes still more enlarged. The umbilical depression is nearly effaced. The uterine murmur may be heard, and soon after the beating of the foetal heart may be distinguished. Ballottement may be detected. The discolora- tion of the areola becomes deeper. Kiesteine in the urine. The infe- rior half of the intra-vaginal portions of the cervix uteri is softened. In multiparae the finger can penetrate the cavity of the neck, which in primiparae remains closed at its orifice, though softened. Seventh and Eighth Months.—Increased size of the abdomen. The fundus uteri is four fingers' breadth above the umbilicus at the seventh month, and fi\Te or six at the eighth. Dilatation of the um- bilical ring, pouting of the navel. The movements of the foetus are more sensibly felt. The sounds of the foetal heart are more clearly distinguished. Ballottement, Avhich is easily detected in the seventh month, becomes somewhat more obscure in the eighth. The soften- ing of the cervix uteri extends above the vaginal insertion ; in primi- parae the cervix is ovoid and shortening; in multiparae it is conoidal, and so patulous as to admit the whole of the first phalanx of the finger, while at the upper portion of the neck it still remains closed. The mammary areolae become darker. The breasts become more fully developed, and there is a show of milk. Kiesteine still appears in the urine. Ninth Month.—First Fortnight.—The fundus uteri reaches the 9 130 development of the ovum. epigastric region and (on the right side) presses the inferior margin of the false ribs. Difficulty of respiration. The abdomen is still more enlarged, the skin is stretched and very tense. The fcetal move- ments are active. The sounds of the fcetal heart are heard. In primi- parae the cervix is softened and its external orifice slightly opened. In multiparae the finger may penetrate its entire cavity to the os inter- num, which remains closed. Ballottement indistinct. Second Fortnight.—The fundus uteri sinks down a little, in conse- quence of the body and neck becoming one and constituting the uterus one rotund cavity. Vomiting is less troublesome and the respiration easier. Walking becomes difficult. Frequent and sometimes ineffec- tual efforts to urinate. In multiparae the internal orifice is dilated, and the finger may reach the naked membranes. In primiparae the "entire cervix is expanded, the os externum remaining closed. Hem- orrhoids, varices and oedema of the lower limbs, and even of the vulva. CHAPTER IX. DEVELOPMENT OF THE OVUM. The Unimpregnated Ovum. THE ovary is principally composed of Graafian vesicles or follicles imbedded in areolar tissue and abundantly supplied Avith blood- vessels. Each vesicle contains a single ovule and consists of two membranes, the outer of which is in contact with the stroma of the ovary, while the inner tunic, or membrana granulosa, forms the im- mediate covering of the ovule and of the liquid in which it floats. For the ovule occupies but a very small part of the cavity of the Graafian vesicle, the remainder being filled with albuminous fluid, granules and oil globules, Avhich, from their greater gravity, support the ovule upon its surface near the upper portion of the vesicle. Here the ovule comes in close relation with the inner surface of the mem- brana granulosa, and at this point there is found collected upon the o\nile a zone of granules called the discus proligerus. The ovule is composed externally of an envelope, the vitelline mem- brane, sometimes called the zona pellucida, which after fecundation is known as the chorion; internally the ovule is composed of the vitellus, or yolk, a spherical, semi-solid mass, or granular, organized liquid. development of the ovum. 131 The ovule is very small, measuring from the two hundred and fortieth to the one hundred and twentieth of an inch in diameter. Within the vitellus, and situated almost immediately beneath the vitelline membrane, is found a clear, colorless, transparent yesicle of a rounded form, called the germinal vesicle. This may measure from the eight-hundredth to the five-hundredth part of an inch in diameter. Whether this vesicle is developed from the ovisac or exists before the ovisac is formed is a point not yet decided. Upon the surface of the germinal vesicle may be seen a dark spot, like a nucleus, called the germinal spot. While the rest of the contents of the vesicle is transparent, this is opaque; and its diameter may be stated to be not more than the two-hundredth or three-hundredth part of a line.* Such is a succinct description of the human ovum in its unimpreg- nated condition. But if we examine the same ovum some three weeks after it has become fecundated, we shall find it so wonderfully changed that, Avere it not for the fact that all the various steps and stages of this remarkable transformation may be traced in the development of the ova of fishes, of birds and of the lower orders of the mammalia, Ave might entirely fail of being able to recognize and prove the identity of the one Avith the other. In fact, as the human ovum corresponds with that of the chick, ovology may be conveniently studied compara- tively. By carefully breaking the egg of a chicken, it will be found that there exists a delicate transparent membrane Avhich contains the fluid parts of the egg, and which constitutes the vitelline membrane, while the yellow portion or yolk is the vitellus. Upon this may be observed a Avhitish vesicle—the germinal vesiele; and in the centre of this the dark germinal spot. The albuminous fluid surrounding the vitellus or yolk is similar in quality, though greater in quantity, to that found in the human ovum. The external tunic becomes the chorion, whose cellular surface is extended into a number of villous prolonga- tions, which form the channel through which the embryo is nourished by the fluids of the parent, until a more perfect communication is subsequently formed. The internal tunic, above described as the membrana granulosa, becomes separate and distinct from the outer one, and is called the amnion. Between these tAvo membranes now intervenes some considerable space, Avhich is occupied by an albumi- nous liquid, in the midst of which is situated the umbilical vesicle. * For a more complete elucidation of this interesting subject, see Dr. Arthur Farre's article on the " Uterus and its Appendages," and Dr. Allen Thomson's article on the "Ovum," in Vol. v., Cyclopaedia of Anatomy and Physiology. 132 development of the ovum. Within the amnion is found another fluid, the liquor amnii, in which is supported the ovum. In the ovule itself the germinal vesicle disappears, and a new cell, the embryo cell, arises in its place. And finally, the entire ovum, Avith its external covering, is enveloped by a double covering, the deciduous membrane, which is developed and reflected from the inner surface of the uterus. The manner of the escape of the unimpregnated ovule from the ovary has already been described, on page 73 of this work, to which reference is now to be made. The description of the manner in Avhich impregnation is effected will be found on page 80 et seq., Avhich see. The changes which occur in the uterus immediately after conception, and the attendant condition of the ovary and Fallopian tubes, have been recounted on pages 86 and 87 ; these should be carefully revieAved. It remains now to describe the changes that occur in the ovum from the first possible moment of observation after impregnation, to the full development of the new being at the period just preceding par- turition. No- change lias ever yet been observed immediately after fecunda- tion, until the escape of the ovule from the ovary into the abdominal extremity of the Fallopian tube. No ovule has yet been observed in the Fallopian tube still presenting either the germinal vesicle or the germinal spot. At what time exactly these features of the ovule become transformed has not yet transpired. But it is certain that the ovule, either while still remaining in the ovary or on its way out from it, gradually loses both the germinal vesicle and the germinal spot. It may be possible that the spot disappears first, the ATesicle subsequently; and it is certain that the space occupied by them becomes filled with granules. This single circumstance alone is sufficient to prove that conception must take place before the ovule enters the Fallopian tube, and that the ovules that have just caused the menstruation cannot be the same that are impregnated. The same circumstance also proves that there is one ovule for menstrua- tion and another for conception. The only change observable in the OA^um during its passage through the first half of the Fallopian tube is the thickening of the A/itelline membrane. During the passage of the ovum through the second por- tion of the. tube, the vitellus evidently becomes more consolidated; and in concurrence with this change a thin Avhite fluid escapes, entirely surrounds the vitellus, and fills the interval between the vitelline mem- brane and the vitellus, occasioned by the condensation of the latter. Other and very remarkable changes take place in the ovule as it development of the ovum. 133 descends through the second portion of the Fallopian tube. One of the more remarkable of these constitutes what is termed the segmen- tation of the vitellus, Avhich, Avith its immediate consequences, may be thus described. The vitelline membrane continues to thicken, and the vitellus becomes divided into two distinct spheres, each of which Fig. 26. Fig. 27. A, the layer of albumen; V, the vitelline membrane. Fig. 28. THE FECUNDATED OVUM AT A MORE ADVANCED STA/JE. A, the albuminous layer surrounding the vitelline membrane V, which is seen to be thickened, and to contain within its cavity the mulberry-like mass. is again divided into two others; these again into others, and so on, during the Avhole course of the descent into the uterus, each minute sphere dividing and subdividing until the ovum reaches the uterine cavity. The vitellus is thus completely dissipated, and what in the first instance Avas its exterior surface comes to resemble a mulberry- seed in its appearance; Avhile its cavity or interior is filled with a liquid containing an infinite number of minute granules. (This process of segmentation is illustrated in Figs. 26, 27 and 28.) These are termed vitelline spheres; they have a somewhat firmer con- sistency than the original substance of the vitellus, and this consist- ency appears to increase as they successively multiply in number and diminish in size. At last they become so abundant as to be closely crowded together, compressed into polygonal forms and flattened 134 development of the ovum. against the internal surface of the vitelline membrane. They have by this time become converted into true animal cells, Avhich, adhering together by their adjacent edges, form a continuous organized mem- brane, called the blastodermic membrane. This constitutes the germ- mass, or plastic material, out of which the entire organization of the foetus is gradually evolved. This blastodermic membrane is subsequently divisible into two dis- tinct layers, which are known as the external and the internal layers; and as the blastodermic membrane, as a Avhole, represents all the foetal organization in its totality, so these tAvo layers represent the com- mencement of all the particular organs of the foetus, and the subse- quent division of all these organs into two distinct classes—those of the vegetative life and those of the animal life respectiA7ely—finds its foundation in this pre-organic stage of organization. For the internal layer of the blastodermic membrane produces the intestinal canal and all the organs of vegetative life; while the external layer is developed into the spinal column and the organs of animal life* As nearly as can be determined, the time occupied by the human ovum in traversing the Fallopian tube is twelve days, and the move- ment is always much more rapid in the first than in the second half of its descent, when the nearer it approaches the uterus the slower it moves, probably on account of the increasing narroAvmess of the tube. The ovum is knoAvn to enlarge decidedly during its continuance in the tube, during which time the. product of conception must be nourished by the granules contained in its interior fluid. When the ovum ap- proaches the uterine cavity, we find in it simply the vitelline mem- brane much thickened and surrounded by a dense layer of albumen which it has collected in passing through the tube, and the vitellus containing some granulations remaining from the decomposition of the mulberry-like body. The vitelline granulations, as they disap- pear, give place to a perfectly Avhite, transparent liquid. In their disappearance these granulations seem to be condensed, and by ad- hering to one another they form a neAv vesicle which lines the first. This fact may be easily demonstrated by macerating the ovule in water, when the neAv vesicle will be thrown off by the water percolat- ing through the vitelline membrane, and be seen to lay corrugated in distinct folds in the above-mentioned transparent liquid. This neAV membrane, or vesicle, is called the blastodermic vesicle. Whilst this process is going on the albumen collects as above stated, becomes ab- sorbed and the vitelline membrane is much thinned. The ovule now for the first time begins to be fixed. development of the ovum. 135 In sixteen or seventeen days after fecundation a rounded, whitish speck is perceptible on some portions of the blastodermic vesicular Fig.. 29. THE OVULE SHORTLY AFTER ITS ARRIVAL IN THE WOMB. A, the diminished albuminous layer; V, the vitelline membrane; B, the blasto- dermic membrane. membrane, and really stands out in relief; this is called the embryonic spot. This embryonic spot is composed of granulations, like those of the blastodermic vesicle, only they are more numerous and more con- crete. It is very evident that the embryonic spot and the blastoder- mic membrane are each developed from processes of a double lamina; which may be separated by means of fine needles. Fig. 30 portrays the doubling of the blastoderm, the embryonic spot assuming an elon- gated form. Finally, the blastoderm exhibits a convex and a concave surface, as in Fig. 32. The concave surface is divided into tAvo dis- Fig. 30. Fig. 31. Fig. 30. The blastoderm with the embryonic spot seen in front; V, the vitelline membrane ; E, the external layer of the blastoderm; F, the embryonic spot. Fig. 31. The same figure in profile, to show the two layers of the blastoderm; V, the vitelline membrane; E, the external, and I, the internal or intestinal layer of the blastoderm. tinct portions, one embryonic, the other becoming the umbilical A7esi- cle. The tache embryonnaire becomes the embryo. The margin of the embryo exhibits a tendency to double over, leaving a cavity (as well as the extremities) of considerable depth. The extremity Avhich 136 DEVELOPMENT OF THE OVUM. is most fallen is called the cephalic, the other the caudal extremity. As the development of the embryo goes forward, numerous minute elevations appear scattered over the external surface of the ovum; these become the villosities which subsequently appear on the chorion. At the same time the external layer of the blastoderm is raised in Fig. 32. Fig. 33. E i Fig. 32. A section of a more developed ovum, in which the two portions, the em- bryonic and the umbilical vesicle, begin to appear; O, the umbilical vesicle ; I, the internal layer of the blastoderm ; E, the external layer; V, the vitelline membrane. Fig. 33. A section showing the origin and first traces of the amnios; O, the umbili- cal vesicle; I, the intestinal, and E, the external layer of the blastoderm; V, the vitel- line membrane; C C, origin of the cephalic and caudal amniotic hoods. folds around the central or embryonic portion. (See Fig. 33.) Figs. 34 to 37 exhibit the continuous approach of the embryo toAvard the cen- tre of the ovum, until the blastoderm has become united over the dor- sal surface of the embryo, their union absorbed, and the embryo sur- rounded by a complete fold of the external or serous surface of the blastoderm, which seems to be a continuation of that upon the abdo- men of the embryo. This fold gradually increases in size at both the cephalic and caudal extremities, and between these points to form, as it were, hood-shaped investments of the embryo. To these Cazeaux has given the name of amniotic hoods. The new membrane thus formed is called the amnion, and becomes distended and separated from the external surface of the embryo by the amniotic fluid. The external or serous lamina noAv forms a rins or membrane by itself, which surrounds the whole. This contains the liquid in which the embryo, with its amnios, swims, and which, as the foetus develops, is forced onward to join the vitelline mem- brane and chorion. Immediately after the formation of the amnios, the doubling in of the cephalic and caudal extremities increases and forms more and more the abdominal cavity of the embryo, and finally DEVELOPMENT OF THE OVUM. 137 a mere canal leading out of the abdominal cavity into a large vesicle, called the umbilical vesicle, and this canal, as it finally closes up, forms the umbilicus of the nine months' child. •Fig. 34. Fig. 35. THE AMNIOTIC HOODS MORE DEVELOPED. Fig. 34. O, the umbilical vesicle; I, the internal or intestinal, and E, the external layer of the blastoderm ; E/, a portion of the external layer converted into the am- nios ; E//, the embryo; C, the limit of the amniotic hoods; V, the vitelline membrane. Fig. 35. This figure shows the amnios almost completed, and likewise the origin of the allantois. 0, the umbilical vesicle; I, the intestines; E, the amnios ; W, the external layer of the blastoderm, or the non-vascular chorion; V, the vitelline mem- brane; C, the amniotic hoods ready to close up; A, the allantois. In the cuts 34, 35, 36, 37 blood-vessels may be seen running from the embryo into this vesicle and again returning, one artery from and two veins returning to the embryo; these are called the omphalo-me- senteric vessels. As this doubling of the embryo goes on (see Fig. 35), we find a slight elevation springing up at the spot Avhere the rectum and bladder are confounded in the earlier days of embryonic life, under the name of cloaca. This begins to take place about the time the em- bryo has nearly exhausted all the nourishment contained in the um- bilical A^esicle, and the embryo Avould inevitably perish at this stage from want of nourishment but for this wise provision of nature, by Avhich a connection is formed Avith the parent; for this little eleva- tion rapidly extends to the villi of the chorion, passing out from the abdominal canal alongside of the umbilical vesicle, and is called the allantois. The allantois is composed of two arteries and one vein, the arteries arising from the primitive iliacs, carrying arterial blood of the embryo, seeking a fountain for allaying its thirst for material wherewith to sustain the little being over which it presides; for the blood always contains all the material elements for upbuilding and for repairing tissue. 138 DEVELOPMENT OF THE OVUM. These arteries seem to compel the growth of the allantois, and Avith the accompanying vein plunge into and take root in the villous coat of the chorion, when the desired nourishment is found in the blood of Fig. 36. Fig. 37. Fig. 36. This figure sliows the rapid progress of the allantois, and how it spreads over the fetus, the umbilical vesicle and the amnios. This latter begins to unsheath the pedicle of the umbilical vesicle and that of the allantois in such a way as to form a commencement of the cord. According to some writers the vitelline membrane dis- appears more and more. O, the umbilical vesicle; W, the amnios; E", the external layer of the blastoderm; C, the point where the two hoods come in contact; V, the vitelline membrane almost entirely atrophied; A, the allantois. Fig. 37. in this figure the allantois has spread over the whole internal surface of the ovum, and but very slight traces are left of the continuity between the amnios and that part of the external layer of the blastoderm which formed the non-vascular chorion; the latter has a tendency to be confounded with the chorion, and the amnios encloses the umbilical cord more and more. O, the umbilical vesicle; E/, the am- nios ; C, the point where the two hoods are fused into each other and form but a single membrane; W, the external layer of the blastoderm; A, the allantois; V, the vitelline membrane. the mother. This is quickly carried back by the vein to the famish- ing embryo, and delivered through the liver, as will be seen farther on. In the subsequent pages, also, it will be shoAvn that the first circuit in the embryonic circulation constitutes the beginning of the placental mass to be afterAvard described. In some animals, and perhaps in the human female, the allantois in its development spreads out like an umbrella; but for all practical purposes it is sufficient to describe it as taking root in a single villus of the chorion, and spreading out more and more as more ample means of supply are demanded till the full time is accomplished. The closing up of the abdominal or umbilical canal brings the DEVELOPMENT OF THE OVUM. 139 amnios in close juxtaposition to the remaining minute stem of the um- bilical vesicle (as seen in Fig. 37), and as this canal closes up the amnios sheaths over the allantois and the small stem of the remain- ing umbilical vesicle, which vesicle is thereby forced out, and is found finally to be a little yellow body lying between the chorion and the amnion, next to the placental mass, and the allantois stem is found to be one and the same thing as the umbilical cord entirely sheathed over by the amnios. With this description of the development of the allantois concludes the principal parts of the ovum; which are therefore: 1, The em- bryo ; 2, the liquid in which it swims; 3, the amnios, filled Avith the liquor amnii, and forming a sheath over the umbilical A^essels ; 4, the umbilical vesicle with the omphalo-mesenteric vessels still to be seen communicating Avith the embryo; 5, the allantoid vesicle; 6, the space betAveen the amnios and the umbilical vesicle, filled Avith liquid; and 7, the chorion, the outer envelope over all. The Development of the Decidua.—The decidua, from first to last, is simply the mucous membrane of the uterus hypertrophied by the influence of conception and gestation. This hypertrophied develop- ment, Avhich constitutes the deciduous characteristic, as previously stated, has already commenced Avhen the impregnated ovule is about to make its escape from the ovary; so that upon its arriAral in the cavity of the uterus, the ovule finds a soft, velvety bed in readiness to receive it. And as the mucous membrane of the uterus is con- tinuous Avith that of the Fallopian tube, so in cases of extra-uterine fcetation, the deciduous development has sometimes, although not ahvays, been found in the uterus; and in one case of development of the ovum in the Fallopian tube, referred to by Miiller, the decidua was observed both in the uterus and in the tube. Into the vegetative bed above described the ovule becomes fixed by the villi of the Aatelline membrane (which becomes the chorion) taking root and growing into it in every direction. The decidua at the same time grows up all around the ovum, which latter thus be- comes implanted in a living cyst, attached to one portion of the Avail of the uterus, usually that of the fundus. When thus encysted the ovum is not only completely covered by the mucous membrane, but by means of the villi of its own membrane, the chorion, it becomes attached to the decidua, growing into it Avhenever they thus come in contact. In the earlier months of embryonic development the decidua is formed of two 'apparently distinct layers, the one being in approxi- 140 development of the ovum. mation Avith the internal uterine surface, and the other enveloping the embryo. The uterine layer has been called the decidua vera, or parietal decidua, Avhile the embryonic layer has been termed the decidua refiexa. The decidua vera presents upon its external surface a rough or shaggy appearance, Avith numerous projecting filaments, Avhich are doubtless due to the separation of the decidua from the proper tissue of the uterus and the remains of uterine glands. The internal surface of this layer, hoAvever, is smooth and shining, and eleArated, according to Dr. Arthur Farre, into numerous projections which may be roughly compared to the convolutions of the cerebrum. It contains numerous minute apertures Avhich are continuous Avith similar apertures on the outer surface of this layer. The inner layer, or decidua refiexa, Avhich invests the embryo, is, so far as histological elements are concerned, composed of the same material as the decidua vera, and it is, indeed, but a part of the same structure. It received the name decidua refiexa from Dr. William Hunter, Avho believed that it was formed by the ovum in its passage into the uterus from the orifice of the Fallopian tube thrusting it before it away from the uterine wall and enveloping itself, so to speak, in it as a covering; in a manner similar to the investiture of the heart by the pericardium. This view of Hunter's has been combated by other investigators, but the mode of formation of the decidua refiexa may be regarded as a question still in doubt. If the intimate structure of the decidua be examined at about the sixth week of embryonic life, it Avill be found to consist of large round and oval cells, nuclei, fat granules and elongated fibre-cells, the Avhole so bound up that if a portion of the membrane be spread out and examined with the microscope, " it is observed to be readily separable into irregular portions or fragments, with clear interspaces, very much, in fact, like a Aveb or netAvork formed by the superposi- tion of several layers of a cribriform membrane one upon another." (Meadows, " Manual of Midwifery," p. 69.) There can be but little doubt now that the opinion of William Hunter in regard to the formation of the decidua is correct—viz.: that it is " an efflorescence of the internal coat of the uterus itself. the internal membrane of the uterus." It assumes in the first in- stance the triangular shape of the cavity of the uterus, and although these are not constant, there are commonly three openings Avhich cor- respond with the orifices of the tAvo Fallopian tubes and the internal os of the cervix. At parturition it is thrown off, either as a whole or in part, as a useless appendage, and replaced by a new formation. DEVELOPMENT of the ovum. 141 The Further Development of the 0\rUM.—Having thus de- scribed the provision made for the primary reception and support of the ovum in the changes Avhich occur in the interior surface of the uterus, we Avill noAv proceed to the more particular examination of the further development of the ovum itself. We have briefly traced this development from the original ova to the production of the embryo, and noticed in a cursory manner the umbilical and allantoid vesicles, the amnios and the chorion. These appendages to the em- bryo, Avhich at the same time protect it and administer to its groAvth, require noAv to be more particularly considered. The allantois, as before partially described, is usually observed to arise as a minute tubercle from the inferior portion of the canal about the tenth day; it then rapidly shoots forward and takes root in the villi of the chorion. This organ is also called the urachus, and is accompanied by, or rather principally composed of, two arteries pro- ceeding from the iliacs and called the umbilical arteries, and one vein. The allantoid vesicle, as such, disappears very rapidly; after a feAV days no trace of it can be found, excepting a cord of no definite length which connects the embryo with the chorion and contains the um- bilical vessels. That portion of this vesicle which is contained Avithin the abdomen of the child is, hoAvever, more persistent in its duration, becomes converted into the urinary bladder, and in the rudimentary state terminates in the rectum and constitutes the temporary cloaca; all of Avhich is capable of demonstration in the human subject. It is here easy to understand what is meant by the urachus, Avhich is really that portion of the allantois which extends from the bladder to the umbilicus; hence anything that is capable of causing descent of the uterus must drag on the bladder from this attachment, and thus re- sults the dragging sensation felt in the umbilicus in such cases from the attachment of the urachus to that part of the body. The umbilical vesicle, Avhen first seen, seems to occupy the Avhole of the cavity of the ovum. Subsequently the embryo is seen on the blastoderm, its back corresponding to the serous external surface, and its abdomen to the mucous or interior surface, of the blastodermic membrane. Thus, at this early period the abdomen is open to the entire umbilical Aresicle. As development goes on the embryo seems to rise more and more toAvard the umbilical vesicle, and to be devel- oped forward and imvard upon the abdomen. In consequence this vesicle loses more and more of its bulk, and assumes the appearance of a long narrow stem. This vesicle contains a yelloAvish and highly nutritious fluid, which, through the intervention of a vascular appa- 142 DEVELOPMENT OF THE OVUM. ratus, seiwes to nourish the embryo until it can provide for itself by other means. This vascular apparatus is supplied Avith two trunks for the transmission of blood—one venous, the other arterial; both, Iioav- ever, accompany the pedicle and form an important constituent part of it. (See large figure on plate facing 143.) " The first, N, called the omphalo-mesenteric vein, enters the abdomen, Avinds around the duode- num, and then opens into the umbilical vein at the point O, just as the latter emerges from the liver. As it passes the duodenum, branches are given off to the stomach and intestines, and when it discharges into the umbilical vein it sends a voluminous trunk to the liver. That portion Avhich furnishes the branches just described persists in the adult under the name of ventral or hepatic-portal vein, Avhilst all the rest Avill disappear Avith the umbilical vesicle and its pedicle. The arterial trunk, P, accompanying the pedicle, has been designated as the omphalo-mesenteric artery. Arising from the aorta, it gains the summit of the intestinal convolution, and gives off branches to the mesentery and to the intestine itself; then it reaches the pedicle and folloAvs the latter to the umbilical vesicle, upon Avhich it ultimately ramifies. The part that supplies the mesentery is converted in the adult into a mesenteric artery, all the rest being effaced. From all which it appears that the Avascular system of the umbilical vesicle rep- resents the primitive circulation in the embryo, corresponding in it to the sanguiferous apparatus of the yolk of fowls."—Cazeaux. The amnion, as before stated, becomes developed by the embryo rising into the umbilical vesicle, thereby completely developing the blastoderm about itself; Avhen the doubled parts unite the bridge unit- ing this neAv ring Avith the former becomes absorbed, leaving tAvo dis- tinct circles formed out of one—the former being the chorion, the latter the amnion. Now, as the amnion becomes distended more and more Avith liquor amnii, of course the umbilical vesicle becomes en- croached upon and grows smaller and smaller; at the same time the abdomen of the embryo curves up more and more, and the pedicle of the umbilical vesicle becomes longer and smaller, being now found on the outside of the amnion, between it and the chorion. At the end of six Aveeks after conception this is seen to be a small yelloAvish point about as large as a coriander seed. The umbilical vesicle is of vital importance to the embryo until after the formation of the allan- tois and its union Avith the villi of the chorion; after which it is no longer of any particular account, and with the exception of the above- mentioned remnant of its artery and vein it becomes entirely atro- phied. '^«—,4-' _• ^* * A- ■ "A. K O M S P EXPLANATION OF THE FIGURES IN PLATE OPPOSITE. No. 1, the human ovum, of its natural size, at about the thirtieth or thirty-sixth day. No. 2, the same ovum, of its natural size, laid open to show its constituent parts. A, A, the chorion ; B, the amnion ; C, the foetus ; D, the umbilical vesicle. No. 3, the same ovum highly magnified and opened in such a way as to exhibit the principal relations existing between the embryo and its appendages. The walls of the abdomen and chest have been cut away so as to bring the viscera into view, and the umbilical cord has also been split up for the purpose of showing how the ap- pendages of the foetus are brought into relation with this latter. A, A, the chorion, consisting of two layers, placed back to back, and confounded with each other, but which have been dissected apart for a limited extent at A' A7. B, B, the amnion laid open so as to show how it is continuous with the umbilical cord, along which it is reflected, thereby forming a sheath which, under the form of the canal B'' W, is directly continuous with the umbilicus or the umbilical walls C C of the embryo. D, the umbilical vesicle, and D', its pedicle. D//, the point where this pedicle communicates with the intestine E. E, the loop of the intestine prolonged into the cord. F, the urachus, continuous by one extremity, g, with the chorion, and by the other with the rectum at the point H. ii, the umbilical arteries. j, the umbilical vein. j', the part of the right auricle from which the umbilical vein comes off. K, the vena cava inferior. M, the inferior surface of the liver. N, the omphalo-mesenteric vein. 0, the point where this vein empties into the umbilical vein. P, the omphalo-mesenteric artery. 1, the heart; 2, the arch of the aorta; 3, the pulmonary artery; 4, the lung of the right side; 5, the Wolffian body; 6, the branchial fissure which is converted into the external ear; 7, the lower jaw; 8, the upper jaw; 9, the nostril of the right side; 10, the nasal canal still forming a kind of fissure, which extends from the eye to the nostril; 11, the caudal extremity, or coccyx, projecting like a tail; 12, the upper extremity; 13, the lower extremity. 143 144 DEVELOPMENT of THE OVUM. The amnion is thus seen to be the most internal membrane of the embryo, and that it is formed by folding the blastoderm over the em- bryo in every direction, which latter is accomplished apparently by the rising of the embryo toward the centre of the umbilical vesicle. When the folding over is complete, and both portions have grown together so as to form a complete shut sac around the embryo, then we have the amnion containing the embryo, the umbilical vesicle, and a quantity of fluid, thick and gelatinous, between the amnion and the chorion, Avhich becomes less and less as the amnion itself becomes dis- tended Avith its OAvn proper fluid. This fluid sometimes exists up to the period of parturition, and is called spurious liquor amnii, or liquor allantoidis. Its escape at an early period of labor gives rise to the opinion, sometimes, that the membranes have ruptured. The amnion consists, structurally, of a fibrous membrane, covered Avith a layer of oval nucleated epithelial cells, but contains neither vessels nor nerves. Its inner surface resembles a serous membrane, and in the opinion of many authors it secretes the liquor amnii ; its outer surface presents a rough and reticulate appearance. The doctrine, however, that the amniotic fluid is a secretion from the surface of the amnion appears to be a mistake, since this liquid is most likely an efflux from the em- bryo itself. From the moment of the complete formation of the am- nion as a shut sac, there is no longer any outlet for the escape of the efflux from the embryo; and that there must be such an efflux must be evident, since there are certain portions of the nourishment flowing into the embryo that are not entirely assimilated—some material car- ried thither from the mother, Avhich, although it has served the pur- pose for Avhich it had been imbibed, must be in part rejected in the form of sensible or insensible perspiration. In fact, there can be little doubt that there is enough of what we may call offal from the embryo and foetus to account for the quantity and quality of the liquid found Avithin the amniotic membrane. As the embryo develops and the liquor amnii increases, the amnion is forced to recede more and more from the foetus; of course it must eventually be forced to join the outer membrane or chorion, and thus form a covering to the umbilical cord all the Avay from the navel of the foetus to the outer membrane or chorion, into which its maternal end is inserted, and all the parts thus enclosed constitute Avhat is called the umbilical cord. Consequently the Avhole abdominal cavity must be in connection with the canal represented by this cord, that the fcetal appendages may communicate with it through the opening thus prepared for them. It is in this manner that the pedicle of the urn- DEVELOPMENT OF THE OVUM. 145 bilical vesicle becomes united to the ileo-csecal fold of the intestine, while the allantois connects with the rectum by the intervention of the urachus. The liquor amnii itself varies in appearance with the time at which it is examined. At the earliest period it is clear, transparent and limpid; at later periods it becomes thicker, more opaque, sometimes flaky, green, yellow, or of almost any other color, according to certain states of the foetus itself, which it demres from corresponding condi- tions of the mother. Its odor varies also; sometimes it is like that of spermatic fluid, with saline taste. The proportionate quantity of the liquor amnii also varies according to the time; in the earlier periods it is much greater than the weight of the foetus. At the middle of the term the relation may be about equal, and after that time the liquid lessens in proportion as the foetus increases; so that at full term the quantity of Avater is usually about a pound and a half, sometimes more and sometimes much less. Its specific gravity is somewhat above that of Avater, and it pre- sents an alkaline reaction. Careful examinations have shown that in addition to Avater it consists of a small quantity of albumen and gelatine, Avith traces of chloride of sodium, ammonia and phosphate of lime. The formation of the embryo involves the formation of the amnion as a matter of course, as a reservoir for the reception of effete matters from the foetus. The amnion also affords protection to the foetus by surrounding its body with an aqueous shield, impervious to bloAvs and shocks, since the embryo floats freely in its centre. The foetus, thus floating in the liquor amnii, is at liberty to accommodate itself to all the movements and varying positions of the mother, and to yield, Avith the least possible disturbance, to all the influences of her mental and moral states. The accoucheur finds in the ballottement practiced by the aid of this fluid an important diagnostic sign of pregnancy; and at the period of parturition is able to correct any malpositions with greater ease before than after the Avaters have been discharged. Again, it serves other useful purposes during labor, by diminishing and equalizing the pressure of the foetus upon the womb, and by distending the membrane into an elastic and conical plug or Avedge affords material assistance in the dilatation of the os uteri. The chorion lies next in order to the decidua, between it and the amnion. " The chorion begins to be formed in the Fallopian tubes as an albuminous layer enveloping the ovum; but as soon as it reaches the uterine cavity a number of small tubular projections, the chorion 10 146 DEVELOPMENT OF THE OVUM. villi, start from every point of its outer surface. At this time no vessels exist in it, but at about the second month the vascular sac of the allantois comes into contact with the inner surface of the chorion, forming its inner layer, or endochorion, and then capillary twigs are sent into the hollow villi; these now take on a rapid development; they become compound branching tufts, enclosing capillary vessels, which are brought into closer interdigitating communion with the capillaries ramifying in the decidual membrane. During the first three months of gestation every part of the chorion remains covered with villi, giving it the appearance, when placed in water, of a beauti- ful white shaggy or Avoolly membrane. After this time, however, a great number of the villi begin to disappear, so that a large portion of the external surface becomes smooth, except within the site of the placenta, where they increase enormously, becoming at the same time more convoluted, and constituting the foetal portion of that organ, their trunks helping to form the umbilical vessel." The Placenta, or After-birth.—In order to obtain a proper idea of the placenta, so named by Fallopius from its fancied resem- blance to a flattened cake, it is necessary to commence its description at the very commencement of its formation. It will be recollected that the allantois shoots from the embryo at a very early period of its existence, and very soon takes root in the villi of the chorion. Examination and experiments prove that this process is adapted to furnish nourishment to the embryo by means of arteries and one vein passing from the embryo to the mother and back. The arteries carry the impoverished arterial blood from the foetus toward the mother, seeking aeration and nourishment in the mother. The vein brings it back, purified and laden Avith all that the embryo needs for its growth and nourishment. In this first circuit there is made the beginning of the placenta, or the placenta itself so far. The next circuit adds to its size by the larger demand made by the increasing embryo; and so it goes on, constantly enlarging, circuit after circuit, until it has attained a full and sufficient size. The placental mass, at its full size, is about six inches in diameter, three-fourths of an inch thick in its centre, tapering to a thin edge at its circumference. In different persons the placenta will often be found to vary in form and size; but the above are about the average dimensions. The cord is usually attached in the centre, but it is sometimes found attached to one edge, constituting what is termed a battledore placenta. The placenta presents an internal or fcetal sur- face, and an external, maternal or uterine surface, and a border. At development of the ovum. 147 full term the internal surface is found covered by the chorion and the amnion. The foetal surface is smooth and shining, from being covered with the amnion—concave and transparent, showing the rami- fications of the blood-vessels of the cord most beautifully at full term. Immediately beneath the amnion is found the chorion, which enters largely into the formation of the placenta, giving it strength and transmitting the ramifications of the placental vessels. The maternal surface is convex, rough, and subdivided into a variable number of lobules, held together by an albuminous tissue, which is so easily torn off that it is very difficult to retain it in separating the placenta.. These lobules, or cotyledons, are the original villi of the chorion very much enlarged and compacted together, although even these are also very easily ruptured and separated into loose, disorganized masses. Fig. 38. Fig. 39. Fig. 38, the internal or foetal surface of the placenta. Fig. 39, the external or uterine surface of the placenta. The villi have been described as compacted together; this results from their having groAvn into the mucous membrane of the uterus, between that organ and the ovum. At the same time the mucous membrane has also gro\vn into the villi and the chorion; so that there is a mutual groAvth of one into the other, each supplying its own share in the formation of the placenta; the villi and their growth forming the foetal side, and the mucous membrane and its groAvth forming the maternal or uterine side of the placenta. Thus, in the very first circuit of the foetal blood in its vessels on the inner side of these villi, it becomes aerated and supplied with all things needful from the maternal blood on the outer side of these villi. In this way the process goes on, hour after hour, day after day, the demand and the supply alike increasing, till large quantities of blood are formed 148 DEVELOPMENT OF THE OA^UM. on each side; their banks, hoAvever, never breaking, while the foetal blood constantly communicates, but never commingles, Avith the ma- ternal blood. This is proved by injecting the vessels on the foetal side; not a particle, even of the finest material, is ever found to pass beyond the foetal side, while on the other hand it is found equally impossible to cause a particle of the finest injection to pass from the maternal to the foetal side. The foetal portion of the placenta, that to which the umbilical cord is attached, receives the branches of the tAvo umbilical arteries, each of which divides into two branches at the point of juncture with the placental surface, and these branches again divide and subdivide until the vessels are reduced considerably in size, and thus pass through the chorion and ramify within the substance of the foetal portion of the placenta. The blood is taken up by the venous radicles and returned by sixteen chief venous branches, Avhich folloAV the course of the main arterial subdivisions, and finally form the single umbilical vein of the cord. The maternal or uterine portion of the plagenta is divided into lobules or cotyledons as before described. Over these is spread a thin and pulpy membrane, the placental decidua, or decidua serotina, which dips down into the sulci of the cotyledons in a manner similar to the dipping doAvn of the pia mater into the sulci of the brain. In exam- ining a placenta cast off during parturition " numerous valve-like apertures are found upon all parts of its surface (uterine). They are the orifices of the veins which have been torn off from the uterus. A probe passed into any of these, after taking an oblique direction, enters at once into the placental substance ; small arteries, about half an inch in length, are also everywhere obsenred imbedded in this layer. After making se\^eral spiral turns they likewise suddenly open into the placenta. These are the uterine vessels Avhich carry the maternal blood to and from the interior of the placenta."—Dr. Arthur Farre. It will thus be seen that the placenta is coArered upon its maternal or uterine surface by a membrane (decidua serotina), and on its fcetal surface by another membrane (the amnion). These give firmness and consistence to the placental mass, and at the edge or circumference they unite and spread out to form the envelope of the foetus and liquor amnii. In regard to the manner in which nutriment is conveyed to the em- bryo through the maternal blood without a commingling of that fluid with the blood of the embryo, we quote the folloAving passage DEVELOPMENT OF THE OVUM. 149 from Dr. John Reid : " When the blood of the mother flows into the placenta through the curling arteries of the uterus, it passes into a large sac formed by the inner coat of the vascular system of the mother, which is intersected in many thousands of different directions by the placental tufts projecting into it like fringes, and pushing its thin walls before them in the form of sheaths, which closely envelop both the trunk and each indiAridual branch composing these tufts. From this sac the maternal blood is returned by the utero-placental veins, Avithout having been extravasated, or without having left her OAvn system of vessels. The blood of the mother contained in this placental sac, and the blood of the foetus contained in the umbilical vessels, can easily act and react upon each other through the spongy and cellular walls of the placental vessels and the thin sac ensheathing them, in the same manner as the blood in the branchial vessels of aquatic animals is acted upon by the water in which they float." Thus it Avill be percei\red that there is no direct vascular intercom- munication between the foetus and the mother, and hence all changes Avhich take place in the blood of the foetus, whether of depuration or of nutrition, must take place by endomosis. There is probably no nervous connection betAveen the foetus and the mother, since no nerves have been discoA^ered in either the placenta or the umbilical cord. The placenta is usually attached to the fundus of the uterus—more frequently to the left than to the right side—but it may be implanted upon any part of the interior uterine surface, and is sometimes found near to or even over the os itself. The umbilical cord, or funis, connects the foetus in utero Avith the placenta, and is the bond of union between the mother and her child. The product of a somewhat advanced state of development, it is not found in the early weeks of pregnancy. The umbilical cord takes its origin in the embryo, in the form of the allantoid vesicle. And as soon as this vesicle has taken root in the villi of the chorion, it is found to consist of tAvo arteries arising from the bifurcation of the abdominal aorta in the embryo, and of one accompanying vein Avhich arises from the vena cava ascendens and the hepatic portal vein. The arteries carry the embryonic blood away, to be replenished and nourished by that of the parent. This is accomplished through the medium of the placental A'illi, as above described. From them the blood is returned by the vein to the embryo; and thus is established the living connection of the foetus with the mother. As the abdomen of the foetus closes up with the advancing de- velopment, it is found that the stem of the allantoid vesicle and the 150 DEVELOPMENT OF THE OVUM. umbilical vesicle are embraced in one common sheath, the amnion. And when the abdomen fails to close up firmly and tightly around the cord, there remains what is called a congenital umbilical hernia, which continues till the child is perfectly formed. The urinary bladder is formed on the abdominal portion of the urachus or allan- toid vesicle. Hence it appears that the bladder is on a line AVith the cord; and Avhen the child has been separated from the mother and the fcetal circulation cut off, the two arteries arising from the bifurca- tion of the aorta are converted into suspensory ligaments of the bladder, which terminate in the umbilicus. The umbilical cord at full term differs very much in length iu different cases; it may be but a few inches, or even five or six feet in length, but it is usually from twenty-one to tAventy-three inches. The existence of nerves has not been demonstrated in the cord, but lymphatics have recently been discovered. Thus, as the waters of the amnion serve to protect the foetus as far as possible from external violence, by allowing it easily to float aAvay and evade any direct attack, so the entire absence of direct neiwous connection be- tween the foetus and the mother prevents the former from being too injuriously affected by any sudden mental emotion or moral ex- citement of the latter. The child must indeed be poAverfully affected in such cases, but through the circulation only; and thus not so rapidly or so violently as if there were direct nervous communication. Fig. 40. An anomaly, described by Benckiser: a division of the cord, just within the mem- branes, into five or six branches. The greater part of the body of the umbilical cord is made up of the arteries and vein, which are imbedded in a gelatinous material consisting of a very delicate cellular structure infiltrated with albu- minous matter; but, what is very curious, the arteries Avind around the cord from left to right through its Avhole length, the vein con- DEVELOPMENT OF THE FCBTUS. 151 stituting the central axis of this regular spiral. The cause of this— for it must have a determinate cause—has not been satisfactorily ex- plained; a similar phenomenon may be observed in pouring fluids through a funnel; they will always gyrate in a single direction. It is very common to find the cord Avound round the child's neck at parturition, requiring to be slipped off upon the emergence of the head; in such cases there is probably an abnormal length of the cord. Other cases are reported in Avhich the cord is tied in knots, but not so tightly as to compromise the foetal life by impeding the circulation. The umbilicus usually constitutes the point of origin of the cord, but it has been knoAvn to arise from the head, the chest, the shoulder, etc.; such anomalies result from some peculiarly disordered condition of the mother during this period of the incipient development of the embryo. It will be observed that as the interior or abdominal portion of the blastodermic membrane represents the organs of the vegetative life, so the umbilical cord, arising from this very portion of the embryo, and connecting with a corresponding portion of the mother, through the placental mass attached to the uterine walls, directly unites the vegetative organization of the mother with that of the child; this organization being thus seen to underlie the whole organic life, and thus to involve all that we understand by hereditary con- stitution. The same ideas are also no less plainly suggested by the fact that the whole life of the child is absolutely dependent upon the vital circulation of the mother, the movement of which is entirely under the control of the vegetative, organic or ganglionic nervous system. CHAPTER X. DEVELOPMENT OF THE FCETUS. HAVING thus described the primary development and organiza- tion of the ovum with its appendages, we now come to the study of the foetus as a whole, with particular reference to its safe delivery from its gestative Avorld to a more independent state of existence. But before proceeding to trace the intra-uterine life to the full term, it Avill be proper to review the ground already surveyed; this will be best done by a careful examination of the Plate (after Cazeaux) facing page 143, in Avhich are delineated the embryo and appendages up to the already described state of development. 152 DEVELOPMENT OF THE FCETUS. Successive Dimensions and Weight of the Farrus.—The first indications of the formation of a neAv human being that it is possible to discover, even by the help of a microscope, consist in an oblong figure, obtuse at one extremity, SAvollen in the middle, blunt-pointed at the other extremity. This rudimentary embryo is slightly curved forward, is of a grayish-white color, of a gelatinous consistence, from two to four lines long, and Aveighs one or two grains. Here a slight depression, representing the neck, enables us to distinguish the head; the body is marked by the SAvollen centre, but there are no traces of the separate extremities. So much can be observed about the end of the third Aveek after conception. At about the fifth week the embryo is found much more distinct. The head is very large in proportion to the rest of the body; the eyes are represented by two black spots; and the upper extremities are represented by small protuberances on the sides of the trunk. The embryo is now nearly two-thirds of an inch in length, and Aveighs about fifteen grains. The umbilical cord can now be distinguished in its rudimentary stage, and the loAver extremities begin to appear in the shape of two minute rounded tubercles. Minute depressions may now be discerned between the vertebrae, and the embryo is so much curved forward that its caudal portion very nearly approximates the head. Till about this time a straight artery has been observed to beat with the regularity of the pulse, but now it appears doubled somewhat in the shape of an adult heart, although as yet it has but one auricle and one ventricle. But as the time advances we find at length the perfect heart, with its two auricles and two ventricles, all developed from the original straight artery. The division of the first cardiac cavity into others is effected by partitions thrown up, or by contractions accomplished in the course of the same natural and orderly development. The septum Avhich divides this primary ven- tricle into two is developed from the apex toward the base between the pulmonary artery and "the aorta, so that we shall open the pul- monary artery from the right ventricle, and the aorta from the left ventricle. At this period the lungs appear to exist in five or six different lobes, and Ave can barely distinguish the bronchial tubes, terminating apparently in minute cul-de-sacs. Along the vertebral column may be perceived tAvo large glandular structures, which extend from the lung to the bottom of the pelvis. These structures, termed the Wolffian bodies, are constituted by an excretory canal which runs through their whole length, and perform the functions of the kidneys DEVELOPMENT OF THE F03TUS. 153 until the latter are developed. By means of numerous caeca which appear on one side only of their surfaces they secrete a fluid Avhich is poured into the canal and thence transmitted into the temporary cloaca. The Wolffian bodies disappear upon the development of the kidneys, and leave no traces of their former existence.—Cazeaux. A second canal, perfectly distinct, although lying alongside of that of the Wolffian body, is also to be discerned, which presents in the adult, and, according to the sex, becomes either the oviduct or the vas deferens. At about the same period of embryonic life may be distinguished four transverse fissures upon each side of the neck, which open into the pharynx. These are separated by fleshy par- titions that correspond with the branchial arcs of fishes, and they may for a time serve some similar or corresponding purpose. In the course of the subsequent development these fissures are dispersed and disappear, with the exception of one on each side (see the Plate), which are converted into the external ears. At about the same period, upon what appears to be the face appear two isolated tubercles, Avhich gradually approach the mesian line as development goes on, and form the upper jaAV. The double hare-lip, so often seen in children, results from the failure of development of the upper jaw and nose, as the nostrils originally constituted one cavity on a mesian line with the mouth. At about the seventh week the first centres of ossification appear in the clavicle, and subsequently in the lower jaw. The intestines still extend some distance along the interior of the umbilical cord; the omphalo-mesenteric canal is nearly obliterated, although it may still be traced as far as the umbilical vesicle, Avhere it is reduced to a mere thread. The anus is not yet opened or formed. The kidneys now begin to be formed, and soon after the genital organs. The urinary bladder is first seen in the form of a small tumor continuous with the urachus. The embryo is about one inch in length. At two months the rudiments of the extremities become more promi- nent. The forearm and hand can be distinguished, but not the arm; the hand is larger than the forearm, but it is not supplied Avith fingers. The cord has not yet become spiral, and still contains a large quantity of intestine; it is four or five lines in length, and is found to proceed from the lowest point of the abdomen. The formation of the placenta commencing, a minute tubercle may be distinguished between the cord and the termination of the spine, marking the locality of the genital « organs, but the sex cannot yet be determined. The length of the embryo is now from one inch and a half to two inches, and it weighs 154 DEVELOPMENT OF THE F(ETUS. from three to five drachms. The eyes are discernible, but still un- covered by the rudimentary lids. The nose forms an obtuse eminence, the nostrils are rounded and separated; the mouth is gaping, and the epidermis can be distinguished from the true skin. At ten weeks the embryo is from one and a half to two and a half inches long, and its weight is one ounce or one ounce and a half; the eyelids are more developed and descend in front of the eyes; the puncta lachrymalia are visible, and the mouth begins to be closed by the development of the lips. The walls of the thorax are now more completely formed, so that it is no longer possible to see the move- ment of the heart. The fingers become distinct, and the toes appear like small projections, Avebbed together like a frog's foot. The um- bilical cord now assumes the spiral form, still contains a portion of the intestine in its base, and its place of attachment appears higher up in the abdomen. At the end of the third month the Aveight of the embryo is from three to four ounces, and its length from four to five inches; the eyeballs are seen through the lids, the pupils of the eyes can be discerned, the forehead, nose and lips can be clearly made out. The neck now ap- pears between the head and shoulders; the cord contains no intestine, and its spirals are more numerous and apparent; the finger-nails re- semble thin membranous plates; the cerebro-spinal axis is divisible into its leading parts; the ventricles of the heart are separate, the pla- centa is separate, and the allantois and umbilical vesicle have dis- appeared. The skin shows more firmness; although apparently Avith- out fibrous structure, it is still rosy-hued, thin and transparent. At the end of the fourth month the product of conception is no longer called the embryo, but the foetus. The body is from six to eight inches in length and weighs six or seven ounces. The sutures and fontanelles are now very large, and little Avhite hairs may be seen scattered OA^er the scalp. The development of the face is still imper- fect. The eyes are now closed by their lids, the nostrils are well formed, and the mouth is shut in by the lips. The sexes are now distinguishable, and meconium is present in the upper boAvel. The tongue may be observed far back in the buccal cavity, and the loAver angle of the face is rounded off by Avhat a little later will be a Avell- formed chin. The umbilical cord is attached to the abdomen still higher up, though as yet much below the centre of the body. A foetus born at this time may survive for several hours. At the end of the fifth month the body of the foetus is from seven to nine inches long, and Aveighs from eight to eleven ounces. The skin DEVELOPMENT OF THE FCETUS. 155 has noAV a fairer appearance and is more consistent; the eyes can no longer be distinguished through the lids, owing to the increasing thickness of the latter. The head, heart and kidneys are large and well developed. The movements of the foetus are usually plainly felt by the mother. At the end of the sixth month the fcetus is from eleven to twelve and a half inches in length, and weighs about sixteen ounces, more or less. The hair upon the scalp is thicker and longer, the eyes remain closed, and very delicate hairs may be seen upon the margins of the eyelids and upon the eyebrows. The nails are solid, the scrotum small and empty; the surface of the skin appears wrinkled, but the dermis may be distinguished from the epidermis. The liver is large and red, and the gall-bladder contains fluid. At the end of the seventh month the length of the fcetus is from twelve and a half to fourteen inches, its weight is about fifty-fiA^e ounces, and it is both well defined and well proportioned in all its parts. The bones of the cranium, hitherto quite flat, noAv appear a little arched, and as the process of ossification goes on the arching increases till the vault is quite complete. The brain presents greater firmness, and the eyelids are opened. The skin is much firmer and red. The gall bladder contains bile. At the end of the eighth month the fcetus seems to thicken up rather than to increase in length, since it is only from sixteen to eighteen inches in length, while its weight increases to four or five pounds. The skin is red, and characterized at this period by a fine doAvny covering, over which is spread a quantity of thick A'iscous matter, called the sebaceous coat, which has been forming since the latter part of the fifth month. The lower jaw has noAV become as long as the upper one, and in the male the left testicle may be found in the scro- tum. Convolutions appear in the brain structure. At nine months the anxious time has arrived; the foetus is from nine- teen to twenty-three inches in length, and Aveighs from six to eight pounds, on an average. Some children weigh very much less; some as much as fourteen pounds; but such extremes are very rare. In most instances the child is covered with a whitish, sebaceous matter, which is really a secretion from the child's skin, Avhich may be dis- solved and removed from the surface after birth by rubbing with some unctuous material, such as oil or lard. At this period the white and gray matter of the brain are dis- tinct, and the convolutions are Avell marked; the nails assume a horny consistence; hair is more or less abundant; the testes are 156 DEVELOPMENT OF THE FCETUS. in the scrotum; the umbilicus is situated midAvay between the head and feet. Upon a careful review of the preceding account of the growth and development of the foetus, it will be seen that this growth is much more rapid in the first and in the last three months of its intra-uterine life than during the middle of this period. The following brief though graphic account of the development of the different parts and organs of the foetus is taken from Meadows' Manual of Midwifery, condensed by the author from Carpenter's Physiology: " The alimentary canal is formed from the vitelline sac or umbilical vesicle, with which a communication is kept up for some time. At first it exists as a narroAv straight tube, having no division of parts and no orifices ; subsequently, the mouth, oesophagus, stomach, large and small intestines are formed; and it is at the junction of the two latter that the vitelline duct exists. " The liver is formed upon the small intestine, and makes its ap- pearance first, at about the third week, by the aggregation of a num- ber of cells at the spot Avhere the hepatic duct afterward opens; this increases, and gradually removes farther from the canal; ducts begin to appear in it, starting first of all from the intestinal Avail; and so rapid is the groAvth that by the fifth Aveek the organ is about one- half the weight of the embryo itself. The subsequent changes which take place consolidate it and adapt it to Avhat Ave see at birth. "The pancreas and salivary glands are similarly developed as offshoots of the alimentary canal. It will be remembered that all the organs of vegetative life arise from the original inner or mucous layer of the area germinativa. " The lungs arise at about the sixth week, as a pair of bud-like processes, from the oesophageal portion of the alimentary canal; their surfaces soon become covered Avith numerous little wart-like projec- tions, caused by corresponding enlargements of their cavity. This goes on increasing; the parenchymatous tissue is developed in the spaces betAveen the bronchi, vessels are deposited in it, and by degrees these organs separate from the tube from which they spring, and as- sume more and more the natural state. " The urinary organs begin as two large tubes situate one on either side of the spinal column; little csecal appendages, the corpora Wolff- iana, are developed on their outer sides; the ducts then enter the allantois, there being at present no proper urinary bladder; this takes place about the fifth Aveek, and by the end of the second month they DEVELOPMENT OF THE FCETUS. 157 have disappeared. These take no part AvhateArer in the deArelopment of the kidneys, Avhich begin to form at about the seventh Aveek, behind the Wolffian bodies. At first as separate lobules, they afterward coa- lesce : for some time the supra-renal capsules equal in size the kidneys, but at the sixth month the former rapidly decrease, Avhile the latter as quickly increase in growth. The ureters at first open, Avith the duct of the Wolffian bodies, into the allantois; but as these bodies disappear a portion of the allantois is nipped off, and thus the urinary bladder is formed. " The generative organs are developed later than the other vegeta- tive organs, and at first they present no essential sexual difference. This applies to both the internal and external organs until at least as late as the fourteenth week. " The internal generative organs appear first at the inner side of the Wolffian bodies. As development advances, the testes become round, thick, vertical in direction, and are united to the vasa defcrcntia ; the ovaries, on the contrary, become long, flat, transversely situate, and remain unconnected with the Fallopian tubes; the former subsequently enter the scrotum, beginning the descent about the middle of preg- nancy ; the latter descend into the pelvis. The uterus is formed by a coalescence of the inner extremities of the Fallopian tubes; it remains bifid or bihorned (the normal condition of some animals) up to about the fourth month. "The developmental changes of the external generative organs are interesting, from the light they throAv on some malformations incident to these parts. So early as the fifth or sixth week a common cloaca exists for the termination of the intestine, the urinary and generative organs. At about the tenth week the former is separated from the two latter by a band, and subsequently these are shut off from one another by a similar band. Then the labia majora or the tAvo hal\Tes of the scrotum, as the case may be, are developed on either side of the orifice of the genito-urinary canal; and above and betAveen these a small body protrudes, being surrounded with a glans and fissured on its under surface. This becomes the clitoris in the female, and, by future groAvth, the penis in the male. The margins of the fissure are, in the former, developed into the nymphce; in the latter they unite and form the urethra. It will noAv be readily understood how, by arrested or morbidly augmented development of these parts, herma- phrodism or other deformities may result. " Turning now to the organs of animal life, a few words upon the development of the cerebrospinal axis may fitly terminate the con- 158 DEVELOPMENT OF THE FCETUS. sideration of the embryological changes affecting indiA7idual organs. This, as has already been stated, takes its origin in the external serous or animal layer of the germinal membrane by a contribution from each side of the primary groove formed by the rising up of the laminae dorsales; it is, in fact, from a portion of these latter, at first separate, but aftenvard united, that the central nervous system arises. The encephalic portion consists at first of three vesicles : out of the first is formed the greater portion of the cerebral hemispheres, the corpora striata, optic thalami and third ventricle; out of the second, the corpora quadrigemina and crura cerebri ; and out of the third, the pons varolii, the medulla and fourth ventricle. At first, all these vesi- cles are arranged in a straight line, very much like the permanent condition of the brain in fishes, but a curve is formed about the seventh Aveek, the hemispheres arching over the thalami and corpora quadrigemina. The lateral sinuses are formed about the third month, the corpus callosum in the fifth, and convolutions appear at the fourth. The membranes of the brain are formed at about the sixth or seventh Aveek, the arachnoid rather later. They are developed from the primary encephalic mass." Ossification sets in in the embryo at an early period, commencing about the sixth Aveek at a point of the clavicle; nearly simultaneously Avith this primary point of ossification bony formation commences in the inferior maxilla; then follow, successively, the vertebrae, humerus, femur, ribs and occipital bone. At the commencement of the third month it occurs in the superior maxilla, frontal bones, radius and ulna, tibia and fibula, and the scapula; and toAvard the close of the third month it has commenced in the metacarpal, metatarsal and phalangeal bones, and the remaining bones of the cranium. During the fourth month the bones of the pelvis and the sacrum begin to ossify, together with the minute ossicles of the inner ear. During the fifth, sixth and seventh months the astragalus and os calcis, the ethmoid bone, the pubis and the ischium commence to ossify. At the eighth month ossification sets in in the last bone of the sacrum. At full term many of the bones still remain in a cartilaginous con- dition, as the carpus, the smaller bones of the tarsus, part of the coccyx, the patella, the epiphyses of the long bones, and usually the os hyoides. The Fcetus at Full Term.—It must be evident that all the mechanical difficulties attending childbirth increase Avith the develop- ment of the child; hence the necessity of particularly studying the most voluminous portion, in order that we may intelligently adapt it DEVELOPMENT OF THE FCETUS. 159 to the passage in the pelvis through Avhich it must pass. The most voluminous, the least yielding and compressible, and by far the most difficult part to manage in parturition, is the head, and of course where this may pass, the remainder of the body can follow with comparative ease. The shape of the foetal head is ovoidal, the posterior part being larger than the anterior. The cranium, Avith which as accoucheurs we are principally interested, is composed of the os frontis, the occipi- tal, the two parietal and the two temporal bones. These are articu- lated by means of sutures, Avhich in the foetus at full term are usually cartilaginous. Angular spaces, called fontanelles, are left at the cross- ing of these sutures. Each suture and fontanelle has its particular designation. The sagittal suture arises from the root of the nose, dividing the frontal bone on the mesian line, runs across the top of the head to the occipital bone, and sometimes divides that bone to its very base. Tlie coronal suture crosses the sagittal at right angles, uniting, the os frontis to the parietal and temporal bones. The lambdoidal suture also crosses the sagittal, although at a more acute angle, uniting the occipital bone to the parietal and temporal bones. Where the coronal suture crosses the sagittal suture there is left a large quadrangular space called the anterior fontanelle. The crossing of the lambdoidal suture with the sagittal leaves a three- sided space, smaller than that of the anterior fontanelle, and called the posterior fontanelle. There are other sutures and fontanelles, formed in a similar manner, between the bones which compose the foetal head, but those mentioned above are the only ones of prac- tical importance to the accoucheur. By means of these sutures and fontanelles the head may be compressed so as to require less space during parturition, thus rendering this function less frequently in- jurious to both mother and child than must othenvise be the case; and these sutures and fontanelles serve as guide-marks for deter- mining the exact position of the foetal head relatively Avith the cavity of the pelvis during labor. The diameters of the fcetal head at term may be reduced, for all practical purposes, to seven in number. The occipito-mental (a b, Fig. 41), extending from the occipital protuberance beloAv the pos- terior fontanelle, to the chin, is five and one-fourth inches. The longi- tudinal or occipitofrontal, d e, extends from the occipital protuberance to the frontal protuberance, and is four and one-fourth inches. The mb-occipito bregmatic, c f extends from the central point between 160 DEVELOPMENT OF THE FCETUS. the foramen magnum and the occipital protuberance to the anterior fontanelle, and measures three inches and three-fourths. These are called antero-posterior diameters. The transverse diameters are, the Fig. 41. Fig. 42. bi-parietal, a b (Fig. 42), extending from one parietal protuberance to the other, three inches and three-fourths; the other, the bi-temporal, c d (Fig. 42), extending from the zygomatic process of one side to the same point on the other, measures three inches. Finally, there are also two vertical diameters: First, the vertical diameter, i g (Fig. 41), extending perpendicularly from the highest point of the vertex to the anterior boundary of the foramen magnum, measures three inches and three-fourths. Second, the fronto-mental, d a (Fig. 41), from the frontal protuberance to the lowest point of the chin, meas- ures three inches. While it is absolutely necessary for the accoucheur to have a perfect knowledge of these various and varying diameters of the foetal head, yet the most important in an obstetrical point of view undoubtedly are, the occipito-mental, five and one-fourth inches; the occipito- frontal, four and one-fourth inches; the bi-parietal, three and three- fourths inches. NoAAr, it will be readily seen that the antero-posterior diameter is quite too long to pass any diameter in the Avell-formed pelvis, even in the dried state, Avhere the largest diameter is only five inches. Hence it must be apparent that in order for the head to be capable of pass- ing in parturition, the longest diameter must lead the way—that is, the long diameter of the head must be made parallel to the axis of the pelvis by making either the occiput or the chin lead the Avay. When this is accomplished it is evident that all the other diameters of the head will be permitted to pass through a well-formed female pelvis. And the more perfectly the antero-posterior diameters of the head are made parallel with the general axis of the pelvis, the easier —other things being equal—will the child be born. A great difference exists between the heads of male and female DEVELOPMENT OF THE FCETUS. 161 children, in the greater size and more complete ossification Avhich are found to obtain in the former. As a proof of this Ave may adduce the one observed fact, that the proportion of stillborn boys to stillborn girls is one hundred and fifty-one of the former to one hundred of the latter. And even of those born alive a much larger number of boys than of girls die in infancy from injuries received during birth. And finally, of the mothers who succumb to consequences of childbirth a majority have given birth to boys. Thus, it appears that the groAvth of the male portion of the race costs much more suffering and a greater loss of life than does that of the female portion. One more fact needs to be studied in this connection, and this is the articulation of the child's head to its trunk. The occiput is articu- lated Avith the atlas in such a manner as to admit of great flexion and extension, while at the same time the atlas is so placed upon the axis as to admit of great rotation—much more freedom of movement in either articulation than is possible in the adult. Hence it makes little difference, so far as the child's neck is concerned, Avhether the occiput or the chin lead the way in parturition. It is, hoAvever, much better, as is usually the case, for the occiput to lead the way; for, as the chin thus rests upon the sternum of the foetus, the long diameter of the head corresponds more exactly with the long diameter of the body of the fcetus, and consequently the Avhole long diameter is more in harmony Avith the axis of the cavity of the pelvis. Thus, the direct force of each contraction of the uterus is received by the propelled body in a mass, none of the force being lost, as would necessarily be the case if the chin were to lead the Avay. For here every contrac- tion Avould tend to throAV the occiput back upon the spine, in which case it Avould not find a firm base, as in the natural position of the chin upon the sternum. The Presentation and Position of the Fcetus at Full Term is a thing of much interest, and the true causes which influence and determine these must noAV be stated and explained. At the earli- est period at which the embryo is seen, it has ahvays been observed to be curved fonvard, and in all orderly developments this position con- tinues as the groAvth increases, until at full term of gestation the head is found flexed so that the chin nearly touches the sternum, the arms are flexed upon the chest, and the forearms upon the arms, so that the palm of each hand is applied to its side of the face and chin. The in- ferior extremities are also flexed in a similar manner, the thighs upon the abdomen and the legs upon the thighs; the feet lying together and within the thighs, the knees and elbows touching each other. 11 162 development of the fcetus. This is found to be the position most economical of space; it forms the body into a compact and ovoidal mass, similar in shape to that of the head, and most convenient for expulsion from the pelvis. Upon a little reflection it must be evident that the same influences that give shape to the embryo and foetus must also shape its position in utero. And furthermore, that the same influences must also deter- mine the presentation of the foetus, not at once, but as it is gradually developed so it is gradually made to assume its best possible position and gradually to present itself at the superior strait with its head dowmvard, the occiput turned to the left ilio-pectineal eminence, its back—relative to the mother—to the left and in front, and its face looking back to the mother's right. This position and presentation is assumed by means of the all-pervading influence of the mother more frequently than all the others put together, simply because it is the most favorable for an easy expulsion from the generative organs, and is consequently the most orderly and natural one. When the fcetus deviates from this it assumes the next most favorable position for an easy delivery, and so on; the greatest number of presentations and positions being by far the best, and the least number being the most difficult. The causes of all these different presentations and positions may be much more rationally accounted for by referring the Avhole matter to Nature's formative process than by attempting to explain them as the effects of gra\rity or of any other mechanical influence; since the same result is obtained where women maintain the horizon- tal position during the entire period of utero-gestation. If the forma- tive poAvers of Nature in the mother are adequate to the folding of the limbs in the compact and symmetrical manner just described, Avhy should they not be deemed sufficient to determine the presentations and the precise position? It is contended by many Avriters, however, that the fact of the foetal head being usually found at the outlet of the uterus is due to gravity. " The reason," says William Hunter, in his work on the Human Gravid Uterus, " Avhy the child's head is com- monly doAvnward may be supposed to be this : the child is specifically heavier than the liquor amnii, and therefore in the various attitudes of the mother is ahvays in contact with and supported upon the de- pending part of the uterus. This in the more common attitudes is the cervix uteri. The child's head and upper part of the trunk con- tain more matter in proportion to their surface than the lower part of the body; hence the head will more generally fall doAvn to the lower part of the uterus." It may be asked, Why, then, are there so many different presenta- development of the fcetus. 163 tions and positions ? The head is sometimes extended upon the back, as in the face presentation, and sometimes the loAver extremities are throAvn over toward the back. All these various attitudes, presenta- tions and positions result from corresponding variations in the vital energies of the mother. Should she be well, in an orderly and happy condition, both mentally and physically, her child will haA^e only natural and orderly presentations and positions. The truth of this is proven by daily experience in practice. For Avomen Avho, for instance, invariably have face presentations of their children, and Avho have always been ill in some particular manner themselves, after the re- moval of their malady have as inArariably had their children present naturally. Hence the great importance of making the most strenuous and persevering efforts to remove the various disorders Avith which Avomen are afflicted, and to advise happy and orderly modes of life in order that the distresses of childbearing may be entirely overcome; Avhich indeed is not only possible, but under the prevalence of the homoeopathic regime quite probable in the course of time. It should be remembered here that the embryo or foetus is not suspended in the uterus by the umbilical cord, but that it floats in the liquor amnii; hence it is free to obey any influence brought to bear upon it by the mother. By presentation we mean the part that presents at the superior strait, as the vertex, the face, the breech, etc, By position Ave mean the particular posture in presentation, as the occiput in the left half of the pelvis, anterior, transverse or posterior. But the further con- sideration of this subject Avill be postponed until Ave come to treat of the mechanism of labor. The development of the foetus needs also to be studied Avith especial reference to the three great functions of Nutrition, Respiration and Circulation, by Avhich this development is accomplished. Each of these functions is evidently maintained during intra-uterine life in a manner altogether different from that after birth. Nutrition.—At no instant in the history even of the unimpreg- nated ovule is it Avithout the support of the mother, from the earliest moment of its existence Avithin the OA^ary till it is ruthlessly washed aAvay by the menstrual flux or broken and destroyed by some other means. But Avhen impregnated the ovule becomes still more espe- cially the object of the particular care of the mother. Hence, imme- diately upon the occurrence of conception the entire natural, spiritual and vital organism of the mother is aroused to provide for Avhat is really a new creature, already a new human being. From this moment, 164 DEVELOPMENT of the fcetus. therefore, commences the nutrition of the embryo. And at the very first this is accomplished in a manner similar to the nutrition of a seed in the earth; which, although in a general manner supported by the external influences of the mother-earth, is in a still more immediate and particular manner sustained by itself, the sprout flourishing upon the remaining substance of the seed till that is consumed. So the impregnated ovum, even after it has left the ovary, is sustained in a general way by a sort of endosmosis from the mother, but in a more immediate and particular manner its primary development is main- tained by, and the embryo itself subsists upon, the vitellus; a substance most nutritious and especially provided for this very purpose. When this original resource is exhausted, the embryo throAVS out the allan- toid vesicle in search of other supplies. These are found by coming in contact Avith the mother's blood in the villi of the chorion. In this great life-fountain the embryo finds a bountiful supply of all things needful for its present wants and future growth and development, The vitellus is indeed very small, but the embryo itself is correspondingly minute; it wants but little. Sufficient proof of these statements may be found in the fact that the umbilical vesicle is entirely constituted from the vitellus, or from what remains of it after the formation of the blastodermic membrane, and in the further fact that the omphalo-mesenteric vessels are found to circulate blood to and from the embryo in a manner altogether similar to that in which it is subsequently done in the umbilical cord. And, finally, the umbilical vesicle and the omphalo-mesenteric vessels soon become obliterated after the nutritious root has become Avell es- tablished by means of the allantoid vesicle, its arteries and veins. Pure arterial blood contains all the needful materials for growth, and for the separation of the waste and decomposition of tissue; these must be first accumulated in the blood, then distributed as needed. For this supply of the elements necessary for growth and repair there is a constant yearning, of Avhich the blood, as a living body, is conscious, and to Avhich it continually seeks to respond. Blood is found in the embryo at the earliest possible period of examination; a circulation has already been established in the embryo and in the omphalo-mesenteric vessels by the time the supply is exhausted which was contained in the umbilical vesicle, into which these vessels ramify in search of nourishment for the blood itself. Upon the failure of the supplies from the umbilical vesicle a new route must be opened up to furnish the demand. This is done by the embryo throAving out the allantois supplied with the tAvo arteries aris- development of the fcetus. 165 ing from the internal iliacs, and containing impoverished blood which must be renovated and returned to the embryo. These arteries are accompanied by a vein. The Avhole apparatus soon takes root in the villi of the chorion, and forthwith a return of nourishment is made to the already famishing embryo. The impoverished blood from the embryo, by endosmosis through the coats of the villi of the chorion, is reneAved and regenerated from the maternal blood. And the arteries anastomosing with the vein, the aerated and revivified blood is imme- diately returned to the embryo for its especial benefit. Now is formed the first nucleus of the placenta; and in this manner is accomplished the continued nutrition of the foetus, by its famished and exhausted blood being thus supplied Avith all things needful by endosmosis from the maternal blood, through the blood in and about the villi of the chorion. From this time the foetus, the cord and the placenta grow pari passu till the completion of the full term. And by no other means is the nutrition of the embryo and fcetus provided. All the plants, and, indeed, the Avhole animate creation, is nourished by a kind of endosmosis from the parent earth, or mother; but the material thus supplied is appropriated by each receiver in its own Avay, in accordance with its own form of life. A positive proof that the nutrition is supplied by means of the cord, and in no other Avay, is found in the Avell-knoAvn fact that compression of the cord so as to arrest the circulation, although but for a very short space of time, is certain death to the child. What change the nutritious material obtained from the mother undergoes before it is fitted for appropriation by the foetus, or where that pre- paratory change is made, Avhether in the foetal placenta or in the foetal liver, is not yet known. Nor is it knoAvn where or hoAV the plant transforms the nutriment derived from the earth into its peculiar sap, fibre and bark. Respiration.—This function is essential to the existence of all the animals of creation, and for every individual thereof; for this is the process by Avhich the effete blood becomes aerated, and gives up the excess of carbon and other useless matters Avith which it is loaded. This, as just above described, is accomplished by the foetal blood coming in contact with the maternal, in a manner not unlike that in which the blood of fishes is decarbonized by being exposed, by means of the gills, to the air contained in the Avater Avhich passes through them. The blood of the mother serves exactly the same purpose for that of the foetus that the water does for the blood of fishes; the Avater contains an appreciable amount of air, or rather of 166 development of the fcetus. oxygen, and so does the mother's blood. In proof of this, it is only necessary to compress the cord so as to prevent the blood of the fcetus from being exposed to that of the mother, and the child turns black and dies, as from asphyxia. Secretion.—As development advances all the secretions are suc- cessively established. The liver secretes bile, the gall-bladder is found full, and there is reason to believe that bile is steadily supplied to the intestines. Even prior to the fifth month the alimentary canal con- tains a substance called meconium, Avhich is principally composed of biliary matter and the detritus of the mucous membrane. There is no positiAre evidence that this meconium is ever evacuated into the amniotic sac, but it sometimes passes off freely during labor, and in other cases not long after delivery. Urine is secreted, and usually passes in considerable quantities after birth; and it is thought by some that the fcetus in utero discharges the urine into the amniotic cavity. But Ave have no positive evidence that the urine is ever discharged from the bladder till after delivery. Circulation.—The lungs of the fcetus in utero not being employed, are small and collapsed, and bear a striking resemblance to the liver in appearance. A very small portion of blood passes through them, and that which does so pass neither gives up impurities nor receives vivifying material, as after birth. In consequence of this the pul- monary arteries are small, and the passage of blood from the right side of the heart would be impeded in consequence of their lack of development were it not for the existence of the foramen ovale, or foramen of Botal, as it is likewise termed, an opening in the septum of the right and left auricle and through Avhich a proper quantity of the blood flows from the right into the left auricle. But not- withstanding the fact that a portion of the blood received by the right auricle is thus conveyed away, there is still too great a quantity to be transmitted through the minute pulmonary artery; and hence a supplementary short and thick vessel is provided, the ductus arte- riosus, Avhich passes between the pulmonary artery and the aorta, and gives free escape from the right ventricle. The right and left ven- tricles thus become in a measure one, and the blood from each enters directly into the aorta; while it will be seen that the right and left auricles are likewise one through the medium of the foramen ovale. Now, in the pelvis of the foetus the common iliac arteries divide into two branches, an external and an internal. The latter go to supply the extremities of the foetus, Avhile the former pass directly upward to the umbilicus as the umbilical arteries, and reach the placenta anomalous pregnancy. 167 through the medium of the cord. Here the blood receives its vivify- ing properties from the maternal blood, as has been already described, and is returned by the venous branches which unite to form the umbilical vein. The blood thus changed. and purified enters again the body of the foetus at the umbilicus, passes upAvard along the anterior edge of the suspensory ligament of the liver, and supplies that organ Avith blood. The current then passes onward to be emptied into the ascending vena cava by means of another short supplementary trunk, the ductus venosus, and is conveyed to the right auricle of the heart. The course of the foetal circulation, then, may be thus stated: start- ing from the placenta, the blood passes through the umbilical vein, along the cord, into the fcetus at the umbilicus, and thence to the liver; part goes to that organ, and the remainder passes onward through the ductus venosus into the ascending vena cava, and through it to the right auricle. Part of the blood recei\red by the right auricle comes through the descending vena cava, and of this a portion passes into the left auricle through the foramen ovale, and thence to the left ventricle, Avhile another portion passes into the right ventricle, is forced by its contractions into the pulmonary artery, and into the ductus arteriosus, Avhich conveys it to the aorta. The blood in the left ventricle is also forced into the aorta, and through the aorta the blood passes upAvard to the head and superior extremities and doAvn- ward to the trunk and inferior extremities. Having reached the internal iliacs in its downward course, it passes through the umbilical arteries of the cord to the placenta again. CHAPTEK XL ANOMALOUS PREGNANCY. Multiple Pregnancy. TTAVING described normal pregnancy, the product of Avhich is -■-J- a single foetus, Ave noAV advert briefly to that form of gestation in Avhich there are two or more. It is by no means an uncommon occurrence for a Avoman to give birth to twins; triplets are produced less frequently; and yet there are well-authenticated instances on record in Avhich four and even five children have been brought forth during a single labor. TAvin pregnancy occurs about once in seventy- 168 ANOMALOUS pregnancy. five cases. Madame la Chapelle records that in 37,441 births there were 444 instances of twins and but five of triplets. Churchill states that in 257,935 births recorded by British practitioners there were 3431 cases of twins and 43 cases of triplets. A great variety of theories have been promulgated by various Avriters regarding the causes of multiple pregnancies. These theories, however, may be summed up into the general opinion that the cause lies in an. extra- ordinary reproductive power, possessed in some instances by the male and in others by the female. As a general rule, in plural pregnancies each foetus has its OAvn set of membranes and its own placenta, although there may be an inos- culation of the blood-vessels of the placentae. It sometimes happens, hoAvever, that there is but a single placenta. This may be, and doubtless is, attributable to there being but a single ovule impregnated, which has contained two yolks and two germinal vesicles, as is some- times observed in the eggs of birds. Twin pregnancy is, as is shown above, the most frequent form of multiple pregnancy. The foetuses in such cases are usually smaller than Avhere there is but a single product of conception, and in after life they are usually marked as " delicate " children; but this is by no means the case in every instance, for twin children are frequently fully and largely developed at birth, and are quite as healthful in after life as are other children. The signs of plural gestation prior to delivery may be regarded as uncertain and unsatisfactory. The disproportionate size of the abdo- men, as compared Avith the period of gestation, Avhich has been ad- vanced as a sign of twin pregnancy, may be due to other causes, such as an excessive quantity of liquor amnii, an unusually large develop- ment of the foetus, dropsy, either ovarian or abdominal, tumors, etc. The appearance of the abdominal tumor as though it Avere divided into halves is equally untrustworthy as a sign, for it may be due to other causes, such as those enumerated above. The only sign that can be regarded as at all reliable is that derivable from auscultation. If two distinct foetal pulsations, not synchronous, can be detected in dif- ferent parts of the abdomen, almost conclusive evidence is afforded of the existence of more than one fcetus. Extra-uterine Pregnancy.—Impregnation is effected within the ovary, as has been described in a preceding chapter. But Avhere the fecundated ovule fails to reach the cavity of the uterus, it may lodge, adhere and become developed in some other place, constituting extra-uterine pregnancy—a very disastrous and happily infrequent ANOMALOUS PREGNANCY. 169 occurrence. Of the causes of this failure to reach the uterine cavity we know but little; the most plausible view being that it is due to a constriction or other morbid condition of the Fallopian tube. Sometimes the impregnated ovule remains in the o\rary and is there developed, constituting ovarian pregnancy. The autopsy of a Avoman dying suddenly has revealed, as the cause of her dissolution, an en- larged ovary rent in twain by a fcetus of four and a half months. Sometimes the ovule is arrested in its progress through the Fallo- pian tube, becomes attached to its walls, and development there pro- gresses. This is called tubarian pregnancy, and is the most frequent form of extra-uterine gestation. The ovum may be arrested in any part of the tube, the Avails of Avhich, becoming distended around the ovum, envelop it in a sort of sac or cyst, In other instances, on account of some abnormality of structure, the ovum slips in between the interstices of the uterine tissue in that part where the Fallopian tube traverses the uterus. This anomaly is termed interstitial pregnancy, and is the rarest of all the forms of mis- placed gestation. OAving to the yielding and distensible character of the uterine walls, gestation may here go on for a longer period than in other abnormal situations, and even exceed full term; but in such cases labor sooner or later sets in, with disastrous consequences to the woman. In some recorded cases of this form of extra-uterine preg- nancy the placenta Avas found to be normally attached Avithin the uterine cavity. In some instances the impregnated ovum either does not enter the Fallopian tube at all, or, having entered it, drops out again and falls into some part of the abdominal cavity, fastens to some portion of the peritoneum and develops there for a longer or shorter period. When the foetus dies shortly after conception in these cases, it may remain Avithin the abdominal cavity in the form of a cyst for years, or an ab- scess may form and discharge either externally or internally. In the latter case this would necessarily result fatally; not so, however, should the contents of the abscess discharge externally, or even into the intes- tines, uterus, bladder or vagina. This form of extra-uterine preg- nancy has been termed ventral or abdominal. The mode of development in these abnormal cases is similar to that m others. Internally, the ovule goes on developing as in normal pregnancies, in the formation of the amnion, chorion, placenta, um- bilical cord, etc. It is doubtful, however, whether a true decidua is formed in these cases, though a substitute for that membrane exists. Externally, to Avhatever point the ovule may become attached, it be- 170 ANOMALOUS PREGNANCY. comes so attached by means of the villi of the chorion groAving into Avhatever structure they are brought into contact with. Simultane- ously Avith this growth on the part of the ovule, the maternal struc- ture grows to correspond and to furnish its part in the reproduction, by growing upon these villi and throwing out blood-vessels to meet those coming from the embryo. Thus the placenta is formed pre- cisely in a similar manner here as in the uterine cavity—only Avith far less present security to the embryo, and Avith almost certain fatal consequences to the mother. After the ovule has thus become fixed in its unnatural bed for de- velopment, its groAvth goes on for a longer or shorter time, according to the strength of the membranes—usually till about the middle of the ordinary term of utero-gestation—sometimes even to the full term. At last, the membranes, from want of sufficient protection, burst and their contents are poured out into the abdominal cavity, and there re- sults a rapidly fatal inflammation of the peritoneum of the ill-fated mother. Sometimes the maternal surface of the placenta becomes ruptured, so as to produce fatal hemorrhage. In other instances the first shock is Avithstood, the contents of the cyst become absorbed or again encysted—as any foreign body may be—and the Avoman not only surviAres, but may even enjoy good health for years. In some cases the foetus itself perishes at about the full term, and makes its exit by means of fistulous openings through the abdominal parietes or other- wise. The diagnosis of these cases will be most easily effected by obser\T- ing that in vaginal examination the os and cervix uteri will be found little, if at all, altered in size, and generally higher than usual. A tumor may also be felt above the vagina, either in the recto-vaginal pouch or on one side of the uterus. This tumor generally pushes the uterus against the pubes or to one side of the pelvis, or draAVS it up into the pelvis almost beyond reach. Little satisfaction is derivable from auscultation, but palpation may reveal the fcetal outlines if the abdominal parietes be sufficiently thin and relaxed. Where the preg- nancy is of the interstitial variety, the uterus will be found irregularly enlarged. Super-Fcetation.—The question as to whether conception can take place while the uterus is carrying the product of a previous con- ception has given rise to a vast amount of argument pro and con. At one time a belief in the possibility of super-fcetation occurring was almost universal; but a careful scrutiny of the so-called facts of the case, together with the plausible arguments advanced in opposition, LABOR. 171 succeeded in engendering an almost universal disbelief in the doctrine. Now, however, there appears to be no bar offered to a belief in the possibility of the occurrence of conception during the earlier months of embryonic life by any anatomical or physiological fact connected with gestation. Dr. MattheAVS Duncan is of the opinion that, Avhile ovulation is suspended during the greater part, if not the whole, of pregnancy, yet there may be exceptions to this rule, particularly dur- ing the earlier months. If, then, ovulation be not suspended, it is of course possible for super-impregnation to take place. It is difficult to understand in the ordinary vieAv of the case how impregnation can occur Avhile the uterine cavity is filled Avith an embryo and the decidua is closely adherent to the inner uterine Avail. Dr. Duncan says that the " decidua refiexa does not become adherent to the decidua vera till after the third month, prior to Avhich sufficient space exists to ad- mit of the passage of the semen, and consequently to allow of a subse- quent conception." This special pleading is not demanded to explain the occurrence of super-fcetation if the views entertained by the writer in regard to the passage of the semen to the ovaries, as laid down in a previous chapter of this work, are taken into consideration. CHAPTER XII. LABOR. T ABOR, or parturition, completes the grand function of reproduc- -*-* tion, and by it, either by nature, by art, or by both conjoined, the new being is ushered forth to assume an independent existence with all other isolated existences. Labor is considered natural Avhen it is accomplished by the unaided poAvers of nature, and unnatural when manual or other assistance is found necessary. Labor is also considered at term when it occurs at about the expiration of the ninth month of utero-gestation, and prema- ture Avhen it occurs at any time betAveen the first part of the seventh month and full term. ProAroked labor is one which has been pro- duced by some mechanical cause, either accidental or designed. A re- tarded labor is one that is delayed beyond nine and a half or ten months of gestation. Premature Labor.—Premature labor may result from a great variety of causes—accidents of any kind, diseases incidental to the 172 LABOR. pregnant condition, etc. For the precautions and remedies to be em- ployed in case of threatened premature labor we refer to the chapter on Abortion. It may be stated here, however, that all Avomen should use extra precautions at about the seArenth month of gestation. In premature labors the first stage is usually longer in proportion than the second, Avhich latter is generally longer than a labor at full term. Also vertex presentations are far less frequent than in natural labor at term, and cross, breech or irregular presentations are much more fre- quent. There is great danger from hemorrhage in premature labors, consequently more need of quiet rest, from the first symptoms and ever after till all danger is past, and so much the more need of care- fully selecting the proper remedy. Retarded Labors.—The ordinary time for gestation is tAvo hun- dred and seventy-five days, but as there are exceptions to all other rules, Ave might naturally conclude they Avould be found here also. Accordingly, investigation has been made, and out of forty-three in- stances of conception after a single coitus, collected by Dr. Reid—all of them resting upon testimony as credible as can be obtained in such cases—of which the average duration of gestation Avas two hundred and seventy-five days—three Avere delivered at the 280th day, two on the 283d day, one each on the 284th and 286th days, tAvo on the 287th, one on the 291st, two on the 293d, and one each on the 296th and 300th days. Natural Labor at Term.—In the study of this subject two orders of facts must be separately considered—the one regarding the physiology of labor on the part of the mother, the other consisting of the movements Avhich the child must execute in order to promote its passage from the uterus through the organs of generation. The former is to be regarded as purely functional, the other as simply mechauical. Let us first consider the subject functionally Avith refer- ence to the vital action of the mother. Causes of Labor.—The causes of labor have been divided into the efficient and the determining causes. The efficient causes are un- questionably the vital energies of the mother, brought to bear in every possible manner upon the child for its expulsion, and at the same time to open up the way as much as possible for its exit. The uterus itself, acting involuntarily, is an agent in the expulsion, aided more or less by the voluntary efforts of the mother, while at the same time an involuntary dilatation is effected of the os uteri, vagina and exter- nal organs. All these processes on the part of the mother are purely functional and involuntary—as much so as are the processes of concep- labor. 173 tion, gestation, digestion, nutrition, etc. The efficient cause of the labor is in fact only the last part of the grand function of reproduc- tion. Hoav important, then, that this most sacred function should not be disturbed by any influences Avhatever, but should be sedulously Avatched over by a careful and skillful homoeopathic physician, ready to administer the proper remedy for Avhatever deviation from the nor- mal condition may occur! Hoav different when the blood is poisoned and the senses stupefied by anaesthetics ; 1ioav impossible then for the mother to give the alarm, or for nature to respond and furnish the symptomatic signs of danger till it is too late! The determining cause may be any influence by which the efficient cause is set in motion. At the full term, Avhen the woman should be delivered, the determining cause becomes spontaneous, the grand func- tion of reproduction is about to be completed ; and here, as in all other vital processes, there is no delay; the work constantly advances till parturition terminates and completes to the very last the great process of reproduction. At the full term, or even a few days before, various kind of accidents, diseases or mechanical means may become the de- termining cause by arousing the efficient cause in the contractive and expulsive action of the uterus; but this function of parturition will not be so safely or so easily accomplished when thus excited by exter- nal influences as Avhen it begins in a perfectly natural and spontaneous manner. As to Avhat it is that immediately excites labor, hoAvever, very little is definitely knoAvn. Various speculations have been indulged in by obstetrical Avriters. By some it has been attributed to the direct ac- tion of the fcetus; others have thought it due to the uterus having attained its utmost limit of distension; Avhile still others have thought that labor sets in at that period at which a menstrual period would have occurred had conception not taken place. Sir James Simpson believed it to be due to the disintegration of the decidua at full term, and a consequent separation between that membrane and the uterus. It is undoubtedly referable to a natural law which at present is not understood or explainable. The Physiology of Labor.—The phenomena of labor may be arranged in three distinct groups or successive stages—the first including the Avhole period from the commencement of the labor to the complete dilatation of the os uteri; the second extending from the dilatation of the os uteri to the expulsion of the child; the third terminating with the final delivery of the placenta. 1. The First Stage.—The approaching termination of gestation is 174 labor. indicated usually by various symptoms cal led precursory or premonitory signs of labor. About the last two weeks a change becomes percep- tible in the form of the abdomen. Its sides become more projecting as the uterine tumor sinks from the region of the stomach and epigas- trium, so that respiration becomes easier and food can be taken with less discomfort. And in many respects the Avoman feels lighter, better and easier. This change results from the cavity of the body and of the neck of the uterus being blended into one by the softening and giving way of the os internum uteri, and by the sinking doAvnward of the uterus, the fundus of Avhich is noAv found to lie midAvay be- tween the ensiform cartilage of the sternum and the umbilicus; at the same time the uterus is projected forward. The calls to urinate now become rather more frequent, owing to increased pressure on the blad- der and its lessened capacity; sleep is more broken by restlessness, and Avalking becomes more difficult. The woman becomes more clumsy, and a little later glairy discharges take place from the vagina, which simply show an increased action of the muciparous glands prepara- tory to the final act of parturition. Finally, the first stage is ushered in by painless contractions, which after a Avhile become someAvhat painful, and finally more and more so. The mucous discharge often becomes more or less tinged Avith blood from the rupture of small vessels about the cervix, due to com- mencing dilatation and separation of the membranes. This, in the parlance of the lying-in chamber, is called a " show." The os uteri dilates more and more Avith every orderly contraction, the parts be- come bathed Avith moisture, and the upper portion of the vagina gradually dilates simultaneously with the os uteri. During this stage the Avoman may walk" about, sit or lie doAvn, as she finds most comfortable. Her respiration is usually continuous with every pain; there may be a sort of shiA^ering-like respiration; at times violent shiArerings and shudderings seize upon her, although she does not feel cold, and she Avonders why it is she shakes so. This shivering is one of the phenomena most usually Avitnessed during an orderly first stage of labor. The pains of this stage of labor are of a "cutting" or "grinding" character, and although they are of shorter duration than those Avhich occur Avhen labor is more advanced, they are, in many Avomen, less easily borne, and give occasion to expressions of impatience. They usually begin in the back, extending around into the abdomen, but are unaccompanied Avith any bearing-doAvn effort on the part of the LABOR. 175 woman. Vomiting sometimes occurs at this stage, but is usually re- garded as a favorable sign. These pains indicate the gradual dilatation of the os uteri. This dilatation of the os is due not only to the pressure dowmvard of the membranes and the presenting part of the foetus, but chiefly, according to Dr. Rigby, to the contraction of the longitudinal fibres of the uterus, which, overcoming the action of the circular fibres, have a tendency by their action to open the os in every direction. This state of things continues for a longer or shorter period until the dilatation of the os uteri is completed, which marks the termination of the first stage of labor. "As a general rule, it may be stated that regular and genuine contractions of the uterus sufficiently powerful to produce pain seldom require more than six hours to effect the full dilatation of the os uteri; in many cases a much shorter time will be sufficient; Avhereas, in others the first stage of labor may last for more than quadruple this period before it is completed; in neither can it be considered abnormal, and Ave usually find that Avhere the pains of the first stage have been slow and lingering, they become remark- ably quick and active during the second stage."—Dr. Rigby. If the hand be placed upon the abdomen during the continuance of a pain, the uterus will be found to be hard and tense, as though it were drawn up into a knot. An examination per vaginam will re- veal a greater or less dilatation of the os, which will be found during a pain to be hard, tight and circular, Avhile the membranes protrude through the aperture, are tense, and communicate a feeling of firmness to the finger, Avhich passes aAvay and they become relaxed again as the pain subsides. Usually in primiparae, at this stage, the os will be found to be high up, Avhile in women who have already borne children it Avill be loAver down and nearer to the pubes. At the same time, if any considerable progress has been made, the vagina will be found to be flaccid and dilatable, hot and moist. II. The Second Stage.—The os uteri is noAV fully dilated, and a marked change takes place in the character of the pains and in the condition and appearance of the patient, Generally at the completion of the first stage, or quite early in the second stage, the membranes are ruptured and a portion of the liquor amnii is discharged. This fluid still farther moistens the parts, and its escape gives rise to a sense of relief to the Avoman, which is very grateful to her. There is quite frequently at this time a suspension of active uterine operations for a longer or shorter period, Avhich likewise adds materially to her com- fort, and gives her an opportunity to gather her strength for the try- 176 LABOR. ing ordeal she has yet to encounter. Soon, however, pains return, and these are of a different character and serve a different purpose from those that preceded them. The efforts of the uterus are increased, the pains are longer, and the intervals between them are shorter; and yet, although there is absolutely greater suffering at this period than during the first stage, the Avoman bears up more heroically and gives less evidence of suffering. This is doubtless due to the fact that her attention is directed to the bearing-doAvn efforts which attend the pains of the second stage of labor. These pains have been termed voluntary, but it is a question Avhether they are entirely so, for there is an undoubted sympathy between the uterus and vagina on the one hand and the muscles of the abdomen and other parts on the other, Avhich gives to them an involuntary or irrestrainable character. To aid this bearing-down or expulsive effort the woman holds her breath, generally grasps something to aid her in bringing into play the necessary muscles of the trunk and extremities, her face becomes red or even dusky-hued, the respiration is quickened, the voice is hoarse, and she replies to questions in a short and spasmodic manner. When this is noticed in a Avoman in labor, it is certain that the second stage has set in and that the os uteri is fully dilated. As the pains come on the presenting part of the fcetus advances, and as they go off it recedes; thus, by this wise provision, the vagina is gradually distended and dilated, acted upon and relieved. An ex- amination per vaginam noAV reveals the disappearance of the os uteri, the cavity of the uterus and the vagina constituting a single channel, in the lower part of Avhich the foetal head is found completely filling up the passage-way. Occasionally the finger will encounter the an- terior lip of the os uteri, for it is sometimes forced down by the ad- vancing head and becomes distended over it. As the pains and the quasi-involuntary muscular efforts continue the head advances more and more, and as it passes along the utero-vagi- nal channel pressure is made on the rectum, the contents of Avhich are expelled, and even a part of the intestine itself in some instances. Finally, the floor of the pelvis is reached, and pressure upon and dis- tension of the perineum and dilatation of the vulva folloAV. The head advances still farther under the operation of the combined mus- cular exertions, the perineum and vulva are distended, while the head of the foetus is moulded to accommodate itself to the channel and outlet, and begins to be extruded through the vulva. Finally, at the moment when the expulsive efforts are at their greatest, and the woman is in a condition of intense mental excitement, the head is LABOR. 177 born. This is usually folloAved by a moment of relief and rest, but frequently the efforts of the uterus are continued, and the child is forced into the world, one shoulder coming out under the pubic arch and the other passing over the floor made by the distended perineum. As soon as the body of the child is born the remaining portion of the liquor amnii, that Avhich was dammed up by the occupancy of the channel by the foetus, is discharged, and the uterus contracts upon itself. This completes the second stage of labor. III. The Third Stage.—After the termination of the second stage of labor in the birth of the child there is usually a lull, as though the uterus Avere resting from its exertions. Soon, hoAvever, there is a return of pain, Avhich is slight and excites no bearing-down effort on the part of the mother. This usually marks the detachment of the placenta and its extrusion into the vagina, or even its expulsion through the vulva. This is commonly followed by a slight gush of blood. The uterus will then be found low down in the pelvic cavity, hard and globular, and contracted to about the size of a foetal head. The subsequent pains—or after-pains, as they are called—serve the im- portant purpose of completing the contraction of the uterus, and by thus closing the mouths of the uterine sinuses, rendered patulous by the detachment of the placenta, preventing hemorrhage which would otherAvise occur. A pain, in labor, signifies the contraction of such muscular fibres as are concerned in giving birth to the child, and the sensation of pain produced in such contractions results from pressure upon the nerves distributed in the tissues, especially of the uterus itself, thus contracting, the forcible distension of the os, and the dilatation of the utero-vaginal channel. The sensation of pain is felt in the back, abdomen and elseAvhere by virtue of reflex action, by which the seat of the pain is located at the central origin of the nerves themselves, rather than at their peripheral terminations. During the entire course of the parturition the child takes no part in its delivery ; it is entirely submissive, as it has been during its entire stay in the uterine cavity; it is entirely neutral and passive, and is expelled entirely by the last act of reproduction on the part of the mother. The more active the muciparous glands in this vital act the more easily is the child brought forth, the abundant glairy discharges rendering the labor a moist one and comparatively easy. Where little or none of this mucus is secreted the labor is called dry, and is con- sequently more painful and tardy. The bag of waters, known as such, is simply the amnion and cho- 12 178 LABOR. rion distended in advance of the presenting part of the child by the bulging of the liquor amnii in consequence of the pain. The Duration of Labor is exceedingly variable—even Avhen no obstacle seems to oppose the delivery—lasting from one hour to a Aveek, and between these two extremes there is every intermediate grade. In general, labor is longer in primiparae than in those Avho have had many children or are nearer the climacteric period of life. As a general rule, the average length of time may be set doAvn at from six to twelve hours. The duration of the labor is expected to be an- nounced as soon as an examination is made per vaginam. But much caution should be used in this matter, for it is discouraging to the patient to overrun the specified time. After the first stage is passed, the second will be two or three times shorter, other things being equal, the diameter of the straits all being normal and there being no undue rigidity of the soft parts. In other cases the time will vary according to the changed conditions. It is, after all, utterly impossible to pre- dict the time of delivery with certainty. The Effect of Labor upon the Mother and Child.—On the part of the mother there is often much despondency at the com- mencement of labor, and during the first stage there is apt to be more or less distress of body and mind—a feeling of despair, as if she could not endure to the end, or a feeling of fretfulness or irritability. But as soon as the second stage sets in the patient nearly always is in better spirits,; she becomes more hopeful and bears her pains, and vol- untarily exerts herself, with greater confidence that she will be deliv- ered all right. She often perspires profusely and becomes much exhausted during labor. The whole process of parturition is apt to be a great shock to the nervous system, and there is danger of great prostration during delivery, similar in effect to that produced in persons sustaining a severe mechanical injury; even a complete col- lapse may sometimes occur. Great care is needed, immediately after the completion of this great event, that the patient get quiet sleep as soon as possible. She should not be allowed to talk, and much less should the accoucheur try to have a little pleasant conversation with her after the labor is over. Such a course cannot be too severely cen- sured, since it may be attended with fatal consequences. A little sleep goes very far toward making all safe. On the part of the child the effect of the labor varies with its severity and its duration; and the shock of the compression of the uterine contractions is more severely felt upon male than upon female children, as before stated. In many cases the sad effects are LABOR. 179 immediate; in others more remote and proportionally more in- jurious. In regard to the force possible to be called into operation during the progress of labor, the experiments and calculations of Professor Haughton are certainly very interesting. He has shown that the ex- pulsive force of the uterus during the first stage of labor in accom- plishing the dilatation of the os amounts to about 3.4 lbs. on the square inch. In addition to this, Dr. Haughton has calculated the force capable of being exerted by the mother in her expulsive efforts to be equal to 38.6 lbs. to the square inch. So that, taking the uterine and abdominal forces together, we have a total of 42.0 lbs. to the square inch as representing the force capable of being exerted in the expulsion of the foetus. It is not to be supposed that this great power is neces- sary, or that it is brought into operation in any stage of labor. The immense power dependent upon the action of the muscles of the woman apart from those of the uterus, is more or less dependent on the will, and hence, it will be perceived, the use of chloroform must interfere Avith labor to the extent that it lessens the power to cause voluntary muscular effort. The Mechanism of Labor. The mechanical phenomena of labor have relation strictly to the child. It is very evident, from the knowledge we possess of the form and mechanism of the pelvis and also of the child, that there must be a mechanical adaptation of the latter to the former, in order that it can be born, and that in order to secure this result there must be certain presentations and positions at the superior strait. Almost any part of the child may present at the superior strait, making almost an infinite variety of presentations, but for all prac- tical purposes it will be sufficient to describe only five; for when the accoucheur recognizes either of these he will be able to deter- mine Avhat, if any, mechanical means may be needed to produce relief. These five presentations are: I. Vertex Presentation; II. Facial Presentation; III. Presentation of the Pelvic Extremity; IV. Pres- entation of the Right Lateral Plane of the Trunk; V. Presentation of the Left Lateral Plane of the Trunk. Each of these five presentations may have one of six positions— as, for instance, in vertex presentations the occiput must lead the way in labor, for it is, as it Avere, one end of the head. Then the occiput is described as being in the left iliac region, anterior, transverse or V 180 LABOR. posterior; or in the right iliac region, anterior, transverse or poste- rior. That is to say, the position is left occipito-iliac anterior, left oc- cipito-iliac transverse or left occipito-iliac posterior, according as the occiput is in the left half of the pelvis and at the ilio-pectineal emi- nence, transversely across the pelvis, or at the sacro-iliac symphysis. And the position is right occipito-iliac anterior, right occipito-iliac transverse or right occipito-iliac posterior, according as the occiput is in the right half of the pelvis and at the ilio-pectineal eminence, trans- A^ersely across the pelvis, or at the sacro-iliac symphysis. In facial presentations the chin would lead. Then the position Avould be styled right mento-iliac anterior, right mento-iliac transverse or right mento-iliac posterior, if the chin Avere in the right half of the pelvis and at the right ilio-pectineal eminence, transversely across the pelvis, or at the sacro-iliac symphysis. And they would be styled the left mento-iliac anterior, left mento-iliac transverse or left mento-iliac posterior, if the chin occupied corresponding positions in the left half of the pelvis. In presentations of the breech the sacrum is regarded as the point determining the position, and the positions are called, according to circumstances, the right sacro-iliac anterior, right sacro-iliac transverse, right sacro-iliac posterior, or left sacro-iliac anterior, left sacro-iliac transverse, left sacro-iliac posterior. In presentations of the trunk, when the right lateral plane presents, the head must be either in the right or the left half of the pelvis, and hence we have the right cephalo-iliac anterior, right cephalo-iliac trans- verse or right cephalo-iliac posterior, and the left cephalo-iliac anterior, left cephalo-iliac transverse or left cephalo-iliac posterior positions. In presentations of the left lateral plane the same terms, according to circumstances, must express the positions with sufficient accuracy for practical purposes. , Each of these presentations will iioav be particu- larly explained. The Vertex Presentation.—This occurs very much more frequently than all the others put together; as, for instance, of twenty-two thou- sand five hundred and thirty-seven carefully observed cases, only eight hundred and fourteen were found to be of any other presentation. And of the vertex presentation the very much larger proportion of cases is found to be in the left occipito-iliac anterior position. This position, which occurs the most frequently, is found to be the most natural of all, and the one by Avhich delivery is most easily accom- plished. The diagnosis of the vertex presentation is made out by feeling a LABOR. Igj large, round, hard, smooth tumor, while examining per vaginam either at the superior strait or descending into the cavity of the' pelvis. The stethoscope will also reveal with much certainty the presentation of the vertex, by the beat of the foetal heart being heard low down in the abdomen. The vertex presentation being made out, it remains to define the position by means of the position of the fon- tanelles and sutures. By carrying the finger a little backward and upAvard on the head the sagittal suture will be encountered, and if it runs from before backward, from left to right, and if the anterior fontanelle is toward the right sacro-iliac symphysis, the position must be left occipito- iliac anterior. But if the anterior fontanelle is found to be at the left ilio-pectineal eminence, the position must be right oftcipito-iliac posterior. Either fontanelle, anterior or posterior, may be ascertained by tracing along on the sagittal suture each way, backward or for- ward. In this manner are all the positions of the vertex presenta- tion ascertained. The mechanism of labor where the position is Avith the occiput in the left half of the pelvis is usually the same in all cases. The occiput being left anterior, transverse or posterior, the contractions having begun and the liquor amnii having partially escaped, the first effect upon the child is to flex the head more perfectly upon the chest, which constitutes the first stage in the mechanism of labor. This has the effect to bring the long diameter of the head in harmony with the axis of the superior strait. The second stage is completed when the head descends into the cavity of the pelvis till its crown presses upon the floor of the pelvis. The third stage and rotation is accomplished from left to right till the progress of the head is arrested by the back of the neck resting upon the symphysis pubis. While the third stage is in progress the shoulders rotate into the long diameter of the supe- rior strait and engage therein. During the fourth stage the shoulders and chest descend to the floor of the pelvis, extension of the head upon the neck takes place, and the head is born by the occiput slip- ping up in front of the symphysis pubis and the perineum retracting from over the forehead, face and chin of the child. (See Fig. 43.) Now the fifth and last stage in the mechanism of labor is accom- plished by the shoulders rotating into the long diameter of the inferior strait, which produces external rotation of the head, and the child is delivered. It will be observed that the external rotation of the head is not an isolated fact, but that it is in consequence of the shoulders rotating 182 LABOR. into the long diameter of the inferior strait, and that this corresponds to the previous rotation of the shoulders into the superior strait sim- ultaneously with the rotation of the long diameter of the head into the inferior strait. The face in these positions ahvays appears on the right thigh of the mother. The right or anterior shoulder is the first to appear in the fissure of the vulva, but the left or posterior shoulder is the first to be set free by means of the perineum retracting from it, and it is thus in reality born first. Fig. 43. In Figure 43 the relative positions of the head are seen in the various degrees of disengagement and extension, the nape of the neck resting first behind and then under the symphysis pubis. The mechanism of labor, the occiput being in the right half of the pelvis, whether it be anterior, transverse or posterior, is all the same usually as that just described. The same stages are passed through, but the rotations are now all from right to left, and consequently the face will appear at the left thigh of the mother instead of the right as in the former case. When the occiput is at the right sacro-iliac sym- physis it should always rotate to the front and appear under the arch of the pubes, precisely the same as when it is at the left sacro-iliac symphysis; which it sometimes fails to do, but slips into the hollow of the sacrum and remains behind till the completion of the labor, when the forehead appears under the arch and the occiput is first dis- engaged at the posterior commissure of the vulva. (See Fig. 44.) It may happen that when the occiput is in the hollow of the sacrum the head becomes gradually extended by the vertex being detained in the sacral depression, and the presentation becomes converted into one of the face. LABOR. 183 Inclined or irregular vertex presentations are usually aided in re- covering a regular presentation by changing the mother's position upon the same side as the inclination; thus, if the sagittal suture is inclining far upon the right side, by turning the patient upon the right side the child's body will fall down upon that side and the inclina- tion will be rectified at once; and if inclined upon the left side, by turning the patient upon that side a similar result will be attained. Fig. 44. In Figure 44 is portrayed the disengagement of the head, it having failed to rotate to the front, as usual, to come under the symphysis pubis. After the birth of the child, if inspection is made at once, it is always easy to tell the position it occupied from the sero-sanguineous tumor upon that part which presented; for the presenting part not being in contact with anything and pressure being made upon all other parts of the child, the fluids are forced into this part; all of Avhich soon subsides after the birth of the child. This sero-san- guineous tumor need not be mistaken for cephalsematonia, for the former exists at birth, the latter does not appear for some hours after; the former is large and purple, the latter smaller, the skin not dis- colored ; it is fluctuating or pulsating and has an osseous border. The sero-sanguineous tumor does not exist if the child perishes long before birth; from which fact a medical jurist can draw an important infer- ence in fixing upon the time of death of a newly-born child. Facial Presentation.—According to standard authorities this pre- sentation occurs about once in three hundred labors. The head, in- stead of being flexed upon the chest, is extended upon the neck, so that the face looks right down into the superior strait. In vertex presentations the occipital end of the long diameter leads the way in parturition; now in facial presentations the other end of the long diameter must lead the way—that is, the chin; of course, then, the 184 LABOR. chin must become the point of departure. Then we have the left mento-iliac, anterior, transverse or posterior; or the right mento-iliac, anterior, transverse or posterior. The cause of this unnatural presentation, except when it is produced by the accidental exchange of other presentations, can only be ac- counted for as the result of some previous conditions of the mother, which may be beyond our power to designate exactly. This presentation of the face is diagnosed by feeling the depression of the eyes, the prominence of the nose, the mouth and the chin, and more especially by feeling the upper and lower gums and the inter- vening tongue. The relate position of the chin will also determine the exact position in this presentation. Mechanism.—As the right mento-iliac transverse position is the most frequent of any of the facial presentations, we will describe the mechanism in this for all the others—since they are similar—only it should be remembered that the rotation will be from right to left, or the reverse, according as the chin is in the right or left iliac regions. After the liquor amnii has been discharged and the expulsive pains begin to operate, the first effect is to produce forced extension of the head upon the trunk, so that every pain has a strong tendency to throw the child's neck backward. (See Figs. 45 and 46.) Descent noAV goes on, the chin leading the way, till its farther progress is ob- structed by the breast coming in contact with the superior strait. Noav, rotation must commence and continue till the chin comes round in front sufficiently for the length of the neck to span the depth of the pelvis, and the chin to pass under the arch. By this time complete descent and rotation have taken place, for the depth of the pelvis is here so shallow as to allow the neck to span it completely, and the croAvn of the head rests upon the floor of the pelvis; and this is the only point at which such a result can be obtained. Flexion now begins to take place slowly around the symphysis as a centre, and finally the chin rises up in front of the symphysis pubis, and the crown of the head descends on the anterior face of the sacrum and coccyx, and is finally disengaged at the posterior commissure of the vulva. (See Fig. 43.) External rotation is effected by the shoulders rotating into the inferior strait. Internal rotation causes the shoulders to place themselves in the long diameter of the superior strait. By no other means can a viable child be born in facial pre- sentations than that rotation shall bring the chin under the arch of the pubis, unless the presentation itself should be changed into one of the vertex or some other. Sometimes this actually does spontan- LABOR. 185 eously take place by the chin, when it is posterior, engaging in the sciatic notch; the progress of the child continuing gradually flexes the head upon the trunk, and the vertex appears under the arch of the pubis, as in original vertex presentations. Inclined or irregular facial presentations—when the chin or one cheek is found in the centre of the superior strait—by continued contractions gradually regain the normal face presentation. Fig. 45. Fig. 46. Figure 45 exhibits the face in the right transverse mento-iliac position, after the forced extension. Figure 46 shows the face in the same position, although more fully engaged. Figure 47 exhibits the passage of the chin under the symphysis, the head descend- ing on the anterior face of the sacrum and coccyx, and the occiput departing more and more from the shoulders. Facial presentations are by no means so safe for mother or child as are those of the vertex, yet in a very large majority of the cases they terminate favorably to both. The position is such that at every con- 186 LABOR. traction the expulsive force upon the child is much diminished by the rolling back of the head upon the spine. Dilatation and rotation are not effected so rapidly on this account, and the child must of course remain, as a general thing, much longer in the pelvis. Presentations of the Pelvic Extremity.—We class as such presenta- tions all those of the feet, knees and breech, since in labor the same mechanism pertains to all alike. In the breech presentation the sacrum forms the point of departure for determining the relative position; the anterior face of the tibia in presentations of the knees; and the heels in footling cases. As in the vertex or face presenta- tions the positions may be left sacro-iliac or right sacro-iliac, and of the anterior, transverse or posterior varieties. Presentations of the breech are much more frequent than those of the face, and very much less frequent than those of the vertex; thus, of sixty thousand four hundred and twenty-tAvo cases reported, two thousand and eighty-two Avere breech presentations. A breech presentation may be recognized, on digital examination, by feeling the cleft between the nates, instead of the sagittal suture as in the vertex; in addition we find in the anus with its sphincter, instead of the fontanelles, a positive and not to be mistaken charac- teristic. The coccyx and sacrum will enable us to decide as to the part of the pelvis they occupy, and consequently to determine the position exactly; when the feet or one foot presents, the heel will enable us to decide as to the position. It must be recollected that a foot is articulated at right angles with the leg, Avhich fact alone will enable us to decide between the hand and foot, since the hand is in a straight line with the arm. The knees seldom present, but when they do it is easy to make them out by recognizing the popliteal spaces. The Mechanism of Breech Presentations.—-The position being the left sacro-iliac anterior, and the membranes ruptured, the first stage is one of descent to the floor of the pelvis, the child's legs, arms and chin being folded in the same position as in the vertex presentation. The next stage is one of internal rotation, where the left hip comes under the arch of the pubes, and at the same time the shoulders are made to come into the long diameter of the superior strait. The next stage is the expulsion of the breech, during which time the child is strongly flexed upon its left lateral border, to correspond to the curve in the excavation of the pelvis. As the breech is delivered the body descends with the arms folded up, and the chest and shoulders rotate into the long diameter of the inferior strait; the long diameter of the LABOR. 187 head passes through that of the superior strait, and finally rotates itself into the long diameter of the inferior strait; and the head is born with the chin still strongly flexed upon the chest, and the back of the neck and occiput under the pubic arch. (See Figures 48, 49 and 50.) Fig. 48. Fig. 49. Figure 48 exhibits the presentation of the breech in the left sacro-iliac anterior position. Figure 49 exhibits the same position after internal rotation is accomplished. Fig. 50. Fig. 51. Figure 50 illustrates the delivery of the breech. Figure 51 exhibits the delivery of the head in the sacro-iliac posterior position. The faint outlines show the successive stages of the flexure of the chin upon the already delivered chest, which may be greatly assisted, if need be, by the pressure of the operator's finger introduced into the child's mouth. 188 LABOR. If the breech is in the right sacro-iliac posterior position, the mech- anism is the same, only rotation occurs from right to left. If the feet appear first, or the knees, the mechanism is still the same as in the former breech positions. Sometimes it occurs that rotation is re- versed, so as to bring the occiput into the hollow of the sacrum, in Avhich case the face will appear under the arch of the pubes, and if the chin remain flexed upon the chest all will go on well. If not, the chin may be flexed by placing a finger in the child's mouth and pulling it doAvnAvard. (See Fig. 51.) Presentations of the feet, knees or breech are more tedious, and con- sequently rather harder for the mother, than are those of the vertex. The largest part escaping first, the smaller quite easily folloAvs; but the smaller escaping first, there is less remaining in the uterus with which to force out the most difficult part. For instance, if all but the head escapes, it often becomes a difficult matter to expel that for Avant of leverage or purchase-power in the uterus itself. The child itself is much safer in vertex presentations. This is true in the first place on account of the cord, Avhich is more likely to be- come compressed and strangulated in breech presentations—an acci- dent from Avhich the child necessarily perishes. For after the breech and abdomen are born up to the navel, the cord must be more or less compressed till after the delivery of the head, since the placental ex- tremity of the cord extends of course far above the head, even to the fundus of the uterus. Another danger to which the child is exposed in breech presentations arises in this manner: the smaller part escap- ing first, the uterus becomes sufficiently emptied to allow the contrac- tions to detach the after-birth before the head is expelled, and the child perishes from asphyxia. Thus, it is evident that it is very much safer for the child to have the head expelled first. It is not safe for the accoucheur to leave a breech presentation, even for a brief period, after the os is well dilated, as it may happen that during an expulsive pain the cord is prolapsed and expelled beyond the vulva. In such a case delivery at once is necessary to save the life of the child. Presentations of the Trunk.—These are all comprised under present- ations of the right lateral plane or of the left lateral plane, either an- terior or posterior. The head is always taken as the point of depart- ure, it being either in the left or in the right half of the pelvis, consti- tuting the left cephalo-iliac anterior or left cephalo-iliac posterior, or the right cephalo-iliac anterior or right cephalo-iliac posterior. In each case the back is either anterior or posterior. It is quite common to find LABOR. 189 the hand or the hand and arm in the A7ulva in either of these posi- tions ; but this is of no account, as it neither alters nor complicates the matter at all. This presentation occurs rather more frequently than do those of the face; many estimates have been made, but a fair aver- age Avould be about one in one hundred and fifty cases. A failure on the part of Nature to place the child in a more auspicious position is the only assignable cause for so unfortunate a condition. The shoulder is usually the first point touched in making a digital examination. The acromion process is distinctly made out, and then the claAricle, the spine of the scapulae and the axillary space, all com- bined and always within reach of the finger, confirm the presentation to a certainty. All these being made out, Ave can tell the position of the child, for the axillary space always looks aAvay from the head, and the clavicle will also tell where the face is, as the scapula Avill tell Avhere is the dorsal region of the child. When the elbow alone is accessible to the finger, it can be recog- nized by three protuberances, the olecranon process and the two con- dyles, and also by the transverse space in the bend of the elboAV, and by the vicinity of the chest and the intercostal spaces, for the arm is always found lying upon the chest. The elbow ahvays points away from the head, and-the forearm is always on the anterior plane; thus we at once know where the head and face are Avhen Ave diagnose an elbow. If the forearm is not doubled up, but lies in the vagina, by turning the palmar surface upward and in front, the thumb Avill ahvays indi- cate which hand it is by its being next to the corresponding thigh of the mother, and then to determine where the head is it Avill be neces- sary to slip the finger up to the axillary space. When the hand comes out of the vulva its dorsal surface will always correspond Avith the direction of the head, and the little finger with the dorsal surface of the child. The presentation of the trunk at the superior strait is ahvays an in- dication for manual treatment. Still, under certain circumstances a spontaneous delivery may take place, and this is effected either by spontaneous version or by spontaneous evolution. Of spontaneous version there are tAvo varieties—one cephalic, the other pelvic. In the former, where the shoulder presents, the trunk ascends under the in- fluence of the uterine contractions and the vertex comes into the supe- rior strait; in the latter the head ascends into the fundus under the same influence, and the trunk comes into the superior strait; and in either case of course a spontaneous delivery is effected. 190 LABOR. Spontaneous Evolution*—" The mechanism of spontaneous evolu- tion is much better understood, and in its description we shall find all the divisions of the mechanism of natural labor in the presentations of the vertex and face. M. Velpeau admits a spontaneous cephalic and a spontaneous pelvic evolution. But since we can conceive of a spontaneous cephalic evolution only in abortions, or in cases where the fcetus is completely putrefied, we shall speak of the pelvic evolu- tion alone. "Take, for example, the first or left cephalo-iliac position of the right shoulder. In this variety we find the cephalic extremity is placed in the left iliac fossa, the breech in the right iliac fossa, the dorsal plane of the foetus being in front, the sternal plane behind; so that its long axis is almost exactly in the direction of the transverse diameter. " Immediately after the rupture of the membranes the waters almost entirely escape; the uterus forcibly contracts, and pressing in every direction upon the trunk of the foetus tends to engage the presenting part in the excavation. " A. Under the influence of the uterine contractions the fcetus in its long axis is strongly flexed upon the side opposite to that which pre- sents ; in the case proposed the head is turned toward the left side and the breech toAvard the hip of the same side. This first change in the situation of the foetus may be designated as the movement of lateral flexion. " B. Then begins a second period, which we may term the period of descent; that is to say, as the contractions are renewed the shoulder tends more and more to approach the inferior strait, and the trunk, bent double, engages itself deeply in the excavation. But here appears the same difficulty as in presentations of the face (see position of the face), that it is impossible for the shoulder—the trunk being thus placed transversely—to reach the inferior strait unless the head at the same time engages with it in the excavation, or unless the neck should be long enough to reach the Avhole length of the lateral wall of the ex- cavation, Avhich AA-e have already seen to be impossible. The descent of the shoulder is governed, then, by the length of the neck. " C. Then follows a movement of rotation, by means of which the long axis of the child, originally transverse, assumes almost exactly an antero-posterior direction, so that the head rests above the hori- zontal ramus of the pubis near its spine, and the breech above, or rather in front of, the sacro-iliac symphysis. The movement of rota- tion being accomplished, that of descent may now be completed, since * Translated from the French of M. Cazeaux. LABOR. 191 the side of the neck is placed behind the symphysis pubis, equaling its Avhole length. Thus the forearm and arm make their appearance at the vulva, the arm and shoulder having passed under the arch of the pubis. " D. Under the powerful efforts of the uterus the trunk, bent double, is pressed into the excavation, but the shoulder can descend no farther, because it is arrested by the shortness of the neck. The expulsive force acts upon the pelvic extremity, forcing it more and more toAvard the floor of the pelvis, and causing it to traverse the anterior face of the sacrum, till finally it reaches, depresses and drives the perineum before it. Presently the vulva dilates, and—the acromion remaining fixed under the symphysis—the superior and lateral portion of the chest, the inferior part, the loins of that side, the hip, the thighs, and finally the whole extent of the lower limbs, success- ively make their appearance at the posterior commissure of the vulva; and the head and left shoulder only remain in the excavation, and these parts are extracted or expelled without difficulty. This last movement may be considered the fourth stage of the labor, and may be named the stage of deflexion or disengagement. This movement has for its centre the shoulder engaged beneath the symphysis; and if from this centre we extend lines to all the points of the side of the foetus, we shall have here the radii which subtend the antero-pos- terior diameter of the inferior strait. " This is, very exactly, the mechanism of the spontaneous evolution in those cases in which the posterior plane of the child Avas primarily in front; that is, in the first position of the right shoulder, and in the second position of the left. For in this latter there is this difference only, that the movement of the rotation must be in the opposite di- rection, that is, the head must turn from the right to the left, and from behind forward; and the breech must, turn from left to right, and from before backAvard. " But where the sternal plane of the foetus is originally turned for- ward—as in the first position of the left shoulder and in the second position of the right—the movement is somewhat different. M. P. Dubois, Avho had an opportunity to see tAvo such cases, states that at the moment of the disengagement of the breech at the anterior perineal commissure the entire trunk of the child experienced a movement of torsion that brought the dorsal plane of the foetus still farther forAvard and upAvard, which, without this movement, would have been directed toAvard the anus. Thus it happens—and we cannot but declare it a very remarkable circumstance—that even here we find 192 THE CARE OF THE WOMAN DURING LABOR. the same general law that Ave have already seen to regulate every natural labor, that whatever may be the primitive situation of the pos- terior plane of the foetus, it ultimately places itself in relation with the anterior parts of the pelvis. " As Avas observed at first, it is easy to submit the mechanism of spontaneous eA^olution to the same divisions as the delivery by the face. We have, in fact, a first period of flexion of the trunk of the fcetus toAvard the side opposite to that which presents; a second one of descent, interrupted by the third movement or stage of rotation; a fourth period of deflexion or disengagement; and according to the ob- servations of M. Dubois for the dorso-posterior positions, we may add a fifth movement, or period of exterior rotation." Such is the account given by M. Cazeaux. Of course no one at the present day Avould think of allowing any of these unnatural pres- entations to continue for the sake of observing a possible spontaneous evolution. Speedy interposition should be instituted for the humane purpose of saving both mother and child. CHAPTER XIII. THE CARE OF THE WOMAN AND OF THE CHILD DURING AND AFTER LABOR. The Care of the Woman During Labor. HEN summoned to attend upon a case of labor, it is better to go provided with a male and a female catheter, a pair of forceps and a blunt hook. Emergencies may arise requiring in haste the use of one or more of these instruments, and no time should be lost in sending for Avhat might so easily be taken in the first instance. A case containing medicines should likewise be taken to meet any emer- gency demanding the exhibition of the appropriate homoeopathic remedy. Before entering the room our arrival should always be announced, that we may not shock our patient by our unexpected entrance. We should take especial care to appear in an easy, unaffected manner; and Ave should have no other thought in our mind than to attend strictly to our business in as agreeable a manner as possible. W THE CARE OF THE WOMAN DURING LABOR. 193 First Ave should inquire into the nature of the pains, with a view to prescribe for any abnormality that may appear in the sufferings of our patient. When this grand function commences, the pregnant Avoman comes into a new physiological state, and if harmony exists throughout her entire organism, her labor will be comparatively free from suffering, and parturition will be accomplished as speedily as is consistent Avith safety. If a want of harmony should exist, symptoms Avill be devel- oped and manifested in some way, by means of which the follower of Hahnemann will be guided to make that selection from the great storehouse of the Materia Medica Avhich shall at once relieve and re- move the disarray and re-establish harmonious action. Anaesthesia should not be resorted to ; oblivion should not be courted at the risk of safety; for the symptoms masked and suffering suppressed, crushed under the ponderous action of chloroform or ether, what guide has the physician to the selection of a remedy for disorder, or to a knoAvledge even that disorder has arisen ? After observing attentively, without seeming to look at the woman, the nature of her pains, we may, Avhen we think it necessary, propose an examination per vaginam, in order to observe the condition of the internal organs, the presentation, etc. This vaginal examination should be conducted in the following manner: The woman should lie on her left side upon a couch or bed, with the thighs drawn up toward the abdomen. The forefinger of the right or left hand of the accoucheur should then be introduced into the vagina, and passed up- ward and backward in a direction toward the promontory of the sacrum, to reach the uterus and detect the os. The finger and even the hand used in making the examination should be anointed with lard or some other innocuous grease, for the double purpose of facili- tating the examination and protecting the hand against possible poisoning. It may not seem out of place to observe that the first object of search Avill be to see if the woman be pregnant, for it has sometimes happened that every preparation has been made for parturition Avhen no pregnancy existed. The Avriter has met Avith such cases Avhere the real facts were not revealed until examination Avas made per vaginam as if to ascertain the presentation. Having, then, determined the existence of pregnancy, AA'hich may be ascertained by noting the condition of the os and cervix, and other signs of pregnancy laid doAvn in a preceding portion of this work, the next thing is to learn if the patient be in labor, or Avhether she 13 194 THE CARE OF THE WOMAN DURING LABOR. have not, instead, certain abdominal or lumbar pains called " false pains." If she be really in labor, we shall find, on retaining the finger in the os uteri during a feAV pains, a rigidity and tenseness of the os accompanying every contraction, and folloAved, after the pain, by a corresponding looseness and state of relaxation. Or if the mem- branes are entire and become tight and firm under the contraction, relaxing as it passes off, the woman is certainly in labor. The next step is to inquire if she is at full term. This inquiry will of course be settled in our own minds affirmatively if Ave find the neck of the uterus absolutely blended or spread out into the globe of the uterus. The internal os will not be felt, the orifice leading to the membranes now being simply that of the os tinea. If the internal os still remains closed or partially so, and the cervix uteri be found still capable of being distinguished, the full term has not arrived; and we must hasten, as in threatened abortion or premature labor, to arrest all further progress by means of quietness and the exhibition of the proper homoeopathic remedy. The accoucheur should determine the position and presentation as early as possible; and if it be one of the usual and natural ones, he has little to do but watch and wait—watch the conditions, note the symptoms, and apply the homoeopathic remedy when needed; and wait for Nature to complete the process she has incepted, in her own best manner. It is Avell to cheer the patient at this period by telling her that "all is right" (if so it really be), as such a communication rarely fails to add to her comfort of mind and her contentment to bear the pangs to come. The next question to determine is, Are the membranes ruptured? And this is not always an easy task, since they are sometimes so closely draAvn over the scalp as to deceive a novice. But during a pain, unless the head has already descended low down in the excava- tion, so much water will be forced down between the membranes and the scalp as to make it quite apparent that the former are still intact. And besides, there is a certain greasy smoothness perceptible in the touch of the unruptured membranes Avhich differs from the sensation experienced in feeling the hairy scalp of the child. Bearing these things in mind, we never need be mistaken if Ave press firmly down upon the scalp, for the rough, hairy condition of the uncovered scalp is never simulated by the unbroken membranes. Next we Avish to determine how far the labor has advanced and what part of the child presents. In primiparae particularly it is not ahvays easy to find the os uteri, for sometimes it is not discoverable THE CARE OF THE AVOMAN DURING LABOR. 195 till we carry the finger far upAvard and backAvard upon the anterior face of the sacrum, nearly up to its promontory. In such cases it may be necessary for the Avoman to lie on her back till the anterior obliquity disappears; and this can be aided by the accoucheur elevat- ing the fundus with one hand applied externally, and with a finger of the other hand in the os to draAV it doAvn. If it now appear that Ave have a timely labor to treat, it will be necessary to provide for it accordingly. Where we can have our choice the Avoman should be placed in a large, airy chamber, exposed to the sunny side of the house, and as much retired as possible, if the above more important points can likewise be secured. The tem- perature of the room should be about sixty-five degrees during labor, about seventy degrees afterward ; the covering should be sufficient for the comfort of the patient. While labor is at its height the covering should be reduced as much as possible, according to existing circum- stances, thus compensating in some degree for the accumulating heat of labor. Bright light should not be permitted to strike the eye, as being liable to induce nervous irritation. Particular care should be taken that the feet are comfortably warm, not alone for the sake of personal comfort, but the pains of labor will be more apt to be natural. A strict adherence to these rules may prevent fatal or at least dangerous accidents, such as hemorrhages, chills, metastases, etc. If the boAvels have not been freely evacuated within twelve hours, she had better take a large injection at once, that no accumulation of feces remain in the rectum. She should noAv be suitably dressed for the occasion. Let her be arrayed in the dress she intends to wear in bed, but so adjusted that it cannot slip down below the Avaist. Next to this let an old sheet or something of the kind be pinned around her, so as to cover all the loAver part of the body, hips and legs. Next the bed must be suitably prepared for its OAvn protection and for the comfort of the patient. An india-rubber sheet about one yard wide should be placed across the middle of the bed upon the mattrass. A clean sheet should now be spread over the Avhole bed. Across the foot of the bed an oil-cloth or another piece of india-rubber a yard Avide should be placed, and this covered with a thick doubling of blanket. The patient should lie upon this, on her left side, with her feet placed against the foot of the bed as a purchase during the expulsive ef- forts of labor. She should lie Avith the breech near the edge of the bed, with her thighs flexed at right angles with her abdomen, and the legs at the same angle Avith the thighs. During the expulsive pains an assistant may hold her hands, or a toAvel may be so attached that she 196 THE CARE OF THE WOMAN DURING LABOR. can assist herself by draAving A\rifh her hands in the direction of the support of her feet. The rule to observe in relation to attendants is to have in ordinary natural labors only the nurse and the doctor. The doctor should be in and out from time to time, as his judgment may dictate. It is better to be absent as much as possible, and keep due surveillance over the case, till toward the close of the labor. In the first stage the woman may make herself as comfortable as she best can by Avalking about, sitting in her chair, or changing from the one to the other. Unless the labor be very protracted, cold Avater or other beverage of a cooling and refreshing nature is the only refreshment required. When the head has commenced descending into the cavity of the pelvis, and the os uteri is fully dilated, the accoucheur should not absent himself from the patient long at a time. It Avill be better for him to take his seat at the patient's bed, in a position to Avatch the appearance of her face, place the finger on the presenting part, mark well its progress, and be ready for any emergency that may arise. Some women are troubled Avith a terrible shhTering during the early part of labor or at its commencement, and sometimes it follows im- mediately afterward, but it is of no account. When it occurs as a first symptom the labor is apt to be quick. No obstetric apothegm carries with it greater Aveight of truthfulness than this, that " meddlesome midwifery is bad" when applied to natural labor. All fingering and manoeuvring, with the hope of bettering the process of nature, is uncalled for and injudicious. Parts that under the severest tax laid upon them by a provision of nature quickly rally to a normal condition and tone, may be seriously in- jured and give rise to much after suffering by being subjected to " manipulation." Interfere judiciously where interference is neces- sary, but trust to Nature where she is sufficient of herself, seeking aid from homoeopathic remedies where aid seems requisite. Women in labor are apt to be frightened at the noise of the rup- ture of the bag of Avaters, so that it is best to forewarn them in time to prevent any alarm. When the labor seems delayed by the tardy discharge of the Avaters, and the os is fully dilated, and yet the head is evidently kept back by something, it is better to rupture the sac during a pain and let the Avaters escape; then the labor will advance much faster. When the membranes are tightly draAvn over the head they can be scratched through by means of the finger-nail, and then they may be torn up each Avay by forcing the finger betAveen them and the scalp. Care should be taken, however, during the examina- THE CARE OF THE CHILD DURING LABOR. 197 tions made in the earlier part of the labor, Avhen the os uteri is not fully dilated, not to rupture the membranes, as such a mischance as the premature discharge of the liquor amnii is apt to render the labor more tedious than it othenvise would be. Sometimes the child is very movable at the superior strait, and several portions present in alternation; in such cases when the head presents the membranes may be ruptured and the head thus caused to engage in the superior strait. Where there is evidently an over- distension of the uterus by excessive amount of liquor amnii, Aveak- ening the contractions, the membranes may be punctured at any time Ave are certain of such a complication. If the membranes should be found to be too dense to be ruptured by the finger-nail, a probe may be introduced into the vagina, carefully guarded by the finger, by means of Avhich a puncture can easily be made during a pain. During the first stage of labor the woman should never bear down, since her strength must be exhausted in making such useless efforts. It is only in the second stage, when the expulsi\re pains occasion a sort of involuntary forcing, that advantage can be taken of this effort, for then only is it useful. Too much voluntary exertion should not be used at the very last, for fear of lacerating the perineum. Nor should a Avoman be alloAved to rise to the chamber near the close of the second stage, for fear of accidents, however much she may desire to eATacuate the bowels, for it is far easier to remove such discharges from the bed than to extricate a new-born child from the chamber, as has sometimes been necessary in such cases. As the head is about to escape from the vulva the accoucheur should bear his right hand upon the perineum, in such a manner as to encircle the labia as much as possible with his thumb and fingers; and Avhile he is draAving doAvn with these upon the labia, he must press gently forward and upward upon the perineum with the palm of the same hand. The Care of the Child during Labor.—Immediately after the expulsion of the head Ave should feel with one finger about the child's neck to ascertain if the cord is around it; if this is the case, a slight elevation of the cord upon the finger will cause the placental extremity to yield; thus the loop Avill become large enough to slip over the head. Should the cord prove too short for this purpose, when the next pain occurs it may still be loosened sufficiently to enable the child to pass through it in safety Avithout becoming stran- gulated. When the head is delh'ered it should be carefully supported and 198 the care of the child during labor. protected from the clots and other discharges from the uterus, the accoucheur patiently waiting for the subsequent contractions of the uterus ,to complete the delivery. The more Ave trust to nature in this respect, the better it Avill be for the mother, and the less Avill she suffer from subsequent hemorrhage and after-pains. No interference should be attempted at this stage unless demanded by the child seem- ing to be in danger of strangulation or apoplexy, Avhich Avill be evi- denced by its face becoming livid, congested and SAvollen. In such cases the child should be delivered at once, even at the risk of hem- orrhage from want of uterine action. Gentle traction may be made by the head; or, better still, if the finger can be passed iip and hooked into the axilla, traction may be made in that Avay. When the occiput remains posteriorly, we should not interfere any more than Avhen it rotates to the front, all the instructions of other accoucheurs to the contrary notAvithstanding. After the expulsion of the child it is better to turn its back to the mother and let her covering fall between the child and herself, thus at the same time bringing the child to our full view and completely protecting the mother from cold or exposure. A soft napkin should now be used to wipe the child's face, eyes and mouth. It usually cries lustily as soon as it is born, but it should be permitted to lie undis- turbed for some five minutes, or until respiration is fully established. By that time, in most cases, the cord will have ceased to pulsate until within three inches and a half of the abdomen. It should then be cut about three inches from the abdomen, care beine: taken that the blood does not spurt over the bed or one's own clothing if pulsation still continues. The child should then be permitted to lie for about five minutes longer, to alloAV the remainder of the effete blood to ooze away—just such quantity as would othenvise have been returned to the placenta. This blood is loaded with effete and noxious material, and on its way to the placenta for such purification as it could there receive Avas arrested in its course, and if permitted to enter into the general circulation of the child, or to lie congested in that part of the cord betAveen the ligature—when applied—and the bifurcation of the iliac arteries, may do great harm to the general health of the child, and I am convinced often does. In one minute the flow from the cord Avill have ceased. For the sake of cleanliness during the Avash- ing of the child, it will be more satisfactory to apply a ligature to the cord after the gush of effete blood has fairly ceased; for in some cases blood continues to ooze for some time, thus keeping the child constantly soih d during washing. The child should then be handed the care of the child during labor. 199 to the nurse, wrapped in a blanket. This may be neatly done by seizing the feet with one hand and placing the other under its shoul- ders and neck, and thus depositing it carefully in its blanket, Avhich should be handily laid for its reception. The mother should not see the newly-born babe until it is washed and dressed. As soon as con- venient it should be washed and rubbed dry. Should the cord seem large and tapering from the abdomen, care should be taken not to wound the intestine, a portion of which may be Avithin it. In such a case the cord should be cut beyond the extruded intestine, and the gut should be returned into the abdomen and retained there by means of the belly-band. After it has been properly Avashed and thoroughly dried, a piece of raAV cotton or cotton batting of the size of the palm of the hand should be laid on the abdomen just above the navel, the remnant of the cord laid on it with its cut end pointing upAArard—the cotton being arranged so as to embrace the base of the cord—and another piece of cotton of the same size placed over the cord, the whole being kept in place by the usual belly-band. So Avell con- vinced am I that this is the best plan of treatment for the navel that I do not think I shall ever change my practice to'go back to old methods. When the breech presents great care should be obsen^ed not to interfere further than to watch the condition of the cord after the lower part of the body is born. We should take hold of the cord Avith the thumb and finger, and draw it down a little to prevent it from being dragged upon at the navel. Then it should be examined to ascertain if pulsation still continues; if not, try to disengage it from compression by slipping it sideAvays or by draAving it a little loAver doAvn; for as long as the cord pulsates there is no danger to the child. But there is danger in this breech presentation of making so much traction upon the child as to pull the body aAAray from the flexion of the head, and thus cause the chin to hang upon the superior strait or to become fixed in the caArity of the pelvis. Great care should be observed till the head has descended into the pelvic cavity, and then, if there is need to hasten delivery, the finger can be intro- duced into the child's mouth, by which means extension may be pre- vented and the child delivered at once. The death of the child in breech presentations is nearly always due to the compression of the cord; therefore when its pulsations are seriously interfered Avith it will be better to make traction upon the loAver extremities during a pain, but with great care; and as soon as the finger can be introduced into the child's mouth a good deal of 200 THE care of the AVOMAN AFTER LAB )R. pressure can be applied to keep the chin down upon the chest, and then almost any amount of force can be exerted upon the shoulders with safety. As already stated, it is better as far as possible to avoid manual interference either with mother or child during labor. The more perfectly Nature can be helped by the use of homoeopathic reme- dies Avhere assistance is required, the better will it be for both parties —much less suffering will be entailed and much better health will be enjoyed in after life. Diet and Regimen of the Woman in Labor.—Cold Avater or lemon- ade is all the refreshment usually required during labor. The use of fermented liquors of any kind should be dispensed with. If the patient is in the habit of taking tea, a small quantity, either cold or warm, Avill sometimes be found very refreshing. A little broth or some other light food may be allowed in case the labor proves tedious, but no spices. It is necessary that the enema should not be forgotten Avhere it may be needed, in order that the rectum may be as free from obstruction as possible, and for other obvious reasons. The patient should be encouraged to evacuate the bladder occasionally during labor, and if there be reason to apprehend an accumulation of urine Avhich she can- not void, the male catheter should be at once employed. Much danger and inconvenience is avoided by such precautions, the over-distended bladder often becoming so paralyzed that the urine cannot be volun- tarily passed for days. Therefore always beware of an over-distended bladder during parturition. After the discharge of the liquor amnii a distended bladder can be detected by the fluctuation betAveen the pubes and the umbilicus. In order to introduce the catheter the patient should lie flat on her back, and the presenting portion of the child should be pressed backAvard and upAvard as much as may be necessary. On the Attentions to the Woman Immediately after Labor. Delivery of the Placenta. After the child has been handed to the nurse the next care of the accoucheur should be for the delivery of the placenta, for until it is removed and the uterus has contracted firmly the woman cannot be regarded as altogether free from the danger of flooding. In most cases there is a momentary suppression of the pains immediately after the expulsion of the child; upon which the pains return in a dimin- ished degree, and the placenta usually becomes entirely detached from its uterine connections, and either lies free in the vagina or is expelled delivery of the placenta. 201 without the vulva. It often happens, hoAvever, that the detachment of the placenta and its extrusion into the vagina folloAvs immediately after the expulsion of the child. If upon introducing the finger into the Angina the insertion of the cord into the placenta can be reached, it may be taken as evidence that the placenta is detached and that it may be extracted. Should the placenta be found to be still attached to the uterus after a delay of about twenty minutes, or should hemor- rhage occur, proper remedies should be administered to promote the expulsion of the placenta, Avhen the hemorrhage will be arrested by the normal contractions of the uterus. This may be aided by apply- ing the palm of the hand to the abdomen immediately over the fun- dus uteri, and making gentle pressure upon that organ as though attempting to clasp it. If the placenta has been detached and is found lying in the vagina, it^ delivery may be facilitated by making gentle traction upon the cord, in a direction toAvard the lower part of the curve of the sacrum, and afterward toAvard the outlet of the vulva, guarding the cord against being ruptured by being drawn over the symphysis pubis. Especial care should always be observed, hoAvever, not to draw too forcibly or too violently upon the cord, for fear of tearing it aAvay from the placental mass. Traction is facilitated by Avrapping the cord several times around the fingers or by enclosing it in a napkin. (See Fig. 52.) Fig. 52. MODE OF EXTRACTING THE PLACENTA. Sometimes the placenta is entirely detached from its uterine adhe- sions but is detained in the mouth of the uterus. In such a case the forefinger should be passed up into the vagina so as to pass above the edge of the placenta; the finger then being hooked into the placenta, it is easily draAvn dowmvard, and aided by traction on the cord is readily delivered. Should the placenta remain attached to the uterus, the question 202 the care of the woman after labor. arises, Should any mechanical measures be resorted to to secure its detachment? According to my personal experience, I should say quite decidedly, No ! The placenta may remain attached for hours without doing any actual harm to the Avoman. Such cases should be carefully Avatched, the indicated remedy selected and administered, and the result is usually a speedy detachment and expulsion of the mass. Cases must be very rare, indeed, in which other means than the above need to be resorted to. Friction over the uterus or pressure upon that organ may bring about uterine contractions and the expulsion of the placenta, but if the end can be secured through homoeopathic medicines it must be much more satisfactory. Nevertheless, should there be hemor- rhage—which may result from a partial adhesion—which we cannot control, we must not wait till our patient is hopelessly sacrificed, but after relying upon the selected remedy as long as Ave may feel safe in doing so, the hand should be introduced into the uterus and the at- tempt carefully made to insinuate the fingers between the placenta and the uterus until the placenta'is, if possible, entirely separated from the uterine surface (see Fig. 53), Avhen it should be carefully scooped out. Fig. 53. THE MODE OF BREAKING UP THE ADHESIONS OF THE PLACENTA. Sometimes the placenta is found to be retained by a spasmodic con- traction of the neck of the womb, so that it is impossible to extract it until this spasm has abated. Sometimes, again, and more frequently, Ave find what is called the hour-glass contraction, as shoAvn in Fig. 54. Other abnormal contractions may occur Avhich Avill render utterly impossible the delivery of the placenta until the proper remedy ha? been giA'en to relieve the morbid irritability which gave rise to the abnormity. All these anomalies have a vital origin, and Ave have only to interpret rightly the symptoms Avhich they present, exhibit the corresponding remedy, and the whole difficulty Avill be removed. the care of the woman after labor. 203 The remedies most usually appropriate for these occasions will be mentioned in the therapeutical portion of this Avork. Fig. 54. THE HOUR-GLASS CONTRACTION OF THE WOMB. When some portions of the placenta are retained and cannot be removed, Ave must treat the symptoms as they arise, and thereby ward off any danger that may accrue from putrid absorption. When any difficulty appears in relation to the delivery of the pla- centa, Ave should ahvays examine through the abdominal walls in order to ascertain Avhether the uterus presents its regular globular form, or whether there may not be a depression in its fundus, shoAv- ing a tendency to inversion; for it sometimes occurs that a complete inversion takes place in this manner. If a tendency in this direction be discovered, and if a remedy can- not be found Avhich will cause a return of the uterus to its natural condition, the hand must be used for this purpose. If there be discovered already a complete inversion, Avith the placenta attached, the latter should first be peeled off, and the uterus returned by seizing it with both hands and very carefully and steadily pressing it upward and backAvard until Avithin the vulva; then with one hand press it gently upAvard, and finally upward and forAvard. " An unfailing test by which we may judge Avhen the placenta has become detached from the uterus, and consequently when it may be removed, even though still in the uterine cavity, is the presence or ab- sence of pulsation in the cord, for Avhile it remains attached to the Uterus pulsation Avill still be felt; the cord Avill also be full and elastic under pressure betAveen the finger and thumb. When, hoAve\Ter, sepa- 204 THE care of the woman after labor. ration has taken place, the elasticity and fullness disappear, the cord gets flabby, limp and cold, and no pulsation can now be detected in it."—Meadows. When the placenta finally begins to emerge from the vulva it should be received into the palm of the left hand, and rotated with the right hand, in order to secure the twisting up and removal with it of the membranous shreds, since even a small portion left behind may occasion serious annoyance to the patient, even if it does not give rise to more serious complications. When any shred thus left behind aftenvard appears at the A^ulva, it may be removed by being seized Avith a dry napkin and extracted. The placenta, with its cord and attached membranes, should then be placed in a vessel conveniently placed to receive it, and removed from the lying-in chamber as soon thereafter as possible. Other Attentions to the Woman.—The woman should then be made comfortably dry, and a soft dry cloth should be applied to the vulva. She should then be straightened out a little in bed, and in all respects made as comfortable as possible. No bandage should be ap- plied. Since this doctrine is so entirely opposite to the usual practice, it Avill be proper to state the reasons which have led to the adoption of this method. First: It Avill be evident, from a moment's consider- ation of the natural position of the fundus uteri, inclining forward, that the application of a bandage could not but change this position, so as to render the uterus itself nearly perpendicular to the plane of the superior strait. This must of course bring the uterus into a line Avith the axis of the superior strait; this position must evidently be more favorable to prolapsus, and it may even lead to retroversion. Second: The great object intended to be secured by the bandage is to promote the contraction of the parietes of the abdomen, both for the safety of the patient and for the symmetry of her form. Now, avo believe not only that this is better accomplished by Nature in her own way, uninterfered Avith by mechanical and compulsory appliances, but that such appliances actually Aveaken the Avails of the abdomen, and so in reality tend to defeat the very object sought to be secured. Third: The omission of the bandage, as we have found by much experience, by allowing free circulation in the adjacent parts and avoiding unnatural compression of the peritoneum and uterus, in many cases removes much of the danger from peritoneal inflam- mation, and greatly facilitates the speedy recovery of the patient. There is also less liability to prolapse of the Avomb occurring after the woman gets about, or of leucorrhoeal discharge. An abundant THE CARE OF THE WOMAN AFTER LABOR. 205 personal experience of the superiority of this non-use of the bandage or binder since the first edition of this work appeared, coupled A\nth the assertions to the same purport of numerous medical men in all parts of the country who have adopted it, warrant me in emphasizing the direction above given. The mother should be enjoined to remain perfectly passive, and she should not be subjected to a disturbing influence of any kind. A pleasant chat Avith the patient after "all is safely over" is very enti- cing, and apt to be indulged in by the nurse and friends, and some- times even by the physician ; but too much cannot be said against this most cruel and injudicious practice, and it is almost impossible to calculate the amount of mischief that has been done by a deviation from the rule enjoined. It is to be remembered that the mother has just emerged from a condition of the highest mental and physical excitation, and if this be borne in mind the necessity for perfect pas- sivity becomes at once apparent, The room should be darkened somewhat moTe than during parturition, and talking and Avhispering should not be allowed. Perfect quietude should be maintained, if possible, in order that she may sleep, AA'hich will prove very advan- tageous and refreshing. Additional covering should at once be ap- plied, and if she desires water she should be allowed to have it in plentiful quantities. After an hour or tAvo, when she may have thus rested, the nurse may safely proceed to place her in bed by gently moving her up to her position, rolling the soiled clothes up into a lump and removing them. Thus the patient will be at the same time ren- dered neat and comfortable, her clean clothes being brought doAvn from her Avaist as the others are removed, and her loAver limbs made dry and Avarm. The nurse Avill, of course, understand her duty of keeping the patient clean and comfortable by constant attention to the lochia and in other respects; but the physician should exercise the greatest care in seeing to it that the nurse does her duty fullv in this particular, as very serious complications have arisen solely through the carelessness of nurses in not giving proper attention to cleanliness. If all goes perfectly Avell with the patient, there is no need to resort to medicinal means. A dose of arnica may be given, however in case the woman complains greatly of soreness or a bruised feeling resulting either from the extrusion of the child or from the general muscular effort incidental to parturition. The accoucheur should not leave his patient for at least a half hour after the birth of the child, until he is assured that there is no danger of subsequent flooding. 206 THE CARE OF THE AVOMAN AFTER LABOR. He should carefully note the patient's pulse, Avateh her countenance Avithout exciting observation, and be governed accordingly. The relief experienced immediately after parturition is in a great majority of cases truly remarkable; according to her own expression, the patient feels " as though she Avere in heaven." Afterward, it is no uncommon occurrence, hoAvever, for the patient to be seized Avith a shivering or chattering of the teeth. With the addition of a little covering this soon passes off; she begins to feel a gloAV of heat, her skin becomes moist, and there is no more trouble. After a little sleep—which, as already suggested, she should seek to obtain as soon as possible—she seems to recover from the shock of delivery and once more appears in a natural, healthy condition. The Avoman should be visited again within from twelve to twenty- four hours. At this visit the folloAving points demand attention: First. The condition of the pulse. Second. The condition of the bladder and Avhether urine has been voided or not. Third. The degree of uterine pain or abdominal tenderness. Fourth. The cha- racter of the lochia. The general condition of the patient, the pres- ence or absence of headache, and Avhether she has had a nap or not, are likewise matters of importance to be ascertained. The pulse of the lying-in Avoman should not reach a hundred beats per minute. If it goes beyond that number there is something Avrong, and if it greatly exceeds one hundred, rising to one hundred and twenty or higher, adwe measures will be necessary to secure a restoration to health. These active measures will consist in the prompt adminis- tration of the appropriate and homoeopathic remedy; and it is some- times almost marvelous Avith Avhat benignity and with what prompti- tude the remedy thus selected acts in restoring the lost equilibrium of the system. If no 'inclination to urinate has been felt, the bladder is probably ^emi-paralyzed and needs help to resume its proper function. This help it Avill get from arsenicum, causticum or hyosciamus, accord- ing to the indications for each, as given elsewhere. All other de- rangements from the line of the true physiological lying-in state should be met Avith the proper homoeopathic remedy. At this second \'isit directions may be given for having the child applied to the breast, should all be going on well. This procedure not only serves to stimulate the mammary glands into action, but it fur- thers the neee.-sary uterine contractions. Dr. Rigby advises that the child should be applied to the breast very shortly after delivery. He says: " Even if the child sucks fairly well for only five minutes, we THE CARE OF THE WOMAN AFTER LABOR. 207 feel satisfied, for Ave cannot call to mind a single case of hemorrhao-e after the effects of this operation." There does not seem any necessity, hoAvever, for subjecting the mother in her weakened and exhausted condition at this early period to what must of necessity in most cases prove an annoyance. Unless spontaneously mo\%l, the patient's bowels should not in any way be disturbed for eight or nine days. The custom—formerly much more general than noAv in allopathic practice—of giving a pur- gative on the second or third day after confinement, is exceedingly pernicious, and sometimes gives rise to very serious consequences. Until after the secretion of milk has been well established the diet should be very simple and the room should continue to be well shaded. During convalescence, commencing after the secretion of the lacteal fluid has been Avell established, the diet may be made more generous in both meats and vegetables (eggs, oysters and fish being strictly pro- hibited), and the light of day should be allowed to enter the chamber freely, rejoicing the Avoman's sight and strengthening her in every way. The bed-covering and her OAvn clothing should provide a sufficient degree of Avarmth, and yet be so light as not to be burdensome. Heavy, close and thick material not only weighs down and swelters her, but prevents the carrying off of the effluvia arising chiefly from the profuse transpiration of the effete material, so desirable to be got rid of at this period. Let the accoucheur, at a subsequent visit, turn down the covering in cases Avhere he finds the patient heavily blank- eted, and the heat and stench escaping from the bed will suggest to him its occupancy by some offensive carrion, rather than by a living human being, and perhaps by two—the mother and her child. Can it be wondered at if such cases make a sIoav recovery ? The room should be ventilated every day, the thermometer never rising above 70° Fahr. The patient should be allowed plenty of pure cold Avater to drink, and her lavements should be sufficient for clean- liness, but always performed under cover. The feet should be sponged almost daily, one foot at a time, which should be rubbed perfectly drv and covered before the other foot is touched. The water for external use should be tepid, and free from alcohol, bay rum, cologne or any- thing of that kind. The patient's clothing and the bed-linen should be changed fre- quently, having been previously Avell aired before a hot fire in an- other room than the lying-in chamber. For two Aveeks she should keep the recumbent posture, using a bed-pan when required, changing frequently from one side of the bed to the other to rest herself and 208 THE CARE OF THE AVOMAN AFTER LABOR. permit the vacated side to be shaken up and prepared for her return to it Avith increased satisfaction; or she may be transferred to another bed or a lounge for a feAV hours daily after the first few days. At the end of the third Aveek she will be the stronger and better for hav- ing spent the first two weeks in a recumbent posture. Physicians should be particular in urging this point, as very much of the comfort, health and happiness of a Avoman's after life depends on the care >he takes of herself during convalescence after parturition. After the second Aveek, other things being equal, the woman may take a sitz-bath, the water being at a temperature of 65° or 70° Fahr. While sitting in the tub, water may be poured over her shoulders and washed doAAm for a few moments, Avhich should then be rubbed dry and covered Avhile the limbs are being Avashed and rubbed dry. The process being completed, she should go at once to bed. In no case should she go out immcdicdely after a bath. Extra caution must be observed in bathing in cold Aveather. During the third Aveek she may drive out in fine Aveather—in cold weather during the fourth Aveek, other things being equal. During the entire nursing period the diet should be plain and sim- ple, but abundant and nourishing. All abnormal conditions should be carefully attended to and the proper remedy given. The room of a lying-in Avoman should be light and airy, and Avhen the proper time comes she should walk out every day in the air and sun Avhen the weather is suitable, riding being entirely insufficient. The underclothing should not in any instance be allowed to hang upon the hips, but should be suspended from the shoulders. No Avoman can hope to remain Avell Avho allows the weight of her skirts to drag upon her hips and loins, and complaints of great magnitude may arise from this apparently trivial cause. If a Avoman should feel Aveak " after she gets about the house," she should not be recommended or permitted to fly to stimulants of any kind for relief, but the physician, being consulted, should seek the ap- propriate remedy, Avhieh may be found under the laAV of the similars. The After-Pains and the Lochia. The uterus by alternations of contraction and repose gradually re- turns after parturition from its enormous distension to its natural size. Its complete restoration in size and position generally occupies about six weeks. Sometimes, on the contrary, it suddenly grows larger from some abnormal condition, and may be felt rolling from side to side as the patient turns in bed. This condition need excite no alarm the care of the woman after labor. 209 —since the uterus will soon subside to its normal size—except in some few instances in Avhich it still remains large, with a sensation of bounding as if it contained a foetus; in such cases a dose of crocus will soon set all things to rights. As the uterus regains its normal size, the new mucous membrane becomes completed, and the spot from Avhich the placenta was peeled off is also supplied Avith a new mucous membrane by a process of granulation. As the uterus returns to its normal state the vagina also groAvs shorter, its transverse rugae return, and in the course of six Aveeks it is in all respects as before pregnancy, except that the subA^aginal por- tions of the neck may be more or less permanently shortened on ac- count of the extreme stretching upward during gestation. The uterus and vagina return to their usual condition by virtue of the elasticity of their tissues, and where this is sufficient the process is unattended with pain. But if necessary, organic contractility is also brought to aid, and this is always attended with more or less pain, constituting what are called the after-pains. During all this time a discharge from the vagina is taking place?__ first of pure blood for a day or two, which groAvs paler and paler till finally it appears as a sero-purulent liquid, often of a pinkish color; then it becomes lighter, watery, and at last entirely disappears. This discharge is called the lochia. The After-Pains. Of the after-pains it is proper to state more particularly that they are really the organic contractions of the uterine fibres, where the elasticity of the general uterine tissue is insufficient to expel the liquids with which the walls of the uterus are engorged, or the clots or shreds of membrane which are contained Avithin its cavity. When they make their appearance at all—which is sometimes not the case—these pains usually come on soon after delivery, and continue with greater or less severity from two to eight days. Fluids o.r coagula, in greater or less quantity, are discharged with each pain. It is very important to diagnose between the after-pains and those which indicate the acces- sion of puerperal inflammation; but this is an easy thing to do, since the former contract the uterus, while the latter do not, and in the former case there is usually considerable abdominal tenderness, which increases, Avhile in the latter this is absent. After-pains are commonly absent in primiparae, but almost always present in a greater or less degree in multipara?. They are generally salutary, as before remarked, but sometimes they become excessive, 14 210 the care of the woman after LABOR. unbearable, and give rise to distressing accompanying symptoms. When they assume this character, they should be checked by the ad- ministration of the appropriate remedy as laid down under its proper heading in the portion of this work devoted to therapeutics. The Lochia. The lochia constitute the discharge from the genital organs which commences soon after the expulsion of the placenta, and continues until the complete restoration of the uterus to its normal condition. This discharge results from the disgorgement of the uterus in its return to its usual size, and it is principally derived from that por- tion of the uterine surface to which the placenta had been adherent. During the first twenty-four hours the lochial discharge is quite san- guineous, and sufficient in quantity to soil ten or twelve napkins. After the first few hours this discharge gradually becomes less and less, as it passes through its four or five successive stages: first, san- guineous ; second, serous; third, milky; fourth, puriform: and when it has nearly subsided it is not an uncommon occurrence for it to freshen up and assume a pinkish hue, and then, resuming the appear- ance of a delicate, limpid pus, rapidly disappear. In about six days after parturition the sanguineous discharge should disappear entirely, and in two or three weeks more the patient should be completely Avell. In severe cases the lochia will cease sometimes earlier, sometimes later, either as a natural consequence of the attend- ant conditions or as an exception merely to the general rule; and in all such variations the accompanying sensations and conditions of the patient will indicate the treatment. During the milk fever the lochial discharge lessens or ceases en- tirely, and returns more abundantly as the fever subsides. In quan- tity this discharge varies in different individuals; some have very little, others have much ; in either case no interference is necessary, unless symptoms arise which shoAv that the unusual quantity results from some abnormal state. The lochia has a peculiar odor, differ- ing in individuals both in character and intensity. The presence of even a small shred of the membranes, Avhich may have become detached and left behind in delivering the placenta, may render the lochial discharge exceedingly offensive. In all cases the fetid nature of the discharge, or any other deviation from its normal character, will go far to indicate the proper remedy for the general morbid con- dition of which this peculiarity is one of the evidences. Throughout the lying-in period the condition of the lochia, if treatment of the child after birth. 211 abnormal, forms one of the surest and soundest indications for treat- ment. The selected remedy must always cover the condition here manifested. Every day the physician should inquire of the nurse as to the state of this discharge, and the first abnormal condition should place him on his guard against other serious disturbances which may result. We should always be watchful for the beginning of mischief, but this one of abnormality of the lochia should be especially guarded against, since it is ATery apt to be overlooked till a late hour. In such cases all the symptoms should be carefully collated and the remedy selected in accordance, but it must always cover the abnormal condi- tion of the lochia. In the treatment of cases in which there is derangement of the lochial discharge such medicines should be carefully studied as are recommended elseAvhere. Hygiene and Treatment of the Child immediately after its Birth. After the cord has been cut and the child has been given to the nurse, it should be Avashed and dressed as soon as may be convenient. Some unctuous matter, such as lard or oil, should be rubbed into all those places covered Avith the caseusa, which latter will then be entirely removed upon being Avashed Avith tepid or warm water and soap. The navel should then be dressed as directed on page 199, and the belly-band applied; then may be added the diaper, the shirt, the flannel petticoat and the outer dress or slip. This constitutes the babe's dress for the bed; Avhen it is taken up it should also have a shaAvl or blanket proA^ided for that purpose, to be laid aside upon its return to the bed. During the process of washing and dressing—which should be conducted Avith as much expedition as possible—the child usually becomes quite cold and blue. It should therefore be quickly placed in bed and covered to that degree that warmth will soon return. At his daily visits the physician should observe that the infant is not smothered Avhile lying in bed, but has an opportunity of breathing like other human beings. Its pilloAV should not be more than two inches and a half thick, and it should be made of hair, untufted, so that it may be pulled apart and made light and airy every feAV hours. Should the child be troubled with retention of urine, aconite will be the remedy most likely to afford relief. (See Dysuria.) If the meconium does not pass off naturally, mercurius, nux v., bryonia or Pulsatilla may be resorted to. (See Constipation.) The child is not ahvays born in so healthy a condition as to be ca- 212 TREATMENT OF THE CHILD AFTER BIRTH. pable of undergoing promptly the treatment above described. Some- times it comes into the world in a state of apparent death. This condition, may result from three distinct classes of causes, and may present corresponding differences in the appearance of the child. I. Apparent death of the child may result from shock to its ner- vous system in general, or from some special lesion of a particular portion of it. In the former class may be instanced the severe com- pression Avhich the brain undergoes in certain cases of contracted pelvis, and from the application of the forceps under difficult circum- stances, especially in the superior strait; in the latter class may be instanced the still more serious lesions of the medulla oblongata which may result from extreme rotation of the head, from undue traction upon the head after it is delivered, or from too much force applied to the body in order to delh'er the head still detained Avithin the pelvis. This latter is one of the most frequent causes of the fatality so commonly attendant upon breech presentations. The injury to the brain, not necessarily preventing respiration, may pass away and the life of the child still be preserved. Such, liOA\e\Ter, is not the case with serious lesion of the medulla oblongata, Avhich renders respiration impossible. HoAvever, as it may not be knoAvn that such injury exists—unless the child's neck should have been distorted by some remarkable ATiolence—every case of apparent death in the neAv-born babe should be treated as if there Avere a possibility of recovery. II. Injuries of the placental circulation may have been the cause of the apparent death of the child. These may ATariously arise from compression of the umbilical cord between the sides of the pelvis and the head or body of the child; from winding of the cord so tightly around the neck as to obstruct the circulation in the umbilical vessels; from the premature separation of the placenta, Avhich may occur in cases of delivery by the breech Avhen all but the head has been delivered, or from great retraction of the uterus itself Avhen only the head remains Avithin it, such retraction preventing the admis- sion of fresh blood into the uterine sinuses in sufficient quantity to supply the child. By either of these causes a real asphyxia may be produced. A similar condition may result from" such an accumulation of mucus in the nose and mouth as Avill prevent the introduction of air into the bronchia. In addition to the breathlessness this condition will be indicated by discoloration of the skin, Avhich may exhibit a violet or blackish-blue color; the muscles are motionless, the limbs flexible and the body warm; but the pulsations of the cord, of the treatment of the child after birth. 213 radial artery, and even those of the heart, are faint or impercep- tible. III. Lesions of the foetal circulation constitute a no less dangerous class of causes of apparent death. These may consist in rupture of the placenta or of the umbilical cord, which affects the life of the child while yet unborn; or if the hemorrhage should be arrested in any way before proceeding to so fatal an extent, the child may be born alive, but in a state of syncope. In these cases the child is very pale, the muscles are relaxed; it may make a feAv short respirations and utter some feeble cries, but unless saved by the administration of the proper remedy, it soon perishes. Treatment.—From Avhatever cause the apparent death or suspended animation of the child should result, no time should be lost in making proper efforts to establish respiration. In cases Avhere the breathing is simply deficient, and there is not a complete suspension of animation, one or the other of the folloAving remedies may be administered in accordance Avith the given indications: Aconite.—The child is hot, purple-hued, pulseless and breathless, or nearly so. Belladonna.—The face is very red and the eyeballs are greatly injected. China.—In cases Avhere profuse hemorrhage has been the apparent cause. Tartar Emetic—When the child is pale and breathless, although the cord still pulsate-. Camphor a may be given a feAv minutes after tartar emetic, if the latter shouW fail. If the child does not soon respond to internal remedies, or in cases of so grave a nature that it is apparent that these remedies can have no effect, it should be immersed suddenly in very cold water, or, better still, cold water, even iced water, should be poured over it. In some pale and apparently lifeless children pouring cold water upon the head and allowing it to run down over the body establishes the circulation and respiration ; the child should then be at once Avrapped in Avoolen blankets until quite restored. Of course in all those cases Avhere respiration is prevented by an accumulation of mucus in the nose and mouth these obstructions should be at once removed. Any or all of the above methods failing, artificial respiration should at once be resorted to by either Marshall Hall's or Sylvester's methods, Avhich are so Avell known that they need not be described here; or the lungs may be filled directly from the accoucheur's lungs, by his closing 214 TREATMENT OF THE CHILD AFTER BIRTH. the child's nostrils betAveen the thumb and forefinger of his hand, ap- plying his mouth accurately to the mouth of the child, bloAving air into the child's lungs, and, Avhen filled, by gradually and carefully compressing the thoracic Avails, emptying the lungs again. This manoeuvre shall be repeated again, not oftener than from ten to fifteen times in a minute. This artificial respiration, and all other methods resorted to to restore suspended animation, should be persevered in for some time, life having returned after even an hour had elapsed, from judicious and continued treatment. Secretion of the Milk. This function is one of the most interesting and at the same time one of the most remarkable of the phenomena transpiring during the lying-in period. While the child is still in utero the maternal prin- ciple and all that pertains to the mother unite to effect its nourish- ment, growth and development there. Suddenly all this is inter- rupted : the child is expelled from the little Avorld Avithin, and has to find nourishment elsewhere. It is supplied as before from the mater- nal blood through the medium of the mammary glands. The reac- tion upon the organism from this change from the uterus to the breasts causes what is called the milk fever, in consequence of Avhich there results a disturbance in the system more or less well marked according to the obstacles to be overcome. Hence appear chills, fevers, headaches and a great variety of pains and sufferings; even intermittent fevers are sometimes developed in consequence of this great physical change. Some women appear to have milk before the babe is born or at its birth, but this is not the real milk, since it is devoid of the true milk- globules, and is called colostrum. The change already referred to has yet to be made, and presently the real milk comes, exhibiting the true, full and plump milk-globules. The quantity of milk varies greatly; in some Avomen it is quite scanty but rich in quality, while in others it is poor in quality but abundant in quantity. Every woman in a perfectly healthy state Avill yield nourishment enough for her own babe, and when this is not the case remedial agents must be administered to bring about this much- to-be-desired result, for no child can possibly do so Avell as Avhen sup- plied with its own maternal aliment. As a general thing, all the dis- turbances incident to the coming of the milk are less when the child is applied to the breast as soon after delivery as practicable. Much advantage is gained both to the mother and babe by this method, DYSTOCIA. 215 since it serves to lessen the suffering of the one from hunger and the danger of the other from fever. When the fcetus perishes near the full term the child is still carried for a while—it may be till term. In general no milk secretes in such cases, certainly not till after the delivery of the dead child. At no time should the milk flow from the breasts except when drawn. In those cases in which it is constantly flowing spontane- ously remedies should be sought to remove the abnormality. In order to relieve the disorders incident to lactation Ave should always rely upon homoeopathic medicines. No bathing or even rub- bing of the breasts should be resorted to. Rubbing the breasts in in order to " rub out lumps" often bruises the breasts and lays the foundation for abscesses. External applications are altogether un- necessary. The remedies to be given for these varied disorders Avill be pointed out under an appropriate heading in the latter part of this work. (See Disorders of Lactation.) CHAPTER XIV. DYSTOCIA. BY dystocia is meant unnatural, " laborious, morbid or difficult labor." Labor does not always take place in what may be re- garded as a truly normal manner. It may become, by a combination of circumstances, difficult, dangerous, and even impossible. In such cases the intervention of art is demanded. These circumstances are exceedingly various and numerous, and they give rise to three dis- tinct classes of difficult labor, viz.: 1. "Those rendered difficult, dan- gerous or impossible by a defect or an excess in the action of the ex- pulsive forces. 2. Those rendered difficult, dangerous or impossible by obstacles to the expulsion of the foetus. 3. Those complicated by accidents liable to endanger the life or health of the mother and child." * In respect to the first of these classes, it should be observed that the pelvis, as Avell as the organs of generation, may be perfectly natural, and the diameters of the child may all be in harmony Avith the pas- sage, and yet the expulsive force may be wonderfully deficient, and at length may cease to act entirely. In deciding on the duration of * Cazeaux. 216 DYSTOCIA. labor, it may be adopted as a general rule that where more than twenty-four hours have elapsed since its commencement serious acci- dents may be feared either to the mother or child, and these should be anticipated by removing the cause of the excessive slowness. The fact Avhich requires particular attention in the prognosis is, that the period of dilatation of the cervix is to that of the expulsion as two or three to one. Noav, the delay may occur either in the first or the second of these stages. The first stage may be prolonged Avithout danger either to the mother or the child unless there be hemorrhage or convulsions, but Avhen the second stage, or the period of expulsion, is extended beyond ten or tAvelve hours, the uterine pains may become irregular in their return and intensity, and the foetus seem to retro- grade rather than advance—there is no expulsion. The condition of the patient at this crisis is thus described by Cazeaux: " The local disorder is accompanied, or at least soon followed, by a violent trembling; the patient has an inclination to vomit, and even throws up bilious matters; she is uneasy, excited and changes her position every moment; the skin is hot and dry , the pulse runs up to a hundred or a hundred and fifty per minute the tongue is dry, and both it and the teeth are covered with a dark coating. The vagina and cervix are hot and sensitive to the touch, and a yellowish liquid escapes from them, which occasionally has a fetid odor; the pressure of the child's head on the cervix vesicae prevents the emis- sion of urine, and the parts that line the superior strait and the pel- vic excavation being compressed for a long time by the head, may become inflamed or even gangrenous, which complications may sub- sequently prove a source of the most serious accidents. " If the Avoman still remains undelivered, these symptoms increase in intensity in a frightful manner; the vomitings become more fre- quent and the abdomen more distended; the excitability of the patient knoAvs no bounds; the pulse is more and more feeble and frequent, and she falls into a half-stupid or a semi-delirious condi- tion, Avhich is soon terminated by death. It is scarcely necessary to remark that in the latter case the life of the child is also most seriously compromised." There are numerous causes Avhich may operate to bring about this condition, some of Avhich are vital, Avhile others are mechanical. Among the former may be mentioned general debility, plethora of the uterus, inflammation of the uterus, mental emotions, various dis- eases, etc.; among the latter, over-distension of the uterus by an excess of liquor amnii, too early rupture of the membranes, etc. DYSTOCIA. 217 When the cause appears to be a vital one, the pains, too Aveak from the first, groAv Aveaker, are irregular or cease entirely, the appropriate homoeopathic remedy will almost always bring about a normal con- dition, and labor Avill go on to its completion in a proper manner. The medicines to be resorted to under these circumstances will be mentioned, together Avith their indications, in a subsequent chapter. A Avoman Avho has had a difficult labor from deficiency of uterine action in consequence of some general disease, such as gout, rheuma- tism, disorder of the digestive organs, etc., and has again become pregnant, should be very carefully treated during pregnancy, that the cause may be abated or removed, in which case she will not be apt to have a return of the uterine atony when she is again taken in childbed. Mechanical Causes of Dystocia.—Over-distension of the Uterus from Excess of the Liquor Amnii.—Cases of this kind can be recog- nized from the fact that the membranes do not bulge into the mouth of the uterus as it dilates; during the contractions the membranes are felt to be tense and to retain the globular form of the uterus. In this case the only plan of relief and of rendering the pains efficacious is to rupture the membranes, which may be readily done by plunging the finger through them during a uterine contraction. Premature Rupture of the Membranes.—In cases of this kind the early escape of a small portion of liquor amnii allows the head to descend upon the undilated mouth of the uterus, so as to hinder the escape of any more of that fluid, and of course it is all retained in the fundus above the child. The contractions gain nothing by forcing out more fluid either through the ruptured membranes or by causing the bulging of a pouch; consequently, the pains are liable to become more and more feeble. The mode of action noAv to be adopted is to introduce a finger and in the absence of a pain raise the head and hold it up during a pain, Avhen the liquor amnii will escape freely. Repeat this process, if necessary, again and again, and the pains Avill strengthen rapidly. Sometimes the child's head becomes engaged in the loAver segment of the membranes and they fit close to it, and there is no opportunity for the membranes to bulge through the os, the consequence of Avhich is that the liquor amnii is all retained above the body of the child and in the fundus of the uterus. In this case the membranes must be stretched through and the head eleA^ated, in the absence of a pain, and held there until the next pain, when the Avaters will gush out and the pains Avill gain in strength. This process may be repeated again and again if necessary, and the pains will become more and more effective. 218 DYSTOCIA. Impaired action of the abdominal muscles, occasioned by the exist- ence of some disease, such as asthma, pneumonia or dropsy, may like- wise be the cause of difficult or retarded labor. In such cases, should it become evident that nature is entirely unequal to the task of emp- tying the uterus, resort must be had to mechanical means for effecting deliA'ery. The pains may be rendered inefficacious from an over-distended bladder, the reflex from Avhich painful condition will cause the uterine contractions to cease. This may be determined by the history of the patient's case, and by great sensitiveness of the bladder when pressed, or by a dullness on percussion if she has not voided urine for a long time. In this case a catheter must be used, the male being preferred, for obvious reasons. A loaded rectum may have the same effect as the bladder in the state above described, in Avhich case it must be washed out with injections. In precipitate labor the chief danger lies in a liability to the rup- ture of the uterus from too poAverful contractions, or of the vagina or perineum. The umbilical cord may be torn asunder by the child falling on the floor, or the child may receive other injuries consequent on sudden and violent action. Some women are always troubled with too rapid labors, and, knowing from experience Avhat to expect, should adapt themselves to this condition by preserving a recumbent posture from the first pain, and restraining themselA/es as much as possible. In some cases the disposition to too slow or to too rapid labor seems to descend hereditarily from mother to daughter. The treatment of precipitate labor is usually unsatisfactory, inas- much as it generally occurs in the absence of the accoucheur. Should, however, the accoucheur be present, and the force and rapidity of the pains be in excess of what may be regarded safe, they may be miti- gated by the administration of coffea, secale, belladonna, conium, nux vomica or chamomilla. The patient should likeAvise be cautioned to refrain from expulsive efforts. Dystocia from Malformation of the Pelvis. We next come to the second group of causes Avhich render labors difficult, dangerous or impossible. The causes are mechanical, and refer themseh^es to the mother or the child. We shall first treat of those Avhich depend on the mother, and the first of these which Ave shall notice are the malformations of the pelvis. A pelvis is malformed, in the sense in which Ave here use the word, when it too greatly ex- ceeds or falls short of the average size. Excess of amplitude or of dystocia. 219 retraction, too great size or narrowness, are productive of notable obstacles in the exercise of the child-bearing function. If the ampli- tude is too great the Avoman is exposed to serious accidents in all the three states, the non-gravid, the pregnant and the parturient. In the non-gravid, because the uterus, being free and movable in an over-spacious cavity, is much more liable to the various displacements of descent, anteversion and retroversion. In the pregnant, because " during gestation the Avomb, finding more space than usual in the pelvic cavity, remains there until a much more advanced period of pregnancy, and the volume of the organ, by com- pressing the rectum and the bladder, often occasions an excessive tenesmus in these parts, Avhich proves very distressing to the patient; sometimes even the discharge of the urine and fecal matters is im- peded ; besides Avhich varices, hemorrhoidal tumors, and a considerable infiltration of the lower parts are found to be developed in conse- quence of the mechanical obstacle to the circulation of the inferior extremities."* In the parturient state, because during labor the too great amplitude of the pelvis exposes the patient to all the dangers resulting from a too rapid delivery, which we do not propose to treat of here. A woman subject to this malformation should be kept in the recumbent posture during labor, and she should be instructed not to aid the pains in any Avay, and not to bear doAvn until the os uteri is fully dilated; and even then as little voluntary effort should be made as possible. But the most terrible deformities of the pelvis are those arising from its contractions; for it must at once be obvious that a just pro- portion must exist between the dimensions of the canal and those of the body Avhich is to traverse it, and that where this relation does not hold, either through the contraction of the pelvis or the abnormal size of the child, delivery by any natural process becomes impossible. The contractions of the pelvis, according to Velpeau, are either absolute or relative—absolute when, although greatly retracted in all its dimensions, it notwithstanding is properly formed and presents no irregularity in its exterior aspect; relative, Avhen only one or more of its diameters is affected by the contraction (the others preserving, or very nearly so, their normal length), and the form is completely changed by this partial alteration. The last group of contracted pehres —viz., the relative—is the only one Avhich Avill engage our attention in this place. This deformity is referred by M. Dubois to one of three principal types—viz., either to a flattening from before backward, * Cazeaux. 220 DYSTOCIA. to a compression on the sides or to the depression of the anterior and lateral parts. The flattening from before backward, or shortening of the antero- posterior diameter, results from a more or less marked approximation of the anterior and posterior pelvic Avails; and of this species of mal- formation there are several varieties, all resulting from the extent of contraction either in height or Avidth. An example of this kind is presented when the superior strait alone is contracted, the excavation retaining its normal capacity. This phenomenon is due to an unusual curvature of the sacrum, Avhich sometimes makes an obtuse angle at A PELVIS IN WHICH THE CONTRACTION OF THE SACRO-PUBIC DIAMETER IS PRODUCED BY THE UNCSUAL PROMINENCE OP THE SACRO-VERTEBRAL ANGLE. its middle part, so that the sacro-vertebral angle is increased to an unusual degree. Sometimes the reverse happens, and the sacrum, instead of affording an anterior cavity, is quite plane, or even convex in front, and then the antero-posterior diameter of the excavation is contracted simultaneously Avith that of the superior strait, and the sacrum seems to lose its natural curvature and project forward in its whole length. Sometimes the shortening of the antero-posterior diameter of the superior strait is accompanied by an enlargement of the corresponding one at the inferior strait. This indeed is the arrangement most usu- ally met with, and this is Avhat generally happens Avhen the sacrum, yielding to the Aveight of the trunk, transmitted to it by the spinal column, tilts—that is, projects forward its base—Avhile pushing back- Avard its coccygeal extremity. Sometimes the coccy-pubic and the sacro-pubic diameters are short- ened at the same time. This happens Avhen the sacrum, instead of DYSTOCIA. 221 performing the tilting movement just mentioned, yields in such a way that its tAvo extremities are thrown fonvard, and two consequences are the result of this action—viz., the anterior curvature is greatly Fig. 56. THE SHAPE OF THE SUPERIOR STRAIT IN THE FIGURE-OF-EIGHT PELVIS. increased, and there is an enlargement of the corresponding diameter of the excavation. Another case of pelvic contraction is thus described by Cazeaux: " In the approximation of the antero-posterior Avails the sacrum is nearly always the displaced bone; but, although much more rare, a flattening of the anterior Avail is also met Avith, and then the sym- physis pubis, instead of presenting a convexity in front, is perfectly flat, or even (as in one instance represented by Madame Boivin) pre- sents a depression, Avhich seems to protrude inwardly toAvard the prominence of the sacrum. This double inclination of the pubis and sacrum toAvard each other gives to the superior strait the form of a figure of eight—that is, its plane is divided into two rounded portions on the sides, corresponding to the iliac fossse, and is separated in the middle by a restricted part of variable Avidth. If the depression is considerable, the antero-posterior diameter of both straits and of the excavation must evidently be affected by it." Or again, the extent of the symphysis pubis may be much greater in its vertical direction than usual, giving rise to Avhat is termed the bar pelvis, or it may have an excessive inclination backward at its lower end; in both these cases the pelvis is narrowed. Sometimes the coccyx is elongated, and it takes a nearly horizontal direction. This, as Avell as an immobility of the sacro-coccygeal articulation, may, it is alleged, contribute to the shortening of the coccy-pubic diameter. Compression of the lateral walls, by Avhich the transverse diameter is shortened, is the rarest of all pelvic malformations—that is, so far as the superior strait and upper part of the excavation are concerned. As regards the inferior strait, the approximation of the two ischial 222 DYSTOCIA. tuberosities, by which this species of deformity is produced, is quite as frequent as the shortening of the coccy-pubic diameter. The pubic arch, in this case, assumes the triangular form peculiar to the male sex. Moreover, the inAvard projection of the spines of the ischia mav produce a sensible diminution of the lower part of the excavation in the transverse direction. "Another variety of transverse contraction is OAving to the fact of the pelvis being less developed in one of its halves than in the other, and consequently to its exhibiting a less degree of curvature in that part than upon the opposite side. In this case the articulation of the spine with the sacrum no longer corresponds to the middle of the pelvis, and the A^ertebral column is found nearer to the hip of the con- tracted side; the transverse diameter is likeAvise diminished at the in- ferior strait by reason of the obliquity of the entering part of the coxal bone. The antagonism before alluded to as existing between the an- tero-posterior diameters of the superior and the inferior straits, Avhereby the elongation of one most frequently coincides with a shortening of the other, rarely exists in the transverse direction ; the deformity pro- duced by a congenital displacement of the femurs is probably the only condition in which the transverse diameter of the inferior strait aug- ments at the same time that the bis-iliac one diminishes, the en- largement in the lower part of the pelvis in this instance being marked by an unusual Avidth in the pubic arch, a great obliquity of the ischio-pubic ramus, a separation of the ischial tuberosities, etc."— Cazeaux. Depression of the Antero-hderal Walls.—The effect of this depres- sion is the diminution of the oblique diameters. It occurs more fre- quently than the preceding, but not so frequently as the first variety. The essential characteristic of this deformity is the flattening or the inward projection of the coxal bone at the part corresponding to the cotyloid cavity and the junction of its three constituent pieces, where- by the curve described by the pelvic circumference is more or less diminished, even Avhen carried to a high degree to the reversal of the curvature, its convexity being turned toward the sacrum, and the pubis pushes almost directly forward, the coxal bones assuming the form of an italic S, instead of presenting a regular arch. We next proceed to describe the oblique-oval pelvis, a malforma- tion produced by an arrest of development on the part of one lateral half of the pelvis, Avhile the other maintains its normal condition. The effect of this, as will readily be seen, is to throw the symphysis pubis to one side of the mesial line of the body, while the sacrum seems to DYSTOCIA. 223 be on the other side. The consequence of this is, that the cavity of the pelvis will be oval, and will occupy one or the other lateral half. A very rare form of pelvic deformity is the funnel-shaped pelvis, in Fig. 57. A PELVIS IN WHICH THE SINKING IN OF THE ANTERO-LATERAL WALLS EXISTS ON BOTH SIDES. which, Avhile the brim is normal, the cavity and outlet are contracted gradually from above downward in all diameters. Fig. 58. K FIGURE TAKEN FROM M. NAEGELE's WORK, WHICH EXHIBITS THE CHARACTERS OF THE OBLIQUE-OVAL PELVIS IN A HIGH DEGREE. The influence of these deformities on the pregnant state is rather un- favorable, from the fact that in the latter half of pregnancy the gravid uterus is not so easily and safely supported, and in the earlier period it is often more easily displaced, or it more slowly rises above the superior strait. These and other similar circumstances have a con- stant tendency to produce abortion or premature labor. It is of the utmost importance that distortion of the pelvis be de- 224 DYSTOCIA. tected as early as possible. Naegelk gives the folloAving conditions as presumptive evidence of the existence of malformation : " The lower jaAV projects beyond the upper, the chin is very prominent, the teeth are grooA^ed transversely, unhealthy appearance, ashy-pale color of the face, diminutive stature, unsteady gait; Avhen the Avoman Avalk> the chest is held back, the abdomen projects, and the arms hang be- hind ; there is deformity of the spine and breast, one hip is higher than the other, the joints of the hands and feet are remarkaBly thick ; curvature of the extremities, especially the inferior, even Avithout dis- tortion of the spine, is a very important sign; wherever the lower ex- tremities are curved the pelvis is mostly deformed. It is well to ascertain also if, Avhen a child, it Avas a long time before she could Avalk alone; Avhether she had any fall on the sacrum; whether, as a girl, she Avas made to carry heavy Aveights or to work in manufac- tories." If, in making an examination per vaginam, the top of the sacrum can be reached Avith the index finger, there is good reason for believ- ing that there is deformity at the brim of the pelvis; Avhich may be the case elsewhere, however. But it does not folloAV that because the top of the sacrum cannot be thus reached there is no deformity. If the deformity exist at the brim, and is great, the fcetal head cannot engage in the inferior strait; but the brim may be normal and the deformity may exist in the cavity, in which case the head may enter the cavity and be unable to proceed farther ; or, again, the outlet alone may be deformed, in which case it is obvious that the head may de- scend to the outlet, and then remain fixed until extricated through mechanical measures. In regard to deformity at the brim, Dr. Rigby Avrites: " Besides the general appearance of the patient, Ave frequently find that the uterine contractions are very irregular; that they haATe but little effect in dilating the os uteri; the head does not descend against it, but remains high up; it shoAvs no disposition to enter the pelvic cavity, and rests upon the symphysis pubis, against Avhich it presses very firmly, being pushed fonvard by the promontory of the sacrum." A great variety of circumstances are to be taken into consideration in regard to the course to be pursued by the accoucheur Avhere he meets with pelvic deformities during labor; for it must be evident that unaided nature is able to do very much more in some cases than in others; and in addition to this, the period of pregnancy at Avhich labor takes place, the size of the child's head, its compressibility and its degree of ossification, the presentation, etc., should all receive due DYSTOCIA. 225 consideration before resorting to any measures to effect delivery by artificial means. It is a good rule, and one that holds good in a very large majority of cases of this kind, to give nature a fair chance to effect expulsion unaided. At the same time it should be borne in mind that there is great danger in waiting until symptoms either of exhaustion of the vital forces or of powerless labor have shown them- selves. The mode of treatment Avhere cases of deformity occur does not differ in the first stage from that pursued in the case of well-formed women. Where the os uteri is sufficiently dilated or dilatable, so as to permit the escape of the head, the experienced accoucheur, by a careful comparison of the presenting part with the passage, will be able to decide on the possibility of a spontaneous delivery. When the vertex presents itself, sufficient time should be allowed for its engagement, descent and final expulsion. The contractions should be supported by means of such remedies as the case may seem to require. But should no advancement be perceptible, the forceps may- be applied and extraction effected if possible; but if there is no reasonable hope of delivery by this means, craniotomy must be re- sorted to. And should the distortion of the pelvis be so great that even craniotomy would not avail, the Cesarean section must of neces- sity be resorted to. When the pelvic extremity presents, the same rules apply as in natural labor; but if the deformity is too great to allow a sponta- neous expulsion, the blunt-hook must be used, as hereafter to be described. When the body is in the act of being delivered, intro- duce as soon as possible the index finger into the mouth of the child and force the chin down upon the sternum as much as possible Avhilst traction is being made upon the shoulders. In this way the longest diameter of the head will be made to occupy the shortest possible space in the pelvis. If then it is not found possible to deliver the head, the forceps must be applied. When the face presents an effort should be made to convert it into a vertex presentation, as described hereafter; and then, if necessary, apply the forceps. Every effort should be made to change the face presentation to one of the vertex, as it would greatly increase the chance of the child's life, afford relief to the mother and contribute to our satisfaction. When the child presents by the trunk, an effort should always be made to convert this into a presentation of the vertex; and if we discover that one part of the deformed cavity is broader than any other, the occipital diameter should be directed to that part as much 226 DYSTOCIA. as possible. If the labor has already continued so long as to make it impossible to bring the vertex into the superior strait, the foot must be seized and the malpresentation converted into one of the breech, Avhen we may proceed as in all breech presentations. It may be stated m general terms that if there be an antero-poste- rior diameter of not less than three and one-fourth inches, the forceps may be successfully used. If this diameter, however, should be less than the above, the forceps Avould not be likely to avail, and if it should be very much less, their use would be altogether out of the question. With an antero-posterior diameter ranging between three and one- fourth inches doAvn to tAvo and one-half inches, it is possible that by turning and bringing the lower part of the wedge that the foetal head forms—according to Sir James Simpson and Tyler Smith—down first, the thicker part of the head may be extracted. If this diameter should be less than two and one-half inches, but should exceed one and three-fourths, craniotomy is available, and may be resorted to with a good hope of success; but craniotomy need hardly be performed with a smaller antero-posterior diameter than one and three-fourths inches, and in such cases the Csesarean section alone remains. It is to be borne in mind, hoAvever, as before remarked, that much more may be done by nature in some cases of pelvic deformity than in others. If we could secure a full knowledge of the existence and the extent of pelvic deformity before gestation has gone on to the full term, it is obvious that a resort to the Caesarean section and craniotomy could be prevented by inducing premature labor. To determine the existence and extent of pelvic deformity has led to the invention of a great variety of instruments, termed pelvimeters, for the purpose of measuring these deformities. French accoucheurs have been especially prolific of these inventions, some of which are quite complicated and apparently useless. A very simple instrument, the invention of an English practitioner, Dr. Greenhalgh, is thus des- cribed : " It is intended for measuring internally the antero-poste- rior diameter at the brim. The principle of the instrument is to assist the finger in measuring this diameter. It consists of a band of flexible metal one inch broad, Avhich forms a ring. This band en- circles the hand, passing across the centre of the palm, the size of the ring being adapted to different-sized hands by a piece of elastic india- rubber webbing. On the surface of the band, corresponding with the centre of the palm of the hand, is a projecting pivot perforated so DYSTOCIA. 227 as to allow a small metal rod to traverse it. The rod is seven and a half inches long, graduated along its central third; at its distal ex- tremity it is bent at right angles into a form which admits of its gliding along the index or examining finger. It is to be thus used : The right hand having the instrument fitted to it, the forefinger or two first fingers are to be introduced so as to reach the sacral promontory. The curved extremity of the rod lies noAv on the radial side of the index finger. The promontory having been reached, the rod is draAvn outward until the ring-shaped extremity is arrested against the arch of the pubis. The distance at which the rod is thus stopped is shown in the index, and Avhen the hand is withdrawn, the antero-posterior diameter of the pelvis can be obtained by measuring the length be- tween the end of the finger and the extremity of the rod." If the hand alone be employed, the tip of the index finger should be made to touch the promontory of the sacrum, and the distance from that point to the posterior surface of the pubes can be estimated, although no very accurate measurement can be taken in this way. Or, again, the index and second finger may be introduced, and while the palmar surface of the index finger is placed against the pubes, the second finger may be stretched across toward the sacral prominence and an effort made to touch it. Yet a third plan is to introduce the four fingers within the cavity of the pelvis, and place them on a line between the pubes and the sacrum. The necessity of overlapping these fingers or extending them to fill up the space, will give a fair idea of this diameter. The greater the deformity the more readily is it made out, and hence Avhen there is great difficulty in ascertaining the existence and the extent of the malformation, in skillful hands, it may be accepted as negative evidence of a favorable character. Causes of Pelvic Deformities. We now pass to the causes and mode of production of the pelvic deformities. For a long time these, together Avith other deformities of the skeleton, Avere referred to a single cause—viz., rachitis—but modern researches have clearly proved that the pelvis may be de- formed in the absence of rachitis, and from purely mechanical causes, operating at a time Avhen, on account of tender age or feebleness of constitution, they could meet but little resistance. From this view of the causes which produce changes in the form of the pelvis, we might collect deformed peh^es into three groups—viz., (1) Those which are deformed from a softening of the bones, either by rachitis or mollities ossiura; (2) Those deformed in consequence of a previous deformity 228 DYSTOCIA. of some other part of the skeleton; (3) Those deformed by absolute narrowness. (1) The Pelvis deformed by Rachitis or Mollifies ossium,—These two diseases, however differing from each other, yet produce the same result—viz., they soften the osseous tissue and thereby weaken its poAver of resistance. But the mere fact of softening the bones, and their consequent Aveakness, is not of itself sufficient to account for the various deformities presented by the pelvis; for it is very evident that the bones, unless reduced to a gelatinous state, would maintain their general conformation unless acted on by some external force, for rachitis diminishes the solidity of the bones, but does not of itself produce any alteration of shape. This exterior force may be looked for in the muscular action, and still oftener in the Aveight of the parts which the pelvis has to support; for the pelvis, interposed between the spine Avhich it supports and the loAver extremities on Avhich it rests, is most favorably conditioned for the action of deformity. The weight of the trunk in its erect position being transmitted from the lumbar vertebrse to the heads of the femurs in the direction of two lines intersecting the sides of the superior strait, evidently tends to increase the curvature of the posterior part of the ilium, and to depress the osseous circle of the pelvic cavity. In this A\ray the sacrum receives a tendency, by almost insensible degrees, to push forward. By considering the action of the pubic bones under this pressure we may see how it is that the superior strait is oftener affected by the contractions of the pelvis than other parts, and Avhy at this strait the antero-posterior and oblique diameters and the sacro-cotyloid inter- vals are more frequently contracted than the transverse ones. When the Aveight acts more particularly on one side of the pelvis, the collapse is more marked in that direction, because in this case a change in the centre of gravity takes place from the inclination of the spine; and there is also a very unequal pressure of the Aveight of the body on the two sides of the pelvis, where, on account of a difference of length in the loAver extremities, one of the coxal bones is more depressed than the other. In this Avay the acetabulum of one side is throAvn almost directly under the sacrum, and at the same time receives the weight very obliquely. The customary attitude of the individual and the nature of her occupations must be taken into account in con- sidering the irregularity of figure in the pelvis. Sometimes there is a complete fusion of the sacrum and ilium, and the sacro-iliac articulation on the contracted side disappears. We simply state this fact without attempting any explanation of it. DYSTOCIA. 229 In estimating the respective influences of mollities ossium and rachi- tis on the bony tissue, the distinctive characteristics of each should be carefully noted. Mollities ossium affects all parts of the skeleton indifferently, and it occurs in the adult only. The softening pro- duced by this disease is very distinctly marked, and the most consid- erable retractions must be referred to it Rachitis affects the bones of the loAver extremities and ascends gradually to the upper parts; it proceeds from below upAvard, so that a deformity of any part by rachitis almost necessarily implies a deformity below. It is peculiar to infancy, and its effects on the skeleton are twofold—it softens the bones and it arrests their development; and as this arrest of develop- ment particularly affects the loAver extremities, it is a necessary con- sequence that the ossa innominata should be much less developed in those subject to this disease than in others, and the limits of the pelvic cavity more or less contracted by it. It is here that Ave may see the difference again between rachitis and mollities ossium, or rachitis adultorum, as it is sometimes called; for the first, exerting its influence at an early age of the patient, at a period when the pelvis has not yet reached its full development, permanently arrests the groAvth of this part of the skeleton; but the last, not occurring until after puberty, at a time Avhen the ossa innominata have reached their full development, may soften the bones, but can- not arrest their groAvth. Moreover, the development and growth of the bones of the skeleton are not only arrested absolutely by rachitis, but their growth is retarded, even after a cure has been effected, dur- ing the Avhole term of development. (2) The Pelvis deformed in consequence of a previous Deformity ofso-me other part of the Skeleton,—These deformities are: (a) Deviations of the Vertebral Column.—Rachitis is not the only cause of this deformity. It is now admitted that several other dis- eases may produce abnormal curvatures in this column. It is thus we establish a line of distinction between those deviations which nearly ahvays attend pelvic malformations and those which often exist Avhen the pelvis is Avell formed. The form'er must be referred to rachitis, the latter to some other affection. The shape and direc- tion of the pelvis are subject to the influences of other deviations of the spine than those Avhich depend on rickets, but it is only in sub- jects of an advanced age that cun'atures occurring after the age of infancy exert an influence of this kind. Curvatures produced by rickets, even when not the essential cause of deformity in the pelvis, heighten the degree of contraction and affect the shape of the pelvis. 230 DYSTOCIA. The aged and the young are alike affected by the spinal deviation, but the effects are brought about more rapidly Avith the young than with the old. The malformation is more or less similar to that de- scribed under the name of the oblique oval pelvis. (b) Congenital Luxations.—These may cause an arrest of develop- ment and subsequent pelvic deformity. (c) Non-congenital Luxations.—A luxation remaining unreduced, and which occurred early in life, is sufficient cause for an atrophy of the iliac bone corresponding to the dislocated femur ; and it is evident that the malformation of the pelvis will be proportionately great as the luxation occurred at an early age. (d) Lesions of the Inferior Extremities.—The curvatures of the lower limbs do not always diminish in length equally, and the pres- sure which they make on the bottom of the cotyloid cavities is not the same for both sides; the consequence of this is that the pelvis may be affected on that side where the pressure is the greater. The loAver extremities may often be curved without injury to the pelvis, provided they maintain the same length, and where they are unequal in length there must result pelvic deformity. The pelvis may be deformed by a shortening of one of the legs from any cause, particularly if the accident occur in early life, when the pelvis is but partially developed. Where one leg is affected Avith chronic disease, and the person is obliged to use crutches, bearing the Avhole length of the body on one leg, or where the thigh has been amputated in early childhood, the pelvis is in either case liable to deformity. (3) Pelvis Deformed by Absolute Narrowness.—The most generally accepted opinion on this topic is, " that we have no positive data con- cerning the causes that give rise to the general narrowing of the pelvis; and that such pelves, as Avell as unusually large ones, should rather be considered as a freak of nature, belonging to the same cate- gory as a want of proportion in the head, which is not unfrequently found too large or too small relatively to the rest of the body." The practitioner of homoeopathy should bear in mind, in consider- ing these various pelvic deformities and their proximate or remote causes, that a majority of them commence very early in life—some of them perhaps even before birth—and that they are due to a morbific influence which lies even beyond the apparent causa occasionalis, per- haps beyond our ken. But, taking into consideration the gravity of these cases on the one hand, and the wonderful efficacv of homoeopathic medicine on the other, it becomes a solemn duty of the practitioner, DYSTOCIA. 231 in treating such cases in infancy or childhood, to spare no efforts to bring about a complete effacement of the dyscrasia, if such it be, that has given rise to the abnormal manifestation, as Avell as a removal of that local manifestation itself. The so called " antipsorica" of Hahnemann act with a benignity almost divine in the various forms of scrofula, and by affecting a radical cure through their instrument- ality in these cases, not only is present good done, but prospective suffering and even death in childbed may be averted. Dystocia from Malformations of the Vulva, Vagina and Uterus. Adhesions of the vulva may occur, hindering the expulsion of the child. In a case of this kind it is only necessary to divide the adhering portion with the scalpel at the moment that the presenting part is pressing down upon the adhesion, if the pressure of the pre- senting part is not of itself sufficient to break up the adhesion. The hymen also may be so persistent as to hinder the expulsion; this also should be divided Avith the scalpel if it does not give Avay under the repeated manual examinations or from the pressure of the presenting part. Contractions and rigidity of the vulva quite frequently delay the expulsion very much, but I have never found it necessary to operate in cases of this kind. Aconite most usually, or some other remedy, has aided the dilatation, and a little patience has always sufficed, and I believe always Avill suffice, in such cases. Rigid perineum.—Remarkable cases of resistance on the part of the perineum are met with when the labor has been much delayed. Aconite or some other remedy has invariably supported the contrac- tions and aided in the dilatation, and the delivery has been satisfac- torily accomplished. In some cases the whole perineum has appeared to fit in such a manner the child's head, and to sink down so low, that it has been found necessary to apply the forceps and simply lift the head directly out of the little sulcus it has seemed to make for itself there. There may be cases, however, in Avhich interference would be ab- solutely required to admit of expulsion of the head taking place without laceration of the perineum. It has recently been advised to make small incisions a little on either side of the median line, upon the principle that an incised wound will heal more readily and nicely than a laceration will. It is barely possible that such a procedure might be necessary. If the perineum be properly supported, and the 232 dystocia. downward pressure of the head be thereby delayed someAvhat, it will be found that the perineum will yield gradually and the danger of laceration will be aATerted. The vagina may be found malformed or adherent, or the hymen may be double or triple, and thrown across high up in the vagina; or there may be a complete septum in the vagina. These cases should all be treated with the knife if necessary, and according to circumstances present; these will indicate the proper treatment. Vaginal cicatrices offer a formidable bar to the progress of labor. These may exist from previous disease of the vagina or in consequence of operations performed thereon. They are hard and unyielding, and seldom give way to the pressure of the head. If their existence is known prior to labor, they may be relieved by the use of sponge tents, etc., but during labor, if they exist in any degree, recourse must be had to the knife. The knife should be well guarded, and should only be used on such parts as are on the stretch during a pain, and but little cutting at a time should be done. It may be necessary finally to use the forceps to effect delivery. Inversion of the vagina sometimes takes place during labor, Avhen the protruding portion from prolonged pressure becomes gangrenous. When this is likely to occur, the forceps should be used at once and the expulsion accomplished. When this condition is apprehended or observed in its incipiency, the accident can be averted by care- fully crowding the descending parts back continually as the labor progresses. GZdema of the labia and nymphee, so far as my experience goes, presents no formidable obstruction to the progress of parturition. Patience and the administration of remedies will assist the Avork of nature, and surgical interference will not be required. The parts are liable to become inflamed and slough if puncturing be re- sorted to. Tumors are also liable to obstruct the passage, so as to cause great and even fatal delay. These may be osseous tumors or they may belong to the soft parts. Exostoses may exist, and form some of the most formidable obstacles to a safe delivery. These usually arise from the anterior face of the sacrum, sometimes from the ischium and the pubes. They may be recognized by hardness, immobility, roughness aud adherence to the bone. These forms of tumor continue to grow in size from year to year, and consequently to become more and more formidable at every successive pregnancy, unless cured by the proper homoeopathic reme- dystocia. 233 dies. The only plan of treatment is that to be pursued in deformed pelvis. Osteosarcoma is another type of malformation, quite similar to the one just mentioned. The only difference is that it is somewhat com- pressible, a mixture of the osseous, fibrous and cartilaginous matter. Even the osseous crepitation can be felt on pressure. The plan of treatment is the same as that in the last case. Fortunately, the exist- ence of both these forms of tumors is of rare occurrence. Other bony formations are sometimes met Avith in the pelvic cavity, obstructing the progress of labor. These arise from the imperfect coaptation of fractured bones, or from the head of the femur being forced in upon the acetabulum. If the resistance offered by these should be very great, the plan of delivery must be conducted as in similar cases of pelvic deformity. Sanguineous tumors sometimes form in the soft parts—in the labia, among the muscles of the pelvis, or even in the neck and lips of the uterus. If the size of these tumors increase gradually, the case should be treated by the administration of aconite, hammamelis, erigeron or any other remedy strongly indicated by characteristic symptoms, which will then be sure to arrest the difficulty and facilitate parturition. Various other tumors are found in and about the track Avhich the child must pursue in its passage to the light of day; many of which need no attention during parturition if they are not obstacles to the expulsion of the child; if they are, they may need' to be punctured, incised or removed, as the nature of the case may indicate. It is always best to Avait and allow Nature to do her own work, if possible. Many of these tumors are not discovered until the hour of parturi- tion arrives, and note should be made of them and the proper treatment resorted to after the lying-in period has passed. Ovarian tumors sometimes offer a very serious obstacle to parturition, and at other times do not. Numerous cases are recorded in Avhich labor occurred naturally, the tumor occasioning no serious accident either to mother or child. If their presence is detected early in the first stage of labor, and the size be not too great, the tumor may be pushed up above the brim of the pelvis, and kept there until the head engages in the superior strait. Under such circumstances labor may terminate naturally and Avithout further trouble. Or if this cannot be clone, and the size of the tumor admits, it may be pushed to one side and the forceps applied to the head. If the tumor contain fluid, a trocar and canula may be pushed into it through the vagina or rectum, and the fluid contents draAvn off. If the tumor should be 234 dystocia. large, hoAvever, and the above methods should fail, craniotomy or the Csesarean section will have to be performed. Sometimes, though rarely, the soft character of these tumors allows of their giving to the pressure of the fcetal head in its descent, and labor is terminated without diffi- culty. Mr. Spencer Wells Avrites, in the Obstetrical Transactions: " 1 know one Avoman Avho during the slow progress of an enlarging ovarian cyst, has gone through five pregnancies, has borne five living children without unusual difficulty, and has never yet had the cyst tapped, nor has labor ever been prematurely or artificially induced. . . . Another patient, upon whom I performed ovariotomy with success in the fourth month of pregnancy, after rupture of the cyst and peritonitis, had borne six living children during the progress of the cyst before its rupture." These cases are of course to be regarded as exceptional. Polypi and other uterine growths are sometimes found obstructing labor. They are usually recognizable by their pyriform shape, and are generally found attached to the os or cervix by a pedicle. The safest and simplest course to be pursued in such cases is to remove the growth. This may be done by torsion if the polypus and its pedicle be not too large, or a ligature may be throAvn around the pedicle and secured, and the growth removed with scissors; or again, the ecraseur may be used and the polypus removed at once. The hemorrhage is not usually great. Fig. 59. POLYPUS PRESSED DOWN BY THE ADVANCING HEAD IN PARTURITION. Ramsbotham mentions what he terms scirrhous glands as a cause of obstructed labor. They are found in the holloAv of the sacrum, and are to be recognized by " their situation, irregularity and hard- ness; by their being very sensitive; by their forming a chain of indurated tubercles, external to the vaginal coats; and by their being more or less firmly attached to the surrounding structures." They DYSTOCIA. 235 are not likely to form any serious obstruction, and should they do so may be pushed out of the way, or the forceps may be applied. Abscesses situated within the pelvis may likewise obstruct the descent of the foetal head and retard labor. The evacuation of their contents might be necessary. Accumulations of feces in the rectum may sometimes seem a very formidable obstruction to labor, but an injection or two of tepid water soon dissipates them. Sometimes, however, it is necessary to use a scoop or spoon. Vaginal hernia, which consists in the descent of a portion of the in- testine into the cul-de-sac behind the uterus, is mentioned by Churchill as a cause of delay during parturition. If it be possible, it should be pressed up above the brim of the pelvis; long-continued pressure upon the intestine should not be allowed, hoAvever, if this cannot be done, and the forceps should be promptly resorted to to effect a speedy delivery. Over-distension of the bladder may usually be remedied by the catheter and when it is prolapsed it must be crowded up into its place. If stone in the bladder exists, an effort should be made to push it up out of the way should it prove an obstacle to labor. This may be done with greater facility in the early stage of labor, before the child's head has advanced. If this should not succeed, the choice will then lie between vaginal lithotomy and craniotomy. Vesical hernia, or cystocele, is occasionally found during labor. It gives rise to great suffering if the bladder is full of urine, and the Fig. 60. VAGINAL CYSTOCELE, TAKEN FROM RAMSBOTHAM. pressure of the child's head may occasion its rupture, Avith fatal results. The male catheter must be introduced at once, and after the urine has been discharged the bladder must be crowded up into its place, and kept there until the head descends and forms a support for it. The 236 DYSTOCIA. tumor will be found posterior to the pubes, fluctuating and free except at its pubic side, and the os uteri will be found above, in its natural place. The introduction of the catheter makes the case clear and unmistakable. Its correct diagnosis is important. Dystocia from Morbid Conditions of the Uterus. Tumors of the Neck and Body of the Uterus.—If encysted tumors prove an obstruction to delivery, they may be punctured and the con- tents draAvn off, or if they contain cheesy matter an incision will allow it to pass out, especially from the pressure during a pain. But unless their size prevent the expulsion of the child they need not be interfered Avith. Pedunculated fibrous tumors, or polypi, have already been treated of. (See page 234.) Ceudiflower Excrescences.—These cancerous or syphilitic growths seldom cause delay, unless their size is very considerable. But when they are large the condition is much more serious. Several cases are quoted by Cazeaux from Puchelt: " In one it was necessary to make incisions upon another part of the hard or scirrhous neck, so as to secure the introduction of the hand; and in a second, to remove the tumor that Avas attached to the anterior lip and occupied all the vagina by the scissors; gastrotomy was resorted to in a third, on account of a rupture of the womb, and not even the child Avas saved ; in another, the extraction of the child was impossible, notwithstanding the per- foration of the cranium, and the woman died before delivery.. Only a single mother survived." As these fungous growths are liable to bleed freely, they may be mistaken for placenta preevia. Carcinoma Uteri.—In this complication much depends on Avhether the child be alive or dead. The mother has a necessarily fatal dis- ease, and if the child be living all care should be bestowed upon pre- serving its life; although the mother should be spared from suffering. Either incisions should be made into the os, turning may be resorted to, or the forceps may be applied. In case the child should be dead, the mother may be saved much suffering by resorting to craniotomy or other procedure to reduce the size of the head. Other Abnormal Conditions of the Uterus affecting Labor. Rigidity of the Os Uteri.—When this exists it may offer a formidable bar to the progress of parturition if not removed by proper treatment. It occurs more frequently in primiparae than in multiparae. The orifice becomes dilated to a certain limited extent, and beyond that it does DYSTOCIA. 237 not yield, notAvithstanding the continuance of the proper pains; and hence the strength of the patient becomes gradually exhausted and untoward symptoms set in. It usually depends upon some functional derangement inducing a spasmodic action, but it may be due to organic lesions of the cervical tissues. In the latter case the measures to be resorted to have already been pointed out. Incisions will probably be required, which may be made by using a probe-pointed bistoury carefully guarded by the fingers from injuring the surrounding tis- sues; and if after these have been made, if dilatation does not progress, india-rubber dilating bags may be used to effect it. But in the ordi- nary form of rigid os arising from some functional disturbance, homoe- opathy furnishes a certain relief, and the measures resorted to by the old school of practice—such as bleeding, opium, chloroform and topi- cal applications—are rendered altogether unnecessary. The properly- selected homoeopathic medicine restores order to the disordered sys- tem, the parts are relaxed and softened, dilatation proceeds as usual, and a happy termination to the labor is the reward. The remedies called for in such cases will be laid down in a subsequent chapter of this volume, in treating of the therapeutics of Labor. Obliquity of the uterus Avould throw the orifice of the neck to one side of the axis of the pelvis—either too far posteriorly, anteriorly or yet to the right or to the left laterally. In such cases the first and possi- bly the only thing the accoucheur has to do is to wait patiently on the operations of nature. Should it be evident that parturition will not be accomplished unaided, the woman should be subjected to " perfect rest on the back when the obliquity is anterior, or on the side opposite to the one occupied by the fundus uteri when it is lateral, and the employment of the hands to support and maintain the deviated organ, or of a large bandage properly applied to produce the same effect. The patient should be advised not to bear doAvn until after the dis- placement is remedied. If these means are not sufficient, it will be necessary Avhile thus operating externally on the body to act at the same time on the neck, for that purpose introducing two fingers into the uterine orifice and taking adA'antage of an interval betAveen the pains to draw it gently toward the centre of the pelvis, while the other hand is employed in pressing the fundus of the organ in the opposite direc- tion."—Cazeaux. In the posterior obliquity the woman ought to re- main seated or standing, or, if possible, even inclining a little forward. Agglutination of the external uterine orifice sometimes occurs, even at the hour of labor. Such a state will be recognized by feeling the outlines of the lips apparently covered over by a thin membrane. 238 DYSTOCIA. At every contraction the line of demarcation between the lips will become more and more apparent, and allow the thin membrane to sink a little betAveen the lips. Now during a pain the thinnest and most yielding spot must be found out, and the finger forced Avithout much violence through the membrane. If the finger is not sufficient, a more potent agent must be used, great care being taken not to wound the child or the mother needlessly. The sioclling and elongation of the anterior lip is a frequent cause of delay in labor. The anterior lip from some cause may not dilate. It may swell and become paralyzed, and hang down upon the head of the child, Avhilst the posterior lip kindly dilates, and the presenting part is ready to pass through but for the stubbornness of the anterior lip. Great and often immediate relief is obtained by pushing up with the finger this anterior lip, and holding it firmly, and even croAvding it up farther during a pain. It then slips up sooner or later above the head, and the distress of the patient is relieved and the labor progresses finely to its completion. It will sometimes be difficult to distinguish betAveen the elongated or swollen lip and a fold of the vagina. In some cases we may find both. The uterine lip will be found hard and unyielding, Avhile the vaginal fold is soft and pliable. In these cases the fold of the Aragina must be pushed up first, and kept up as Avell as possible out of the way. Then the uterine lip can be made to folloAV more readily. Sometimes considerable time Avill be expended in making these manipulations. Induration and hypertrophy of both lips are found in some cases, when the distress of the patient during labor Avill furnish the symp- toms necessary for the indication of the remedy which will effect the desired dilatation. Incisions may have to be resorted to. Complete obliteration of the cervix uteri, it is admitted by all medical Avriters at the present day, does sometimes occur. Of course no os, in this case, can be found by exploring in any direction far back toward the promontory of the sacrum and in other directions; but much care is necessary here, for sometimes it is found at an incredibly distant point toward the promontory of the sacrum. When not the faintest line of demarcation of an os can be discovered, one must be made at the lowest or most pendant point of the uterus. Hernia of the womb, it is admitted, sometimes takes place by the inguinal or crural rings becoming so much dilated as to allow the escape of the uterus. Pregnancy may continue to the full term, when a reasonable time should be allowed for spontaneous delivery, but it is most likely that a Caesarean section will be found necessary. DYSTOCIA. 239 A prolapsed womb may become pregnant, or the womb may pro- lapse suddenly after conception, and the full term be accomplished; a slow and difficult labor Avill result, but it may take place fairly, and the uterus return to its place. Rupture of the Uterus and Vagina. Rupture of the uterus is one of the most serious complications or accidents which can possibly occur during the puerperal state. It may occur at any time during labor, but is much more frequent in the latter stage than in the former. Primiparae are much less liable to the accident than multiparae. It may occur in the body or in the neck : when it occurs in the neck, it almost always involves a rupture of the vagina also. The entire thickness of the uterine parietes may be ruptured, which is the most common form; or the peritoneum may not be involved; or again, the peritoneum may alone be torn. The cause of so unfortunate an accident may be referred to many circumstances: great thinness, a softening or a diseased condition of the walls, mechanical injuries, the administration of ergot, or too violent contractions may all be enumerated among the circumstances, especially too A'iolent contractions with an undilated os. When this accident occurs, a sharp, tearing pain is felt, and that so suddenly and severely as to cause the patient to scream out with great force. Sometimes the patient will complain of something having given Avay, followed by a cessation of uterine action. Cold and clammy sweats break out, the pulse is very small and quick, the presenting part of the child recedes beyond the reach of the hand, and if it escapes into the abdominal cavity, it can be felt through the ab- dominal walls. Collapse sets in, and there may be convulsions; vomiting follows; breathing becomes quick and labored, the pulse more accelerated; and unless reaction sets in, death shortly occurs from collapse. Hemorrhage to a greater or less extent always occurs. " Of all these symptoms, the peculiar sharp and sudden pain, the cessation of all uterine action, the recession of the child, and the being able to feel it easily by the abdominal wall, the hemorrhage and the collapse,—these together make up a total which are almost certainly indicative of ruptured uterus. Of course there is not only hemor- rhage per vaginam, but a good deal of blood may also escape into the peritoneal cavity—so much, indeed, that this alone causes death in some cases."—Meadows. When this accident occurs at an early stage of gestation, before the 240 DYSTOCIA. uterus contains much to be discharged through the rent, the product of conception may dam up the passage and cause the contents of the uterus to be retained for some days; so that when a reaction ensues after the first shock, a calm precedes a more violent set of symptoms after the final escape of the product of conception into the cavity of the abdomen. In the later months of conception the diagnosis is easier to be made, as described above. Should the patient survive the immediate consequences of a lacerated uterus, after some hours reaction sets in, and the symptoms of col- lapse are succeeded by those of inflammation of the peritoneum and womb, which is usually very severe, and consequently presents symp- toms of peculiar aggravation. If this should abate Avithout destroy- ing life, it may be folloAved by the formation of abscess or by cellu- litis, etc., Avhich will probably carry the patient off. There are cases on record, hoAvever, in which recovery has taken place even Avhen the foetus has not been delivered, but has become encysted in the abdom- inal cavity. Terrible as this accident is, therefore, it is evident that nature unaided has been able in some cases to overcome the tendency to death, and much more may be done by proper manual and instru- mental interference and by Avell-directed after-treatment. The first step to be thought of in cases of this kind is, the delivery of the child where that is at all practicable, for it is to be remem- bered that it is alive and may be born alive. If the os be either dila- ted or readily dilatable, the forceps should be promptly resorted to if the head can be reached. But if the child has passed upward, so that the head cannot be reached, or if the condition of the os contra- indicates the use of the forceps, turning should be resorted to and the child delivered with promptness. It is humane to the mother to de- liver the child as soon as possible, for her best chance of recovery rests on that. Care must be taken, in effecting delivery either by the forceps or by version, that no part of the intestines be drawn through the rent in the uterus, or that it be not alloAved to remain thus constricted after extraction has been accomplished. If nei- ther of the above methods is applicable, then the Cesarean section should be resorted to. This operation has been successfully per- formed and the mother has recovered even under such unfavorable circumstances. During the condition of collapse, the use of stimulants is perfectly admissible and perhaps necessary. The after-effects will be all the more successfully combated by a strict adherence to homoeopathic DYSTOCIA. 241 medication. (See the remedies under Puerperal Fever, Metritis, etc.) Rupture of the vagina may likewise take place independent of any laceration of the uterus. A similar condition prevails in all respects as in rupture of the uterus, except that the pain is not so severe and other symptoms may not be so intense. The treatment to be pursued is similar to that recommended in case of rupture of the uterus. Rupture of the Bladder. This can only occur from injudicious management, culpable neglect or ignorance. The laceration may take place either upon the perito- neal or the vaginal side of the viscus. In the former case, urine is extravasated into the peritoneal cavity, and violent inflammation is induced which may destroy life. In the latter case, while the imme- diate effects are not so serious, yet the consequence, in the shape of a vesico-vaginal fistula, is very severe and distressing. The evidences of rupture of the bladder will be similar in many respects to those of rupture of the uterus or vagina, but there will be little or no hemorrhage per vaginam; uterine contractions will be continued, the presenting part of the child and the uterine os will be found in their proper places, and the evidence of the child having escaped into the abdominal cavity will be wanting. This possibility of rupture of the bladder may be averted if the accoucheur sees to it that during a protracted labor the bladder is properly evacuated. Should the natural efforts of the woman fail of accomplishing this, the catheter should be used. If the accident does happen, however, from any cause whatever, delivery should be effected by the forceps or by turning, unless it be apparent that the child will soon be born without mechanical assistance. If urine is poured into the peritoneal cavity, the resulting inflammation should be treated according to the general principles of homoeopathic practice, and may thereby be successfully combated. Should vesico-vaginal fistula result, on the contrary, the niceties of the surgeon's art will be re- quired to relieve the suffering woman from her horrible situation. Laceration of the Perineum. Laceration of the perineum is more liable to occur in primiparae than in women who have already borne children. The extent of the injury varies a great deal. It may be a mere nick in the anterior thin border of the perineum, may extend from the fourchette to the sphincter ani, or may involve the sphincter and in some cases the entire 16 242 dystocia. recto-vaginal septum. Again, the anterior part of the perineum may remain intact, and perforation of the perineum take place, the child being actually driven through the perineum from mal-direction of the uterine expulsive force, from disease of the perineal tissues or from deformity of the pelvic outlet. Sometimes the perineum is preternaturally broad, and in such cases the head pressing downward forcibly distends it in every direction, and becomes, as it Avere, invested by a perineal cap. Laceration or per- foration Avill be pretty sure to take place unless the head be lifted out of the investing perineum by means of the vectis or blade of the for- ceps and supported thereby, care being taken that no pressure is made on the perineum by the instrument, the hand of the operator serving as a fulcrum for the lever. Laceration of the perineum may be caused by too speedy delivery, by rigidity of the perineum itself, by narrow- ing of the pubic arch, or by the use of instruments to effect delivery. It may also be occasioned by degeneration of the tissues of the peri- neum, or by the woman straightening herself out at the last moment when the head is emerging from the vulva. The treatment of ordinary cases of lacerated perineum, Avhen the sphincter ani is not involved, is very simple. Indeed, the natural restoration of the parts after labor will reduoe what at first appeared to be a formidable laceration to a very insignificant one. Rest upon the back for a number of days, and keeping the limbs in constant apposition, combined with perfect cleanliness, will suffice to restore these simple cases. It may be necessary to draw off the urine with a catheter, but as the bowels are not generally moved until the ninth day, fecal matter is not likely to disturb the healing of the Avound. The more serious cases require surgical interference. The torn surfaces are to be coaptated and held in place by sutures—quilled, interrupted or twisted sutures, as may be selected—and perfect rest enjoined. The operation should be performed immediately after labor, for obvious reasons. No serious case of laceration of the perineum should be neglected by the accoucheur, as prolapsus or procidentia uteri, or non-retention of the fecal matter, may give rise to serious trouble in after life, unless the structures are restored to their normal condition. Labor Complicated by Previously Existing Disease. There are certain diseases which may complicate labor that require special and particular attention. Of this kind are haemoptysis and hcematemesis. In these cases the remedies must be resorted to which DYSTOCIA. 243 are usually employed in treating such diseases. As a general rule, hemorrhages will be controlled and labor will terminate in a regular' natural Avay. But if Ave are not thus fortunate, the labor must be terminated as soon as possible by artificial means. In asthmas, pal- pitation and diseases of the heart, we should be governed in our action by the principle stated aboA-e. In aneurism, where there is a great danger of rupture at any pain, immediate resort should be had to artificial means of delivery. When hernia exists it should be reduced as soon as possible, and when it is utterly impossible to reduce it, the best practice is to resort to artificial means of delivery, in order that the hernial protrusion may not be strangulated longer than necessary. When the hernia is liable to return after reduction, it may be kept back by constant pressure. Syncope is curable by using the proper medicines. (See Therapeutics of Labor.) When there are great exhaustion and debility, and they cannot be relieved by the proper medicines, resort to arti- ficial means for delivery. Labor Complicated by Convulsions, Hemorrhage and Placenta Prcevia. These terrible complications of parturition are fully treated of in the latter or therapeutical portion of this volume, under the proper headings. Dystocia from Abnormal Conditions of the Fostus. We noAV commence the study of those obstacles to its ready expul- sion which depend on the foetus and its appendages, the passage being in a normal condition and the expulsive force sufficient. Hydrocephalus.—Some disease of the fcetus may develop a true hydrocephalic condition, in which the head becomes so large as to make it impossible for it to pass through the cavity. This state may be knoAvn from the cranial bones being separated far from each other, and each seems to swim, as it were, in water Avhen pressing upon them; there is also a Avide suture between the bones of the cranium. The trecdment in such cases depends on circumstances. Degen- eration of the foetal head may have occurred to the extent that it re- sembles a membranous bag, and under such condition it may be ex- pelled without operative interference. Such cases are of course rare. Again, the scalp may be ruptured and the fluid contents of the cranium expelled. But should it become evident that labor cannot be com- pleted without assistance, the head should be punctured and its con- tents discharged. For this purpose an ordinary trocar and canula 244 DYSTOCIA. or Braun's long obstetrical trephine may be used. The operation should not be delayed too long, as there is danger of rupture of the uterus occurring, or the pressure of the head upon the soft parts of the mother may give rise to very serious inflammation and sloughing. In some cases the breech or inferior extremities are born first, and a hydrocephalic head is found to be impacted either within the pelvis or above the brim. It would naturally be more difficult to correctly make out the condition of the foetal head under such circumstances than when the vertex presents, the neck and shoulders preventing to some extent a free examination. But by patiently forcing the finger upward to the head the condition may be made out. Here the trocar may be pushed into the base of the head with similar results. The instrument of Braun will perhaps be safer and more efficient. Hydrothorax may exist. This disease may be diagnosed after the expulsion of the head or breech by the arrest of progress, by the in- tercostal spaces being extended, and by the fluctuation of water between the ribs. Ascites may occur and arrest the further progress of the child. When this is the case fluctuation and enormous distension solve the mystery. In the last two or in similar cases the trocar is the only remedy. A small trocar should be used in these cases, as the abnor- mal conditions are not necessarily fatal to the child. An emphysematous condition may occur when the foetus has been long dead and has become so distended with gas as to hinder its ex- pulsion. The trocar is to be used also in this case. Upon using this instrument large quantities of offensive air escape. Tumors of the fcetus may also cause a delay until the tumor is removed if solid, or punctured if containing fluid. We must be on our guard against accidents, and be duly prepared for every exigency which may arise. Anchylosis of the foetal articulations has been known to exist, causing great delay. On the application of the forceps and making forcible traction the child Avill be delivered. Excess of volume on the part of the child may be a cause of delay; the volume may be so much in excess, indeed, as to constitute the child a monster. The application of the forceps or blunt-hook is the remedy in cases of this kind,—that is if the vital forces are inadequate to effect delivery. Multiple and adherent foetuses and other monstrosities constitute a A'ery formidable cause of dystocia. We can often ascertain before the time of delivery the fact of the presence of two or more foetuses in utero, DYSTOCIA. 245 but Ave cannot ascertain whether they are separate and independent until the hour of delivery has actually come. If tAvo bags of water are found to be present, it is necessary to rupture the membrane twice. The same must be done if we have evidence of there being two distinct gushes of liquor amnii. We may then be assured that two pouches have ruptured, and it is made certain that there are no adherent foetuses present; for adherent children are always enclosed in a single set of membranes, and perfect twins are seldom enclosed in a single amnion. If, moreover, the head and feet appear at the superior strait, and par- ticularly if Ave can draAv upon the feet without causing the head to ascend, Ave may be sure that there is no adhesion. If three or four feet appear at the vulva at the same time, and on pulling at one another moves simultaneously, but the others remain at rest, we may be sure of the foetuses being detached from each other. If all move simultaneously, we can only ascertain this fact to a certainty by carry- ing the hand up into the uterus. In all cases, Avhether there is an adhesion or not, sufficient time should be alloAved for nature to operate unaided, but efficient aid should be rendered the moment that there is reason to believe it to be called for. Whether the union takes place at the head or the breech, the expulsion takes place, the one after the other, without difficulty. But if the union be at the occiput and the full term has expired, craniotomy Avill probably have to be resorted to. Where there arc two heads to one trunk, one head will engage after the other, and the body will descend subsequently. Where each head has its body, and the union takes place at any point of the trunk, one head may be born first; the feet belonging to this head may be brought down ; next the feet of the other child may be brought down, and lastly the head of this same child. When there is but one head to two bodies, the head may be born first, and the two bodies simultaneously with each other. If the breech of one body comes first, the hand may be introduced and the feet of the other child brought down. But it is impossible to lay down positive rules for all the anomalies which may arise. In special cases the accoucheur, in deciding on his course, must be led by general principles. Multiple and independent foetuses, twins, triplets, etc., are often de- livered one after the other, promptly and with but little delay, but usually these cases are more tedious. The child first presenting can- not be acted on as efficiently as if there were but one, for the uterine contraction must force one by acting upon the other. 246 DYSTOCIA. Moreover, the over-distension of the uterine walls serves to weaken the contractile powers for the first child. When the first child presents by the breech, there is likely to be more difficulty in the birth of its head on account of the remaining child's hindering the direct applica- tion of the uterine contractions upon it. Hence Ave must not overlook the importance of introducing a finger into its mouth in order to flex the chin upon the chest, and make sufficient and prompt traction for a safe delivery. Soon after the birth of the first child, in the course of twenty minutes, the contractions return, feebly at first, but soon more efficaciously, and the next child and the next are promptly expelled. The accoucheur, as soon as one child is born, should always place his hand on the abdomen of the mother, to ascertain Avhether others are present there, and so on successively until all the births are effected. If another remains, the abdomen will seem to be but a little smaller for the expulsion of one or two: the presence of more Avill be unmis- takable to both sight and touch. Sometimes, after one child has been born, a rest of some hours seems necessary before the exhausted fibres are sufficiently recovered to reneAv their contractions. Sometimes even days elapse before labor is renewed. The accoucheur should not inter- fere in such cases unless it be absolutely necessary to do so. Nature is generally competent unaided. All troublesome symptoms, such as flooding, fainting, etc., may be relieved by the proper homoeopathic remedies, according to the principles already mentioned. If the pains are delayed very long, they may be reproduced if necessary by re- sorting to the remedies referred to under the head of Therapeutics of Labor. Sometimes it may be necessary to rupture the membranes for the passage of the second child, in order to excite contractions, and sometimes to tickle the os with the finger in order to excite a reaction. Sometimes both heads incline to present at the same time, in which case one must be pushed aside to alloAV the other to descend. The same course must be adopted in case the breech presents. If either child presents by the shoulder, and version is determined upon, great care must be exercised to seize the feet of the child to be turned; this is an easy matter by constantly keeping the hand on the child Avhose shoulder presents. When tAvo feet appear at the vulva, and it should seem advisable to interpose assistance, hut one foot should be draAvn upon, and that very gently at first, in order to ascertain Avhether the other moves simultaneously as belonging to the same body; and if this is found not to be the case, every effort should be made to return that Avhich DYSTOCIA. 247 does not. A good and perhaps the only Avay to accomplish this is to suspend the patient by the feet, at the same time holding on to a leg of one of the children; the others would then return into the uterus, to be extracted after the expulsion of the first. No attempt should be made to deliver the placenta of the first child before the second is expelled, as hemorrhage would certainly result; and care should be taken that no traction is made upon the cord for the same reason. Prolapsus of the cord is a serious complication for the child, Avhilst it brings no harm to the mother, the life of the child being alone en- dangered : Fig. 61 exemplifies a case of this kind. The first evidence Fig. 61. THE RIGHT POSTERIOR OCCIPITO-ILIAC POSITION COMPLICATED BY A FALLING OP THE CORD. which the accoucheur has of this accident is actual presence of tlie cord with the presenting part of the child. The fold of the cord hanging may be of different lengths, simply hanging below the superior strait or it may be six inches long or more. If the child is living, the cord Avill be felt to pulsate one hundred and twenty to one hundred and forty beats a minute, and it will be felt to be firm and like a living tissue. But if dead there will be no pulsation, and the cord will feel shriveled, soft and lifeless. The treatment of this complication needs to be very prompt, lest the presenting part descend and cause strangulation and consequent death of the child. The only plan of safety possible is to take a piece of wet sponge, about twice the size of a hen's egg, and cut entirely through its centre a hole large enough to receive the fold of cord. Then pass a string through the loop of cord, and next pass the same string through the sponge. Noav by holding on to the string and slipping the sponge upAvard the fold of cord is drawn into the sponge. 248 DYSTOCIA. Slip the sponge Avell up, so as to secure a full introduction of this fold into the sponge. Then with the fingers crowd the sponge and all well above the superior strait. The sponge will dilate and retain all above the presenting part safely. It may be well to be always prepared with a small piece of sponge ready for the occasion. If the presenting part of the child has become so firmly engaged in the superior strait as to render the return of the cord impracticable, the labor should be termi- nated either with the forceps or the blunt-hook. Should the shoulder present, and podalic version become necessary, the cord should be carried up Avith the hand used for this purpose. When the breech presents, it may become necessary to hold the sponge at the superior strait until the part becomes so engaged as to retain the sponge without further effort. A little thought and reasoning will enable the accoucheur to Fig. 62. THE LEFT OCCIPITO-ILIAC POSITION STRONGLY INCLINED ON ITS POSTERIOR PARIE- TAL REGION. quickly adapt himself to any variation which may occur. He should always endeavor to adapt himself quickly to circumstances as they arise. Shortness of the cord may occur as a complication, and delay the labor very much. It has been known to be not more than four or five inches in length. The strongest symptoms of this state of things are found in the continued retraction of the child, time after time, after the cessation of each pain, without any perceptible ad- vancement. If this condition of the patient continues too long, so as to endanger the welfare of the mother or child, the aid of instruments must be invoked. When the presenting part has advanced so far as to expose the cord, it should be severed at once, about an inch and a half from DYSTOCIA. 249 the child's body. It may be tied, or held tightly betAveen the fingers of an assistant, until a complete delivery takes place. There is danger of a rupture of the cord or of a separation of the placenta, exposing the child and mother to a severe loss of blood before the child is sufficiently far expelled to expose the cord; in this event the treat- ment is still the same; apply the instrument necessary for hastening the expulsion of the child. Inclined position of the foetus constitutes another cause on the part of the child of its tardy birth. Fig. 62 illustrates a case of this kind. In making an examination per vaginam, one ear, the side of the head and the neck are felt. In all similar cases it is only necessary to turn the patient so that she shall lie on the side opposite to the place where we feel the neck of the child. The body falls down on the same side, and soon rectifies the inclination. Inclined breech positions can be managed on the same principle, the mother being ahvays turned, in such inclinations upon the same side as the anus points to. Fig. 63. THE LEFT POSTERIOR MENTO-ILIAC POSITION COMPLICATED BY A DESCENT OF THE LEFT FOOT. Inclined facial positions should always be managed in the same Avay as any facial presentation; they should be converted at once and Avithout delay into vertex presentations, as will hereafter be described. Inclined positions of the trunk must also be interfered Avith at once and conATerted into vertex presentations or delivered by the feet as directed a little farther on. Complicated presentations, something similar to Fig. 63, must be managed by the application of general principles. The child is forced quite closely down into the superior strait. 250 OBSTETRIC OPERATIONS. Now, it is evident the trunk cannot go back and the head be brought down, because one foot has advanced too far. If the feet Avere far- ther up, the forceps might perhaps be applied, and the head brought down, and the cord Avould be less liable to become compressed. All things being considered, then, it is very evident that the best course to be pursued is to use a linen handkerchief as a fillet on the foot most advanced. An assistant should make powerful but steady and care- ful traction upon it, whilst the accoucheur steadies the uterus with both hands placed upon the abdomen. The labor will then terminate in the most favorable manner. The exercise of sound judgment is called for in all these unusual conditions. CHAPTER XV. OBSTETRIC OPERATIONS. Turning. VERSION, or turning, is that manual operation by Avhich we change one presentation for another more favorable to delivery. It is, when carefully performed, capable of effecting a great saving of life in difficult labors. There are two kinds of version: the podalic, Avhich consists in introducing the hand into the uterus, seizing one or both feet and delivering by the inferior extremities; and the cephalic, which consists in changing the head in such a man- ner as to bring a more favorable part of it to present, and thus facili- tate delivery. It is proper to be remarked here that when the history of a given case of parturition indicates a probable malposition in a future preg- nancy, the Avoman should be subjected to careful medical treatment, with a view to curing that abnormal condition of the system which led to the previous difficulty. If a malposition be detected near the close of gestation by means of auscultation or palpation, it is claimed that pulsatilla will so affect the uterus or the foetus, or both, as to bring about a change to the normal situation of the fcetus in utero. Con- siderable evidence has been given as to the truth of this assumption— to the extent, indeed, that a mere negative theoretical opinion does not suffice to disprove it. It is, at all events, worthy of careful trial. OBSTETRIC OPERATIONS. 251 Podalic Version.—When it is deemed necessary to change the presentation of the child by bringing down the feet, there are certain rules Avhich under all circumstances must be observed : 1. The patient should by all means be apprised of the nature of her case, and as simply and kindly as possible be made acquainted with the nature of the operation to be performed. When she is once made to understand that the proposed operation is for her safety and that of her child, she will the more cheerfully submit; her free con- sent must in the first place be obtained. 2. Her position must be upon the back, Avith the breech near the edge of the bed, her feet also near the edge of the bed, the thighs flexed at right angles with her body; the head and shoulders must be elevated to a reasonable height. 3. The accoucheur should slip off his coat as gently as possible, in such a manner as not to make a great flourish and thereby alarm his patient. The hand and wrist to be used in the operation should be rubbed with lard until perfectly smooth, that hand always to be em- ployed whose palmar surface corresponds with the face of the child. For obvious reasons care should be taken not to lubricate the palmar surface. 4. The os uteri must be sufficiently dilated or dilatable to admit of the free introduction of the hand and the passage of the child. If there is the least rigidity of the fibres, we must defer the operation a little longer, otherwise we incur the risk of rupturing the uterus or of badly injuring the patient in other respects. 5. The introduction of the hand can be easily effected by placing first the fingers and then the thumb within the vulva, at the same time bringing them all together into the form of an elongated cone. Now press carefully, slowly and steadily from before backward and ' from beloAV upward, and the hand will enter the vagina and soon come in contact with the child. Great care must be exercised in pass- ing the vuhTa and entering the vagina, especially in prirniparae, as this is sometimes the most painful part of the Avhole operation. The fingers should be straightened as the hand passes the os externum, to prevent the knuckles giving unnecessary pain, and this may have to be observed likewise in passing the vulva. The palmar surface must be spread out and kept upon the anterior surface of the child until we come in contact with one foot. If there is difficulty in finding the foot, carry the hand upward to the thigh, and then the hand can follow the thigh and leg along to the foot. Having ascertained that it is really the foot, make a firm grasp about the ankle close down 252 obstetric operations. to the foot. If action is taken before the rupture of the membraues, the hand should be insinuated gently between the membranes and the uterus, and passed upward until the foot can be felt. The mem- branes should then be ruptured by scratching with the nail, and the foot seized. By this means Ave gain the advantage of having the fcetus floating in liquor amnii, for that fluid cannot escape in any quantity Avhen ruptured in this Avay. Care should be taken that the membranes are not ruptured prematurely. All this stage can be accomplished from time to time during the intervals of the pains. During each pain the hand should remain perfectly quiescent and Fig. 64. Fig. 65. Fig. 64. In this the head has been pushed up into the left iliac fossa, and one hand takes hold of the foot while the other supports the organ externally. Fig. 65. The same position, in which the version is commenced by drawing down , the foot. spread out flat upon some part of the child, any part being prefer- able to the abdomen. The surest Avay to suceeed in finding a foot, especially Avhen the liquor amnii has been discharged, is for the hand to tra\Terse the body, thigh and leg. Never feel for the foot until the body, thigh and leg lead on to it. The free hand must be placed upon the abdomen in order to steady the uterus, or this office may be performed by an assistant. Having secured a foot, then, during the absence of a pain, the hand should be gently and carefully withdraAvn. If we have been careful to carry the hand upon the anterior surface of the child and secured a foot there, we shall succeed in turning the child by doubling it more and more upon its anterior surface. By doubling obstetric operations. 253 the child upon its anterior plane we run no risk of breaking its back or neck, as in doubling it backward. Moreover, by bringing down only one foot and allowing the other to remain in its usual position, we leave the breech to occupy a bulk nearly as large as the head, so that as it passes through the organs more dilatation is effected, which the head requires in order to pass freely, and Avith less compression upon the cord, and of course Avith less danger of strangulation. Fig. 66. ^ig. 67t Fig. 66. The version is here completed, and the occiput, which was placed in the left iliac fossa aWhe commencement of the operation, will now come down behind the right acetabulum. Fig. 67 shows the mode of management of the cord. Further, as one leg is left distended upon the abdomen of the child, it serves to protect the cord during the passage of the body. This is a self-evident fact. After the turning of the child is fairly accomplished, the labor may be effected by the natural process alone, or Ave may continue to act as occasion requires. Wait, by all means, if it will seem to answer to do so, but if not make traction upon the leg, but act only in concert with the pains. " The pains sometimes do not return for a whole hour, but then so poAverfully and quickly that the child is born in full vigor and activity."—Wigand. Do not draAv down the other leg; wait until it is fairly expelled, foot and all, for it may be the saving of the child's life to do so, the cord being in this manner protected. Now 254 obstetric operations. the chief danger arises from the strangulation of the cord by its being compressed between the head and the bony walls of the pelvis. 80 long as Ave can feel the pulsation of the cord all is well. Should the pulsation cease, a slight effort may be made to draw it doAvn a little. If this can be done, pulsation will often become re-established, and, all things being equal, Ave can still wait. If it cannot be draAvn down and pulsation ceases, Ave must hasten delivery as much possible by making careful traction upon the body of the child. As soon as pos- sible Ave must hook doAvn the arms by placing the index finger in the bend of the elboAv, and then as soon as possible hook the same finger into the mouth of the child and flex the head as strongly forward as possible; hold it thus Avhile with the other hand placed upon the shoul- ders make steady and strong traction, and the patient will soon be delivered. Manage all breech presentations in this way when inter- ference appears necessary in order to save the child or mother; other- Avise trust to nature. It sometimes happens that the arms slip up by the sides of the head, when it Avill be necessary to disengage them before the head can engage. This can be done by slipping two fingers up from the shoul- der along the humerus, and allowing these fingers to lie along on its Avhole length; Ave can pass them forward and downward on the child's face, and in this manner run no risk of fracturing its arm. The pos- terior arm should be disengaged first, and the sub-pubic afterward. In all cases of difficulty in the introduction of the hand to perform this operation from rigidity of the uterine neck, the difficulty can be overcome by the administration of the proper remedies for rigid os. It should be further observed that complications from^hemorrhages, etc. can all be controlled by suitable medication, and in this way time can be obtained for dilatation and other necessary advantages without resorting to brute force or allopathic measures. Let it not be forgotten that version must never be attempted until the os uteri is fully dilated or freely dilatable. It can then be safely performed, both to mother and child, Avhether the membranes are ruptured or not; but the fittest moment for the operation is Avhen the os uteri is fully dilated and the membranes are still unruptured. The operation becomes the more difficult the longer the time that has elapsed after the membranes have been ruptured and the less the quantity of liquor amnii contained within the uterus, for then the uterus more closely envelops the child and the hand is passed Avith greater difficulty. Some obstetric Avriters—Dr. Robert Barnes more especially—insist that the knee rather than the foot should be seized and brought obstetric operations. 255 down. On this point Dr. Barnes says: "There ought to be some good reason for going past the knees to the feet, which are farther off and more difficult to get at. Now, I know of no reasons but bad ones Fig. 68. Fig. 69. Fig. 68. Delivery of the posterior arm first. Fig. 69. The mode of flexing the head by drawing down the chin and pushing up the occiput. (This mode is several times mentioned or referred to in the text.) for taking this additional trouble. You can turn the child much more easily and completely by seizing one knee." (Barnes' Obstetric Opera- tions.) While it is true that the knee is reached sooner than the foot, and Avhile there are cases in which the seizure of the knee would not only be more easily accomplished, but would be equally satisfactory with a seizure of a foot, still, in a majority of cases where turning is required, grasping one foot and bringing it down is, in my opinion, the safest and most satisfactory procedure. " Combined internal and external version may be practiced in cases Avhere the os only admits the forefinger, provided the membranes be entire or the uterus be not too rigid. It depends for its efficacy upon the mobility of the child in utero by mere external palpation, and has the advantage of being simpler, less dangerous and difficult, and of being applicable in cases where ordinary version could not be per- formed."—Rigby. The simplicity and efficacy of this combined procedure in arm, shoulder, neck or transverse positions, when detected at an early stage of labor, will be apparent. The operation consists in introducing one or two fingers of the left hand within the os uteri, in order to reach a 256 OBSTETRIC OPERATIONS. finger's length within the cervix. The position of the child having been made out, and it having been ascertained to Avhich side of the os uteri the head lies, the right hand is placed on the abdomen of the patient over the fundus, and an effort should be made to make out the position of the child's breech by palpation. With the hand on the abdomen, gentle but firm pressure is to be made against the breech to push it over toAvard the right side, folloAving it by a gentle gliding movement of the hand over the abdomen as it recedes; while at the same time the hand within the vagina pushes up the head in the oppo- site direction, so as to gradually raise it above the brim. Thus, it will be perceived, by pushing the different extremities of the child in opposite directions by the two hands employed, the child Avill gradually be turned around within the uterus, until finally the knee or the foot is opposite the os and may be brought doAvn. As the head passes from reach under pressure of the fingers Avithin the uterus, and the shoulder, body and breech successively come Avithin reach, they are to be "moved on" in the same manner, until the knee or foot is felt. This method might be resorted to in securing a cephalic rather than a podalic presentation where the neck or the trunk presents under favorable circumstances. Dr. Braxton Hicks, Avho has Avritten more fully on the subject than any other author, says: " We should first of all endeavor to induce cephalic presentation, and then, should there be any difficulty in accomplishing it, to change our plans to podalic." And he thus describes the modus operandi of inducing cephalic pres- entation : " Introduce the left hand into the A7agina as in podalic version; place the right hand on the outside of the abdomen, in order to make out the position of the fcetus and the direction of the head and feet. Should the shoulder, for instance, present, then push it with one or two fingers on the top in the direction of the feet. At the same time pressure by the outer hand should be exerted on the cephalic end of the child." In regard to the question as to what limb of the child should be seized in effecting podalic version, Sir James Simpson has laid it doAvn as a rule that the limb should be chosen which is on the opposite side to that of the presenting part. By so selecting, the action upon the pre- senting part is more decided, and it readily recedes as the limb upon which traction is made is drawn down. On the other hand, if that foot be chosen Avhich belongs to the same side as the presenting part, there is danger that the limb may be draAvn doAvn without causing a corresponding retrograde movement of the presenting part, and thus OBSTETRIC OPERATIONS. 257 complicate the presentation still more. This is a good rule, and its force is more apparent in shoulder and arm presentations. It is possible that an arm may be seized and brought down, to the great confusion of the accoucheur, who supposes he has an inferior extremity Avithin his grasp. In other words, a hand may be mis- taken for a foot or an elbow for a knee. To distinguish between a hand and foot we have the following points: The fingers are longer and of more uniform length than the toes. The thumb is much more apart from the fingers than is the great toe from its fellows, and the thumb is more movable laterally than the great toe. The fingers can be folded upon the palmar surface of the hand, whereas the toes merely admit of being curled upon themselves, as it were, and not flexed upon the plantar surface of the foot. The hand comes off from the arm in a line with it, whereas the foot comes off from the leg at a right angle. To distinguish between an elbow and a knee Ave have the following points: The knee is larger, rounder and appa- rently more of a square than the elbow, while the elbow, on the con- trary, is sharper and smaller than the knee. Again, in the knee we find the movable patella, which can readily be distinguished from the olecranon process of the elbow. " We distinguish a knee from an elbow by there being two round prominences (condyles), with a de- pression between them; the elbow presents also two similar promi- nences, but there is a sharp projection (olecranon) betAveen them."— Rigby. The outer and inner hamstring, with the popliteal space between, is also a good point in making out a knee. Dr. Rigby lays down the follovving excellent advice: " When the arm presents, Ave should pass our hand, if possible, along its inner sur- face, as this Avill guide us to the breast and abdomen of the child. If the hand protrudes, the palm is almost certainly turned in the same direction as the abdomen of the child. "If you can just reach the extremity of the foot, hold it still dur- ing a pain; you will find that you can get further hold of it when the pain has ceased." Cephalic version is seldom practiced, although it may be very useful in some malpositions of the head. It consists in substituting a more favorable presentation of the head for one not so favorable. The different steps of this operation must necessarily vary Avith every case in which it is resorted to. In all cases the patient should lie on her back Avith her limbs drawn up, in order that as much muscular relaxation as possible may be gained. Manipulation with the fingers within the os may be aided by the hand applied to the abdomen, and 258 OBSTETRIC OPERATIONS. used after the method described in the combined method of effecting podalic version. General Directions to be Observed in all Cases where the Head, Face, Breech or Trunk presents. When the head presents do not change it for the feet. If hemor- rhage occurs and there be placenta prsevia, manage as directed for that condition. If there is not placenta prsevia, control the hemor- rhage by medicines. (See Uterine Hemorrhage.) Remove all other difficulties by medicine if possible. If not, apply the forceps or resort to craniotomy, as the case may seem to demand. It is a very unsafe plan to exchange the head for the feet if it can possibly be avoided. It is much safer in all respects for the child, as Avell as for the mother, to deliver by the aid of the forceps. In case of malformation of the pelvis, the advice of Simpson to turn and bring doAvn the loAver side of the fcetal cephalic wedge, upon the ground that the head can thereby be more readily delivered, should be taken Avith a good deal of caution, and his proposition should be regarded as problematical. As a principle, then, worthy of all confi- dence, never exchange the head for the feet. If the face presents, and we are called before it has become fairly engaged in the cavity of the pelvis, if it be in the right mento-iliac position, Ave must introduce the left hand, when the face will rest in the palm, and by proper manipulation with the fingers the face can be rotated upward so as to flex the chin upon the sternum, and thus bring the vertex into the superior strait, when the labor can be abandoned to nature. If the position be one of the left mento-iliac, the right hand is to be used and the same result brought about. If the face has become too much engaged to admit of a reason- able doubt as to final success, resign the case to nature, at the same time Avarding off hindrances and complications, as in vertex pre- sentations. In these facial presentations we must wait Avith great patience, sup- porting in the mean Avhile the vital energies for expulsion Avith such remedies as each individual case may seem to require. We must Avait until rotation is effected, bringing the chin under the arch of the pubes. When the chin is even found exactly posterior, by waiting and pre- scribing such medicines as may be indicated the chin will rotate to the front and spontaneous expulsion take place. Ramsbotham says of all face presentations that there is little doubt that originally they OBSTETRIC OPERATIONS. 259 were presentations of the head which have been changed by the action of the uterus. It does sometimes occur, however, that when the chin is posterior, instead of being transverse or anterior, it seems as descent takes place to lodge in the great sciatic foramen, and be retained there until the presentation is converted into one of the vertex; this should be re- garded as a very happy event. When it becomes necessary to offer instrumental aid to facial presentations, the forceps must be applied in such a manner that the chin may be in harmony with its concavity. This would favor the rotation Avhich brings the chin under the pubic arch. After the chin has engaged under the pubic arch very great assistance is often afforded by applying the forceps in such a manner as to gently aid the process of flexing. It will be recollected that at this stage the occiput is lying back in the cavity of the sacrum, and the expulsive forces are so applied as to render the flexion of the head very tedious, so that the life of the child may often be saved by producing flexion of the head by artificial means. Fig. 70. THE MODE OF USING THE BLUNT-HOOK IN BREECH PRESENTATIONS. When the breech presents it may be allowed to descend, turning being rarely admissible in these cases. If artificial means are thought necessary, the blunt-hook may be used. It can be applied by putting one finger on the presenting part as a guide to the point of the hook, 260 OBSTETRIC OPERATIONS. the handle being held in a perpendicular posture. Noav, whilst this point is kept in contact Avith the breech, the handle should be de- pressed until the hook is slipped over the thigh and into the groin. Before traction is made one finger must be slipped up between the thighs of the child and placed upon the point of the hook, where it must be kept during each traction, for fear of accidents. The hook must be kept closely applied to the groin, for fear of fracture to the femur if it slips down upon the thigh. HoAvever, later experience proves most conclusively that it is much safer and better practice to apply well-curved forceps such as Bethell's, instead of the blunt-hook; well-curved forceps apply to the breech very nicely, and Avill not slip off. When the trunk presents we always knoAv at once that the inter- vention of art is inevitable, and we must at once determine where or in Avhat position is the anterior surface of the child, so that Ave may be able to choose Avhich hand is to be used, ahvays remembering to use that hand whose palmar surface corresponds to the face of the child. In these cases we should generally resort to podalic version by introducing the hand into the uterus, seizing a foot and bringing it down. Version by the combined method may, howeArer, in some cases, be effective. If the child's arm be found hanging from the vagina, Ave must attempt to turn the child at once by introducing the proper hand. Seizing a foot very gently, withdraw the hand as before directed. No attention need be paid to the arm hanging in the vagina. If the arm is not hanging externally, the shoulder being felt in the superior strait merely, introduce the proper hand and make an effort to push up the child, so as to allow the head to fall into the superior strait in place of the shoulder. We may be aided in this operation by gravity. If the head is found to occupy the right iliac fossa, after crowding up the child as much as possible alloAV the patient to lie over upon her left side, whilst the accoucheur is still holding up the child, and the head will be aided in its descent to its proper place. The hand may then be partially withdraAvn, and at the same time aid in placing the head in the proper position. If Ave succeed, the case can then be abandoned to nature, aided, when requisite, by the forceps. If we fail, the hand should not be withdrawn, but should pass on upward, and, seizing a foot, bring down the breech. All Ave have to think of in any position is to diagnose the child's relative position, select the hand accordingly, and proceed as above directed. In those very difficult cases Avhere the body is so crowded into the superior strait as to make it almost impossible to introduce the hand, OBSTETRIC OPERATIONS. 261 and quite impossible to hold on to the foot, Avhen once secured, to produce version, Ave must hold the foot, form a slip-noose with a strong handkerchief around the arm holding the foot, and then slip the noose up little by little Avith the other hand, on to the ankle, Fig. 71. Fig. 72. Fig. 71. Introduction of the hand in the second position of the right shoulder. Fig. 72. Mode of seizing the foot in the same position. taking care to secure the noose properly and firmly, when powerful traction can be made and version produced. All these manipulations should be slowly and very carefully performed. The Forceps. We noAv come to treat of the forceps. Of all the artificial means resorted to for the relief of women in childbed, the use of forceps is the most effective and results in the greatest saving of life to both mothers and children. Although the instrument has undergone a great variety of modifications since its invention by Chamberlen, its general principles remain unchanged. Its power is exerted in three different ways—as an extractor, compressor and lever. Forceps are commonly described as being of two kinds, Long and Short Forceps, though the difference in length of the two varieties lies more in the handles than elseAvhere. They consist of two branches or blades, each of which is divided into three portions—viz., the handle, which alloAvs of their easy introduction and the tractive efforts of the accoucheur, and Avhich is A^ariously constructed and shaped; the cephalic portion, Avhich is intended to grasp the fcetal head, and which is curved in tAvo directions—one to accommodate the blade to the cephalic globe, and the other to accommodate the blade to the curve 262 OBSTETRIC OPERATIONS. of the pelvic axis; and an intermediate portion or shank which joins the other two portions, and which usually furnishes the "lock" by Avhich the two blades are held in apposition Avhen adjusted. Straight forceps are such as have only the cephalic curve. These are preferred by some practitioners, but we are at a loss to understand how they can be preferred in a high position of the head. The short forceps are used to deliver the head only when it is low down in the pelvis—the long forceps Avhen it is situated high up. Many obstetricians, however, use only the long forceps, as the instru- ment is adapted to all cases where the use of forceps is indicated, how- ever low or high the head may be. " The long forceps possess a more scientific adaptation to the pelvis throughout the whole canal than the short forceps; and if the long forceps is found in practice capable of taking the head through the pelvis from brim to outlet, it folloAvs that, since the whole contains the parts, the long forceps is qualified to take up the head at any point below the brim." Fig. 73. Fig. 75. The short forceps in most common use, and undoubtedly the best instrument of its kind, is Davis's (Fig. 73). Of long forceps, Hodge's (Fig. 74), or Hodge's as modified by Wallace (Fig. 75), can be very highly commended. Bethel's forceps, likewise a modification of Hodge's instrument, I have long used with great satisfaction. The "St. Louis forceps" (Fig. 76), the invention of Professor T. G. Corn- stock of St. Louis, appears to be constructed upon sound principles, and has been highly spoken of by those who have used the instru- ment. Each blade is numbered—the left or male blade, Avhich is to OBSTETRIC OPERATIONS. 263 be introduced first, is marked plainly No. 1, and the right or female blade, which is to be introduced last, is marked No. 2. Thev may be applied in all cases Avhere the long forceps are required, and conse- quently where the short forceps are required also. This instrument _____ Fig. 76. Fig. 77. is very nicely made by Mr. J. J. Teufel of Philadelphia. Elliot's forceps (Fig. 77), the invention of Professor Elliot of NeAv York, by means of an adjuster in the handle gives the advantage, if it be an advantage, of lessening the amount of compression exerted by the instrument upon the foetal head. When the forceps are required to be used the woman should be apprised of the fact, though in as gentle a manner as possible. The accoucheur might speak of having artificial hands in his posses- sion which would enable him to reach the child's head and hasten its deliverance, thereby relieving her more speedily of her sufferings. as well as rendering the saving of her child's life more certain. At all events, her full and free consent to their use should be obtained. Application of the forceps having been decided upon, and the con- sent of the patient having been gained, she should be placed in the following position: She should lie upon her back, with her hips Avell down to the edge of the bed (if the child's head is in the superior strait, the mother's breech should be brought down quite to the edge of the bed, so that the handles of the forceps when locked may hang over the side of the bed); the thighs and legs should be flexed, separated and supported on two chairs or by two assistants; one hand of each assistant should be placed upon a knee while the other holds a foot. The accoucheur takes his place between the separated limbs of the patient, and stands, kneels or sits as he may prefer. Care should be taken that the position of the patient is made as comfortable to her as 264 OBSTETRIC OPERATIONS. circumstances will permit. The forceps may be applied while the woman is lying upon her left side in the usual position of parturition, but the dorsal position is for all reasons by far the best. When the forceps are applied to the head at the outlet, it may not be necessary to subject the patient to the inconvenience of being placed on her back and moved to the edge of the bed, but it will be found in a o-reat majority of cases, even of this character, that an adherence to the above directions in regard to position will be most conducive to the proper use of the instrument. Before applying the forceps each blade should be dipped in hot Avater, that it may be warmed to blood heat, and the external or convex surface should be anointed with lard. The operation of using the instrument may be divided into four stages—viz., introduction of the blades; locking; traction and lever- age; removal of the blades. They are applicable in the following cases: 1. When the os uteri is either dilated or is soft and yielding, and there is a proper degree of moisture of the parts, but the action of the uterus appears to have subsided or ceased altogether, and the patient is becoming exhausted. In such cases, after a reasonable use of homoeopathic remedies without avail, the child should be delivered either altogether or partially by the forceps. It may not be necessary to continue the tractive force so as to complete the labor, for Nature sometimes seems to rouse from her sluggishness under a moderate de- gree of traction by the instrument, and is able to complete the act of parturition without further assistance. 2. In some cases of facial presentation, where the diameters of the head are opposed to those of the pelvis—the long diameter of the head lying in the short diameter of the pelvis, for instance—and a reasonable waiting on the efforts of Nature or other measures have failed to bring about a favorable change. 3. Where there exists disproportion between the cephalic globe and the maternal pelvis, yet not to a degree requiring crani- otomy or other more serious operative interference. In these cases the compressive power of the blades reduces the size of the head, while tractive efforts draw it through the pelvic cavity. 4. Where the hand, foot or cord presents with the head, the forceps may be needed to bring doAvn the head and effect delivery. 5. When certain emer- gencies which complicate the labor occur, such as convulsions, rup- ture of the uterus, etc., and it is necessary to effect a speedy delivery to save the life either of mother or child. 6. When the after-coming head in breech presentations is compressing the cord, and the head cannot be delivered by manual aid alone. Here the forceps must be OBSTETRIC OPERATIONS. 265 promptly applied and delivery quickly effected, or the life of the child will be sacrificed. The use of the forceps is contra-indicated when the os is undilated and the soft parts are rigid and unyielding, and again Avhen the dis- proportion betAveen the foetal head and the pelvis is so great as to give no reasonable hope of effecting delivery, either from the amount of compression the instrument is capable of exerting or the amount of traction that may be applied. In serious malformations of the pelvis, or where bony tumors obstruct the pelvic passage-Avay, its use is out of the question. The mode of application of the forceps varies slightly in different cases, although the general principles regulating the introduction and adjust- ment of the blades are the same in all cases, whether long or short for- ceps be used. The position of the patient has already been described. Now, having placed her in this position, and the forceps having been warmed and greased as directed, the accoucheur takes his position, and, having ascertained the position of the fcetal head and its relation to the surrounding parts of the mother, proceeds to. introduce the male blade first—that is to say, that blade the convexity of the cephalic curve of Avhich will adapt itself to the concavity of the left iliac fossa of the mother. This he does in the following manner: The blade is to be held in the left hand and in a perpendicular position; tAvo fingers of# the right hand should then be inserted into the vagina and passed up for a short distance Avithin the cervix uteri, between the uterus and the fcetal head; then the point of the blade should be laid against the inside of the fingers thus introduced and slipped along them until the blade reaches the foetal head. Noav the blade is to be introduced still farther, and in such a manner that its concavity will be adapted to the convexity of the foetal head, and this will be executed by laying the blade flatAvise upon the head and gradually lowering the handle, Avhile at the same time the blade is gently pushed onward, or rather alloAved to glide omvard, until the convexity of the head is Avell grasped by the fenestrated portion of the blade. This done, the handle should be pushed back still nearer to the perineum, in order to get it out of the way of the second blade. The second or female blade is to be held in the right hand and in a perpendicular position, while two fingers of the left hand are insinuated betAveen the cervix uteri and the fcetal head. The blade is then to be slipped along the inner surface of these fingers until the head is reached, Avhen its further introduction is accomplished in the same manner as before described. Both blades having been thus introduced, they are to be locked by 266 OBSTETRIC OPERATIONS. lightly seizing a handle in each hand and gently bringing the blades into apposition, being careful at the same time to guard against en- tangling the hair or any of the soft parts of the mother Avith the lock. It may be regarded as an axiom that if the blades do not readily lock one or both have been improperly introduced. In such a case one or both should be Avithdrawn and reintroduced, for no force should be exerted in locking. It is absolutely necessary in introducing the blades to proceed with the utmost gentleness. Force is altogether uncalled for, and great in- jury may be done by a disregard of this admonition. It may generally be taken for granted that when the blades are introduced easily they are introduced properly. "The rule, then, is this: hold the blade lightly; let it feel its way, as it Avere; let it insinuate itself into position. It will be sure to slide into the space where there is most room." Unless the necessities of the case compel us to resort to the most prompt measures to effect delivery, the blades should be introduced only during the absence of pains, and extractive force should be ex- erted only during the presence of and with the pains. The general direction is given to apply the forceps to the sides of the child's head, over the ears. This is not necessary, nor is it ahvays practicable. On this point Dr. Ramsbotham says: "In employing the short forceps I lay it doAvn as a rule that the blades should be passed over the ears; the head is more under command when em- braced laterally, and there is less danger of injuring the soft parts during extraction. But I confess that I have for many years been accustomed, however low the head may be, to introduce the blades Avithin each ilium, because they usually pags up more easily in that direction." It Avill be seen from this that this distinguished accoucheur regarded more the parts of the mother than the position of the fcetal head. The above description of the manner of introducing the for- ceps applies more particularly to the short instrument, but the mode of introducing the long forceps does not differ from it in any great degree. In using the short forceps the position of the foetal head is to be taken into account, and in some degree regulates the position of the blades, but in the introduction of the long forceps the pelvis only is to be considered. " The position of the head may be practically disregarded. The pelvic curve of the blades indicates that these must be adapted to the curve of the sacrum in order to reach the brim. They must therefore be passed as nearly as may be in the transverse diameter of the pelvis. One blade Avill be in each ilium, and the OBSTETRIC OPERATIONS. 267 head, Avhatever its position in relation to the pelvic diameter, will be grasped between them. The universal force of this rule much sim- plifies and facilitates the use of the instrument. Not only does it apply to the position of the head in relation to the pelvic diameters, but also to all stages of progress of the head, from that where it lies above the brim down to its arrest at the outlet."—Dr. Robert Barnes. In introducing the long forceps when the head is in the superior strait, the position of the patient is the same as already described, except that the breech must be brought to the edge of the bed, so that when the forceps are applied and locked their handles may hang over the side of the bed, for here the traction at first is dowmvard and somewhat backward. The blades are to be introduced in the same manner as described for the introduction of the blades of the short forceps. As a blade penetrates farther and farther within the pelvic cavity to grasp the head, the handle sweeps from before backward through a curve extending from an imaginary line prolonged upward from the anterior surface of the symphysis pubis to an imaginary line representing the prolongation of the axis of the superior strait or of the coccyx; and conversely, as the head is extracted the handles again sweep through this same curve from behind forAvard, while the head itself is traversing the " curve of Carus." If the os uteri should lie unusually high up, extra care will be necessary to insinuate the points of the blades within the cervix. If they should slip off into the cul-de-sac between the vagina and cervix, very serious injury might be done by pushing them through the vaginal wall into the cavity of the peritoneum. When the blades of the long forceps have been introduced, an easy locking indicates not only that they have been properly adjusted, but that the case is one suitable for their use; for their not locking without a resort to force shows either that they have not been properly applied, or that there is pelvic deformity to that extent that the blades cannot lie opposite to each other in the same diameter of the pelvis. Being firmly locked, pressure should be made upon the handles, and if this occasions no pain to the patient, we may feel assured that no part of the soft parts is included between the blades. Traction should then be made Avith a vieAV to accomplishing delivery. The direction of the handles Avill to a great extent indicate the direction in which the tractive force is to be applied. When the head is in the superior strait and the instruments are locked, the handles will always be at the extreme posterior commissure of the vulva, which shows (the 268 OBSTETRIC OPERATIONS. woman lying on her back) that the tractive force is to be made down- ward and backward, just as the handles point. As the head descends into the cavity more and more, the handles will elevate themselves more and more, till at the instant of the disengagement of the head from the A^ulva the handles will point almost or quite directly up- Avard. While operating, then, it is wise, after any tractive effort, to let go the grasp, that the handles may point in Avhat direction the next effort should be made. But the accoucheur should always bear in mind the curved axis of the pelvic canal through which the head has to be brought to be delivered. Traction should be made with every pain, and only then. The tractive efforts should imitate the uterine contractions as nearly as possible, resting Avhen the uterus rests, and drawing as carefully and gently as possible Avhen the uterus exerts its expulsive force, yet with sufficient force to be effectual. And we should, at the same time, relax the grasp upon the handles between the expulsive pains, to relieve the foetal head from the con- sequences of continuous compression. "Continuous compression is opposed to the course of Nature, which intermits the expulsive act, giving periods of rest, during which it is presumed that the brain may better adapt itself and its circulation be maintained. Hence the laAv that we ought in "forceps labors to imitate this intermitting action by interposing intervals of rest, endeavoring so to time our efforts as to be simultaneous with and in aid of the natural expulsive efforts." Great care should be used not to wound the soft parts by SAvaying the instrument sideAvays or upward and dowmvard, as all these move- ments are unnecessary. As the perineum becomes distended Ave should proceed very sloAvly and cautiously, giving the parts time to dilate, so as not to endanger a rupture or laceration of the perineum. The use of anaesthetics in these operations is particularly objection- able, since their use tends to increase the danger; for Avhen pain i? produced by pressure Avith the forceps we know all is not right, and hasten to correct the error; but where the patient is rendered uncon- scious by the use of anaesthetics, this valuable indication is lost. The direction to keep the blades of the forceps in introducing them closely applied to the child's head is of considerable importance. It sometimes happens that the cord lies close down to the occiput, and it is possible for it to fall between the point of a blade and the f etal head, and it would in that case naturally be compressed and the child s life endangered when the two blades were locked. If upon making traction the child should be felt to jerk about or struggle (as the squirming of a fish is felt by the angler), this untoward circum- OBSTETRIC OPERATIONS. 269 stance may be suspected to have occurred, and the blades should be instantaneously loosened and AvithdraAvn, to be reapplied. It is sometimes necessary to exert very poAverful tractive force to effect the delivery of the head. Should the accoucheur have satisfied him- self that the case is one adapted to the use of forceps, and that the instrument has been properly applied and locked, this may be resorted to without serious detriment to mother or child, provided traction is made steadily in the right direction, and only at the right time; that is, during the expulsive uterine efforts, even though these may be feeble. The vis a fronte exerted by the forceps supplements the defi- cient vis a tergo exerted by the uterus. Fortunately, cases requiring a great expenditure of muscular effort are of infrequent occurrence. The forceps may be applied to deliver the after-coming head—in breech presentations, for instance—where the hands alone and flexing the head by pressure with the finger in the child's mouth are not sufficient to secure expulsion. Should the cord be compressed by the retained head, very prompt action within a feAv minutes will be re- quisite to save the child's life. The best method of using the forceps in these cases is as folloAvs : The body of the child should be draAvn well forward toward the symphysis pubis, and held there by an assist- ant; then pass the left hand into the vagina and insinuate two fingers betAveen the cervix uteri and the child's head on the left side of the pelvis; slip the forceps blade up the palmar surface of these two fingers to its proper place on the head, then introduce the right hand into the right side of the pelvis, slip up two fingers as before, and let the blade for that side glide into its place, guided by these two fingers; then lock the blades. Then exert tractive force first in the direction of the axis of the superior strait, gradually changing the direction of the handles from behind forward as the head comes down, and finally, as the occiput appears. under the pubic arch, carry the handles well forward, so as to take off the strain from the perineum as the face and forehead SAveep over it. The late Dr. Casanova was in the habit of using, in cases where other practitioners would resort to ordinary metallic forceps, an instru- ment which he termed a " Tocological Flexible Forceps" of his own invention. Dr. Tuthill Massy of England published an article on the use of this instrument and of Casanova's " Flexible Cephalo-ex- trador? in the "British Journal of Homoeopathy," vol. xxix., p. 327, with two plates exhibiting the instruments and their application. 270 OBSTETRIC OPERATIONS. The plates are here reproduced, together with their description and that of the use of the instruments as given by Dr. Casanova: Fig. 78. No. 1. " Fig. 1.—Eepresents the head seized with the double forceps, and the manner in which it is extricated from the pelvic strait. " No. 1. A single forceps seizing the head round the middle and inferior part of the chin. " No. 2. A single forceps seizing the head round the occiput. " No. 3. A frontal safety check-band, to prevent the forceps from receding and choking the infant. " Each of these forceps is composed of a piece of whalebone about three feet long, three-tenths of an inch in breadth, and one-tenth of an inch in thickness; of two silver rings at their extremities, well fastened, and the whole well polished. OBSTETRIC OPERATIONS. 271 "The frontal safety check-band ought to be placed at about four inches from the centre of the forceps No. 1 on each side, and it must be well secured. A piece of silk or any other smooth cloth will answer. Its length is from seven to eight inches. Fig. 79. C FIG. 2 " Fig. 2.—Represents the cephalo-extractor seizing the head of the infant after its death and separation from the body. "This instrument is made of two pieces of whalebone of the same dimensions in every respect, as those of the forceps, without rings in their extremities. These two pieces are fixed by their centre with a silver pin riveted on both sides, flat and 19 272 OBSTETRIC OPERATIONS. smooth to allow the pieces to move or open and close as the blades of a pair of scissors. (iSee Fig. 2.) When closed and held by the two extremities, they represent one of the forceps. When opened, and holding the four extremities in one hand (see a), thev represent Fig. 2. " Fig 3 "Represents the head seized in a different manner; as the diameter ia generally found to be less from A to B than from C to D, 1 have found it much easier to seize and extract it in that way (when such a difference is clearly mani- fested) than otherwise. , , . . " Fig 4. Represents a plain silver plate of an oval shape, Avith three holes in it* centre to allow the four extremities of the cephalo-extractor to pass when it \m seized' the head. The lateral extremities pass through holes Nos. 1, 1, one by each and the anterior and the posterior both pass through the hole No. 2. (See Fio- 2 a) This plate renders the instrument open and immovable, and it serves to "press'the head as much as may be required to extract it, without injury to the mother. Dr. Casanova was led to the use of the flexible forceps for effecting delivery, through the success he met with in a difficult case where metallic'forceps could not be had, and where he used successfully a pair of loops or fillets made of rattan shaved down smooth and thin, and applied under the chin and occiput respectively. He thus de- scribes their mode of use, for which we are likewise indebted to the article by Dr. Massy : "Flexible forceps should be applied as folloAvs: The patient lying on her left side over the edge of the bed or on her back, as circum- stances may require, you should bend one of the branches of the instrument and hold the two extremities together Avith your right hand; the bent part, being pressed and guided by the left, will be introduced over the face of the child or over the occiput, according to its position, that you may reach the inferior part of the chin or that of the occiput. The head being thus seized, you will be able to extricate it by pulling toAvard you in the most favorable direction. Should one branch be not sufficient, introduce the other on the oppo- site side of the former; and Avhen you are assured that both branches are properly placed, you can move them in any direction you please, and perform the necessary rotations to extract it Avith safety. (See Fig. 1.) The simplicity of this instrument and its flexibility render its application much more easy and more safe than the old iron for- ceps. There is no force required to accomplish this operation, nor is any compression exerted on the child's head laterally. If you be patient and Avateh a favorable opportunity when pain is present, you will succeed in bringing forth the infant without any injury to it or to the mother. " For more than twenty years I have been in the habit of using OBSTETRIC OPERATIONS. 273 this kind of forceps exclusively, and the experience of that time has taught me to appreciate its utility from the successful results I have obtained Avith it." Doubtless skill acquired in the use of the above-described instru- ment enabled the eminent Casanova to do Avith it what other men Avould do Avith metallic forceps. But it is to be remembered that the only force capable of being exerted in any marked degree by the flexible forceps is that of extraction; while compression and lever- age, Avhich enter so largely into the valuable forces capable of being brought into use through the metallic forceps, are almost entirely want- ing to a flexible instrument. Nevertheless, it is apparent that there are many cases in Avhich such forceps as Casanova used could be made available in very many cases of immovable head in the inferior strait or at the \mlva, with less of suffering to the mother and less detri- ment to the infant than sometimes results from the employment of the ordinary instruments. They are referred to here as worthy of trial, and especially so as they are so highly praised by their in- ventor, a man Avho deservedly stood high in the esteem of all practitioners of the homoeopathic school of medicine. The Vectis. The vectis is an instrument which might be used to advantage much more frequently than it is. It resembles someAvhat a blade of the forceps, and may be used as a lever, or even, to a moderate de- gree, as a tractor. The ordinary instrument is about twelve inches in length, one-half of Avhich are taken up in the handle. It may be readily applied over the occiput, face or sides of the head, and by making a fulcrum of one hand considerable leverage can be made with the other hand, and at the same time a moderate degree of trac- tion may be exerted. In some cases of facial presentation, Avhere the head is impacted, it might be made very useful, and again, in brow presentations, by bringing down the vertex by means of the vectis, a facial presentation Avill be prevented. It should be Avarmed'and greased before being applied, and is to be introduced much in the same manner as a blade of the forceps. If it is intended to pass the instrument within the cervix uteri, the same precautions should be observed to ensure its going in the right direction as Avere laid doAvn for introducing the forceps blade—viz., two fingers should be insinu- ated betAveen the cervix and the foetal head, and the blade of the vectis should slide along their palmar surface until Avell within the cervix. After its introduction, and before any power of any kind is 18 274 OBSTETRIC OPERATIONS. exerted, the free hand should be placed at the vulva in such a manner as to afford a fulcrum for the instrument. In no case should the maternal parts be used as a fulcrum for the play of the instrument. Craniotomy. The operation of craniotomy is dictated by that natural law of humanity which commands us to save the life of the mother if pos- sible, even if it involve the sacrifice of the child. It consists in making an opening into the cavity of the fcetal cranium, discharging its contents, and thereby securing a diminishing of the bulk of the head, either by the compression exerted upon it by the soft parts of the mother under the force of uterine contraction, or by additional instrumental resources, thereby rendering possible its expulsion or extraction. It is indicated in cases where the child cannot be de- livered with safety to the mother either by the forceps or by version, and yet there is reasonable ground for believing that it might be if the bulk of the head were reduced. If no such hope can be enter- tained, the Caesarian operation alone remains to be resorted to. Obstetricians have variously stated the minimum pelvic measure- ments for the performance of craniotomy. It may be stated, however, that if the antero-posterior diameter at the brim or the transverse at the outlet measures less than two inches, delivery by craniotomy could not be accomplished. But there are cases requiring crani- otomy in Avhich there is no abnormality of the pelvis or soft parts of the mother. Here the difficulty is due to the enlarged condition of the fcetal head, as by hydrocephalus. If the head in such a case is not sufficiently moulded by the maternal parts, or cannot be suf- ficiently compressed by the obstetric forceps, craniotomy must be resorted to. It is impossible to lay doAvn any fixed rule in regard to the time at which the operation should be performed. If, however, its necessity is apparent from the first, the sooner it is resorted to after the os uteri is sufficiently dilated the better it will be for the patient. The os uteri should be dilated at least sufficiently to admit the instrument used in effecting perforation. If it be dilated more than this it is an advantage. A variety of instruments have'been invented for effecting perfora- tion of the cranium. Of these probably the best in skillful hands is the modified " Smellie's Scissors" (Fig. 80). Braun's Perforator (Fig. 81) is likewise a valuable instrument, and may be used with great advantage, particularly Avhen cran'otomy is required to deliver OBSTETRIC operations. 275 the after-coming head. The proper method of using the last-named instrument is suggested by the instrument itself. Fig. 80.. If craniotomy is to be performed, perforation is the first step, and Smellie's scissors being selected, the operation should be conducted in the following manner : The bladder and rectum ha\Ting been emp- tied, as before other obstetric operations, the patient should be placed in the same position as Avhen forceps are applied. Two fingers of the left hand are then to be passed up to the head, keeping the 'cervix uteri upon their dorsal aspect. The instrument should then be intro- duced very carefully along the palmar surface of the fingers, Avhich should serve not only as a guide, but as a guard to protect the parts of the mother from injury. In this way it is to be passed up to the head, great care being taken that its point does not touch anything until it strikes the foetal head. The most depending part of the head is usually selected as the site of the operation. This reached, the instrument by a combined boring and pushing movement is made to pierce the cranium; if a bone is to be perforated, extraordinary care will be requisite to prevent the point of the blades slipping off and doing serious injury to the mother. The instrument is then to be pushed into the head, up to its shoulder, which is about an inch back of the point of the cutting blades. While this is being done an assistant should support the uterus externally, making firm doAvn- ward pressure, to force the head -of the child doAvnward, and keep it fixed, and thus prevent its rolling about or retreating from the pres- sure of the instrument. The blades are noAv to be opened, when their outer cutting edges will enlarge the aperture, and if they are 276 obstetric operations. then closed, turned at right angles to their first position, and again opened, a crucial incision will be made Avhich Avill not readily close, and which will be sufficiently large to discharge the con- Fig. 82. MODE OP INTRODUCING AND USING SMELLIE'S SCISSORS. tents of the cranium, as well as break up the cranial arch. The brain should then be broken up by the perforator, which not only facilitates its extrusion, but at once destroys the suffering of the child. The instrument should then be carefully Avithdrawn, guarded as before. The second step of the operation consists in extraction of the child. Uterine action alone may now be sufficient to accom- plish this. At all events, should there be no reason for effecting immediate delivery, it will be well to wait for the "pains" and see what they can do. One authority says: "After perforation wait an hour or two for the pains;" and indeed this may be done if no unfa- vorable signs be present to indicate a more expeditious delivery. Should nature not be able to accomplish the expulsion of the child, instrumental aid must be sought. The craniotomy forceps, the crani- ocl'ast or the crotchet are instruments devised for this purpose. By their aid the accoucheur effects compression and traction. The great- est care is to be exercised in their use to guard against injury of the maternal parts, either by the instruments themselves or by pieces of the cranial bones that may be broken off and brought away. The most generally useful of all these instruments is the craniotomy obstetric operations. 277 forceps; of which those invented by Professor Meigs (Figs. 83 and 84) fulfill all that will be required of such instruments. By the craniotomy forceps the perforated head may be seized and extracted or, where that cannot be accomplished, portions of the cranial bones may be removed and extraction accomplished afterward. If the vault of the cranium be removed, so that its base and the face are Fig. 83. Fig. 85. alone left behind, the head thus reduced can be seized by the forceps and drawn through a comparatively small opening. But if this re- moval of the cranial bones should not be necessary, traction may be made by introducing one blade within the cranium while the other passes on the outer side and a hold is thereby taken. Simpson's cranioclast (Fig. 85) is justly regarded as a most excellent craniotomy forceps. It has separate blades, which are to be intro- duced much in the same manner as the obstetric forceps, and locked after their introduction. Professor Elliot of New York considers it the best craniotomy forceps. With this instrument, one blade being passed into the cavity of the cranium and the other on its outside, the bones of the cranium, particularly the occipital bone, may be broken up, and the size of the head thereby considerably reduced. Traction may then be made by means of the instrument. The crotchet is a dangerous instrument, even in skillful hands. The principle of its application is, to pass it into the perforated cranium and by means of its hooked process to obtain a purchase 278 obstetric operations. upon the head. The hook takes hold of some part of the cranium, or it may be passed through the foramen magnum. The danger to the mother is very great from the liability of this instrument to slip and produce laceration.. To guard against this accident, a finger should be passed up on the outside of the cranium, to serAre as a guard and support to the sharp point of the crotchet, which is fixed into the bone inside the cranium. The instrument is noAv constructed Avith a second blade, which passes up on the outside of the fcetal head, and takes the place of the finger in acting as a guard. If a firm hold can be taken on any part of the cranium, very powerful traction can be exerted through the crotchet; but, unfortunately, however firm the hold may seem to be, it is possible for the parts to give way, and the greatest care therefore should be exercised in its use. Cephalotripsy is an operation to effect delivery by means of crush- ing or breaking up the foetal head and reducing its diameters very considerably by means of an instrument through which great crushing power can be exerted. This instrument is termed the cephalotribe. It has two blades Avhich have some resemblance to the blades of the ordinary forceps, Avhile there is a screAV-poAver in the handles by which the crushing process is regulated. The blades are introduced in the same manner and Avith the AAroman in the same position as Avhen the obstetric forceps are used, and when locked the crushing process should be commenced. Before the cephalotribe is used, per- foration of the skull and evacuation of its contents should be effected, to ensure a more successful compression. This operation, hoAveArer, can only be regarded as a substitute for the ordinary method of crani- otomy, to be resorted to in extreme oases. Where there is very great pelvic deformity, after perforation and evacuation have been accomplished, it is recommended, in some cases where efforts at extraction haAre failed, to wait for some time until incipient decomposition has rendered the parts more yielding and capable of collapsing. Embryulcia. This formidable obstetric operation consists in perforating and eviscerating the thorax or abdomen of the child, or both. It may be demanded in cases of extreme pelvic deformity, Avhere, the head having been perforated and delivered, the delivery of the trunk in its natural condition is impossible; or it may be called for when the thorax or abdomen is greatly enlarged by dropsical effusions. Smellie's scissors is the best instrument to employ for this purpose. OBSTETRIC OPERATIONS. 279 The instrument should be pushed into the thorax through one of the intercostal spaces, and if necessary one or more of the ribs should be divided; or it should be pushed into the abdomen Avhere that is re- quired ; in both instances the instrument should be used with great care and the mother carefully guarded against possible injury. It has been stated that "this operation is required sometimes in cases of arm presentation, where the membranes have ruptured, the liquor amnii escaped, and Avhere the uterus is so firmly contracted on the child, Avhich is thus jambed doAvn into the pelvis, that turning has become impossible." I am by no means willing to coincide with this opinion, for I do not believe that turning is impossible in any of these cases under the manipulation of that most important obstetric instrument, an educated hand. Decapitation. I am not able to conceive of any case in which a resort to this operation Avould be an absolute necessity. If any such case should arise, a pair of strong, sharp-pointed scissors would be the best instru- ment for the purpose. With these the neck should be penetrated, the spinal column and cord should then be severed, and the soft parts subsequently divided. The head can be removed aftenvard by the forceps or other means. The Cesarean Section. This operation consists essentially in delivering a child through an opening made by dividing the abdominal parietes and the uterus of the mother. Its intent is to sa\'e the life of one or both Avhen delivery per vias naturales is regarded as impossible. Concerning this opera- tion, Dr. Robert Barnes writes as follows: " The Caesarean section occupies a doubtful place between conservative and sacrificial mid- wifery. It is conservative in its design, in its ambition; it is too often sacrificial in fact. It is resorted to with a feeling akin to de- spair for the fate of the mother, which is scarcely tempered by the hope of rescuing the child. It is looked upon by the great majority of obstetricians as the last desperate resource, as the most forcible example of that kind of surgery which John Hunter regarded as the reproach of surgeons, being a confession that their art Avas baffled. On the other hand it is regarded by some enthusiastic practitioners, dazzled perhaps by its false brilliancy, as an operation deserving to be raised into competition with turning, craniotomy or cephalotripsy." It is impossible to lay down such rules as Avill serve as infallible 280 OBSTETRIC OPERATIONS. guides to the obstetrician in making up an opinion for or against the operation, but Ave may state broadly our conviction that it should be regarded as a dernier ressort. "The Csesarean section is the last refuge of stern necessity." While, hoAvever, statistics of the operation shoAV quite a large rate of loss, both of mothers and children—about two-thirds of the former and one-half of the latter—it is to be borne in mind that the recent great advances made in operations upon the abdomen give a much better chance for recovery of the mother and of a safe extraction of a living child than formerly. The Csesarean section may be regarded as indicated Avhere there is pelvic deformity to the extent that the channel through which the child must pass does not exceed tAvo inches in diameter. Again, it may be called for in some cases of ruptured uterus, where the child is known to be alive, Avhere the mother's life is threatened in cases of extra-uterine pregnancy, or Avhere the mother has died suddenly un- delivered. In the last-named case the operation has to be resorted to promptly, and very expeditiously performed, probably not more than eight or ten minutes after the mother's death, in order to secure the extraction of a living child. It is questionable whether the Csesarean section should ever be performed when the child is knoAvn to be dead. The operation should be performed in the following manner: The rectum and bladder having been evacuated, the woman should lie upon her back, Avith head and shoulders slightly elevated and the pelvis supported and likewise slightly raised. An assistant should give firm and equable support to the sides of the abdomen, to prevent extrusion of the boAvels through the incision. An incision should then be made in the linea alba, extending from the umbilicus to within a short distance of the symphysis pubis—about eight inches. The linea alba is selected as the proper place for the incision, because there will necessarily be less hemorrhage, and because also the uterus will be found lying immediately beneath, uncovered by intestines. After this first incision—Avhich should not extend into the abdominal cavity—has been made, an opening into the abdomen should be secured, through which the finger or a grooved director should be introduced, and the abdominal incision then completed by cutting from Avithin outAvard, to avoid inflicting injury to the intestines or cutting unnecessarily the uterus. This incision completed, the uterus is seen. Before making the uterine incision, the location of the pla- centa should be made out, that it may be avoided. This may be done, according to Dr. Pfeiffer, by placing the hand flat upon the uterus, Avhen a peculiar thrill or vibration communicated to the hand OBSTETRIC OPERATIONS. 281 will mark the position of the placenta, and, in connection with this, the slight bulging of the part, "as if a segment of a smaller globe were seated on a large spheroid," will likewise serve to indicate the place of attachment of the placenta. The uterine incision should then be made, four or five inches in length, on a line with the cut through the abdominal parietes. Neither the fundus nor the cervix of the uterus should be involved in the incision, Avhich should be limited to the body of the organ, as by dividing either of these por- tions the subsequent contraction of the viscus would be interfered with. Then " an assistant hooks the forefinger of each hand in the upper and Wer angle of the uterine wound, and, lifting them up, fixes them in contact Avith the corresponding angles of the abdominal wound. This shuts out the intestine effectually, and tends to prevent the blood from running into the abdominal cavity." The membranes should then be ruptured and the child carefully extracted, by seizing- it, if possible, by the feet. Should the head of the child be caught and firmly held by the lips of the wound, it will be better to enlarge the incision rather than attempt to extract the head by force. The placenta and membranes should then be removed, together Avith all coagula, and the operator should ascertain that the os is free to admit of the passage of the lochial discharge. Dr. Barnes directs that a probang be passed through the os uteri and Angina to ensure this. Should the uterus now contract, the incision will be reduced to a small slit, and the hemorrhage from its divided vessels or from the mouths of the uterine sinuses made patulous by the detachment of the placenta will soon cease. If it should not thus spontaneously con- tract, direct pressure should be made upon it Avith the hand, or ice may be applied directly to it, and a piece be left in the uterine cavity. Should these measures fail to induce contraction, galvanism must be resorted to, and a proper apparatus should be at hand in case it should be needed. In regard to securing the uterine wound, authorities appear to be divided as to Avhether sutures should be used or not. If the con- traction of the uterus be firm, they will probably not be required; but on the other hand, in fatal cases autopsy has revealed the uterine wound in a gaping condition where sutures had not been used. Barnes states the case as follows : " If the patient is operated upon at a selected time, if the danger of ATomiting is lessened by not taking chloroform, and if the uterus contracts well after the operation, the sutures may be dispensed with; but under the opposite circumstances it would be better to stitch the uterus." If sutures are used, either 282 OBSTETRIC OPERATIONS. the uninterrupted silk suture or interrupted sutures of silver Avire may be employed; or any other that may be thought most suitable. Before closing the abdominal Avound, blood or other foreign mate- rial that has found its way into the abdominal cavity should be re- moved. The lips of the Avound should be brought together and held together by means of silver-wire sutures, introduced pretty closely together, and passing through the divided peritoneum as Avell as through the abdominal wall, so that there may be two peritoneal surfaces opposed to each other on the inside of the Avound. Adhesive inflammation is soon set up, and union is speedily effected. Broad bands of adhesive plaster should be applied across the abdomen as a means of support, and over these a soft compress should be laid. .\ broad flannel body-bandage should then encircle the abdomen to secure uniform support. The compress and the bandage should be saturated in the region of the wound with a solution of equal parts of calendula and water. The dangers arising from this operation are: immediate shock, hemorrhage, peritonitis and septicsemic puerperal fever. Should any of these arise, they should be treated strictly in accordance with homoeopathic principles; an adherence to Avhich Avill greatly lessen their dangers. The patient should be kept very quiet after the ope- ration, and for some hours should be allowed to take little or nothing into the stomach save cold water, which may be freely allowed. To excite vomiting is to add an additional and unnecessary risk. The danger arising from vomiting contra-indicates the use of chloroform; ether Avill be preferable. Local anaesthesia by means of rhigolene or ether spray has been recommended, and is free from the danger of exciting vomiting. Where this operation is performed under the most favorable circumstances there is a Arery great probability that the lives of both mother and child Avill be saved; but Avhere ex- haustion from protracted labor or other unfavorable conditions exist, the probabilities run strongly in the opposite direction. The Sigaultean Operation, or Symphyseotomy. This operation has been performed with the same object in view as in the Caesarean section—viz., the extraction of a living child which could not be born by the natural passages. It consists in cutting through the fibro-cartilage which constitutes the symphysis pubis, so as to separate the pubic bones, and by that means to increase the diameters of the pelvis sufficiently to allow of the passage of the fcetal head through the pelvic canal and A7agina. As it has been obstetric operations. 283 abundantly proven that the pubic bones, when their symphysis is thus divided, admit of but slight separation, and that this separation adds but very little to the diameters of the pelvis, the operation has fallen into discredit, and is seldom or never resorted to. Induction of Premature Labor. The induction of premature labor is admissible under certain cir- cumstances. By premature labor Ave mean that only which may take place after the viability of the child is established beyond a doubt. This period first occurs immediately after the close of the seventh month. In all cases where the excavation of the pelvis is so obstructed by any cause, either by pelvic deformity or by tumors of any kind that cannot be reduced or pushed above the superior strait, which will prevent the passage of the child at full term, premature labor may be effected; provided always that such a course will give a reasonable assurance of saving the life of the child, and at the same time of pre- venting greater sufferings and danger to the mother. Should the history of the patient prove that she cannot give birth to a child at term, and should the smallest diameter be about two inches and a half, premature labor should be resorted to immediately after the completion of the seventh month. If we could be assured that the smallest diameter is three inches, we may delay the operation till about the eighth month; if three and a half inches, two Aveeks before full term Avould suffice. Under judicious homoeopathic treatment no diseased condition of the patient would ever render necessary a premature delivery. Neither would it ever proA^e admissible to induce premature labor because the previous history goes to show that the child perishes at the eighth or eighth and a half month ; for all such cases are perfectly curable by medicines. Various methods of inducing premature labor have been resorted to. The author regards the following as the safest and best: The patient to be operated upon may assume the same position as in labor. The bed should be protected with oil-cloth or india-rubber cloth, arranged so as to guide a stream of Avater from the vulva into a pail or tub placed near the bed. Another pail must be provided, contain- ing tepid Avater: Avith a common syringe the Avarm Avater should be thrown directly upon the os uteri. This operation irritates and softens the neck of the ut""i s, so that contractions set in in the course of an hour or two, and thus labor is provoked and takes place in the most 284 obstetric operations. natural manner possible, except when it occurs in Nature's OAvn way at full term. The operation will fail unless the stream is so directed that it shall fall directly upon the neck of the uterus. It should be repeated in the course of two hours, unless the first experiment is successful. The common pump-syringe is the best for this purpose. The quantity of Avater used at each operation should be about ten quarts. Another method, and one very highly commended by Dr. Barnes, is to pass an elastic bougie or catheter six or seven inches into the uterus, avoiding the placenta and taking care not to rupture the membranes. The remainder of the bougie should be coiled up within the vagina, and this will serve to keep the instrument in situ. Sooner or later uterine action Avill set in. The os may then be dilated by means of Barnes's dilators, the membranes ruptured, and the rest left to nature if it is found that expulsive pains come on sufficiently. If not, the forceps or turning may be resorted to. Premature labor should never be induced without grave considera- tion of the case, and professional advice should be sought by the accoucheur in all such cases, as Avell for the advice as for a division of the very great responsibility. Of the production of abortion we have this to say : Can it be right under any circumstances Avhatever? Is it right to commit willful murder under any circumstances Avhatever ? If not, then it is never right to procluce abortion under any circumstances whatever, for is not abortion murder ? We have abundance of proof that under homoeopathic treatment no state or condition of health demands the production of abortion— that is, premature delivery before the product of conception is viable— for the subject of such a malady as might be thought to necessitate it under allopathic resources may be cured by homoeopathic medication, not only of the ills immediately occasioned by pregnancy, but of all ailments reducing the standard of general health. Abortion, there- fore, under such circumstances Avould be a terrible mistake; and not only does it destroy the life of the embryo, but it lowers the standard of health and endangers the life of the mother. Cases in which the least diameter of the pelvic excavation is below two and a half inches had better be alloAved to go to term, and then submitted to operative interference. If the Csesarean operation should then be performed and under favorable circumstances, the lives of both mother and child may be saved; the chances in favor of which are undoubtedly in- creased by the after-treatment being conducted in accordance with homoeopathic principles. disorders incidental to pregnancy. 285 CHAPTER XVI. DISORDERS INCIDENTAL TO PREGNANCY. IN a state of perfect health all the functions of the body are so har- moniously carried on—each receiving its proper portion of the vital force in due season—that no one preponderates over another. But where, as in cases of excessive intellectual development in chil- dren, any one structure obtains more than its just share, the others must suffer in equal ratio. Gestation is indeed a normal condition, but the remarkable development of vital action in the uterus renders it an exceedingly difficult task for nature perfectly to adjust the bal- ance. But while in general a similar increase of vital action seems to pervade the entire system, the health remaining perfect, there are numerous and sometimes most distressing exceptional cases. The greater number of these appear in connection with the nervous sys- tem, and at first take the form of sympathetic irritation. There are other disorders in the pregnant state Avhich arise from mechanical pressure, and even displacement of the abdominal organs, by the gravid uterus. And there is still another class of disorders, severe functional derangements, and even deeper-seated derangements of the elementary constituents of the blood, which seem to be the re- sult of some of those before mentioned. All these sympathetic irritations, structural difficulties and derange- ments of the constitution of the blood, acquire a still greater import- ance from the fact that they become the occasion for the development of every constitutional weakness and hereditary taint. The way is long and tedious; what AAronder then that the heavily-laden system of the pregnant woman sometimes stumbles? Hoav much greater the wonder if the nine months of gestation, even before being concluded by perhaps twice as many hours of almost convulsive effort, should not expose and aggravate every inherent debility and fully develop every latent miasm! There is yet another class of difficulties, which, if they do not actually make their first appearance during gestation, then at least for the first time become seriously troublesome; this class includes disorders con- nected Avith the uterus itself and with its appendages. Some of these are structural diseases of the vagina, os or cervix uteri, unnoticed be- fore, now rapidly deAreloped. And even if there Avere no morbid conditions, the suspension of the regular catamenia! flow could not but 286 DISORDERS INCIDENTAL TO PREGNANCY. exert an important disturbing influence upon the more delicate female constitution. But from Avhatever cause they arise, and to whatever class they may be referred, all the disorders of pregnancy require the most patient and careful attention on the part of the homoeopathic physician. The season of gestation is the time given him for sowing the good seed from Avhich his patient may reap a rich harvest of improved health during all her subsequent life. The fact just mentioned, that the almost herculean labors of nature tend to develop and ultimate all the hitherto latent, hereditary predispositions to disease, renders this period of gestation at once of the greatest value to the true physician and of the most serious importance to the patient. For even as an hereditary tendency to phthisis pulmonalis may be most readily and radically cured Avhen its temporary development in a bad cold, or even in a severe attack of pneumonia, renders its characteristics more apparent, so the exaggerated manifestation of her constitutional disorders which in one form or another so afflicts the pregnant woman, may be made the opportunity for radically purging them from her own system, and at the same time of purifying the constitutions of all her children. As already intimated, the tremendous strain upon the constitution during pregnancy finds its crisis in the agonizing labors of par- turition. These are rendered all the more terrible, are sometimes folloAved by the most disastrous consequences, and even rendered immediately fatal, by the culmination of the disorders developed during gestation. Thus, the same sedulous attention on the part of the true physician which will relieve her from present sufferings during the long months of pregnancy, will also render her confine- ment much more safe and easy, and entirely prevent those conse- quences Avhich so often fill her subsequent life with wretchedness. And the invaluable means and methods committed to the homoeopathic physician Avill often enable him not only to ameliorate the unfortu- nate condition of his suffering and despondent patient, but in many instances to secure for her the preservation of the fruit of her womb. In the homoeopathic jurisprudence, morning sickness and all other forms of gastric derangement must be entirely stricken from the list of justifiable causes for inducing premature delivery. The most distressing of these cases are relieved and the offspring preserved, where under allopathic regime the health of the mother was often rendered permanently wretched, and the child inevitably sacrificed at an earlier or later stage of pregnancy. And in many instances in which the mother had suffered for many DISORDERS INCIDENTAL TO PREGNANCY. 287 months from the disorders of pregnancy incidental to her constitu- tion, and had in consequence greatly deteriorated in her own vital nutrition, the child, if not actually destroyed, became of necessity greatly enfeebled. Such results are too common in allopathic prac- tice to attract much attention, and such offspring go far to savcII the bills of mortality to the frightful extent of one-triird of all who are born dying within the first three years. Contrast with this the fine healthy child born after the mother has been relieved of her dis- tressing disorders of pregnancy, and in a great measure at the same time cleansed of her constitutional impurities by homoeopathic medi- cation, and you have a picture of Avhat has been done in thousands of cases, and of what it is now the duty of the homoeopathic'physician at least to attempt to do in every case of the kind. He is the true physician who seeks not only to relieve the present suffering, but at the same time to remoA-e its cause in the constitution itself, and thus prevent the return of the evil. He is truly a benefactor of his kind who, not content Avith curing the generations with whose successive portions he mingles, thus seeks to improve his present opportunities in the light of an adA^anced and beneficent science, in such a manner that the race may be rendered more healthy in all the years to come. Our object in these remarks is simply to call attention to the pro- found importance of most carefully treating the disorders incident to pregnancy; even in cases Avhere their severity does not entail suffering, they may thus be seen to afford most precious opportunities for permanently improving the health of the mother, and of render- ing her confinement comparatively comfortable and perfectly safe, and of ensuring the preservation and health of the offspring; and finally, of securing the comfort of both mother and child during the season of lactation. We Avould state that, for reasons rendered obvious by the preceding remarks, the most valuable and efficient remedies for the disorders incident to pregnancy will be found among the anti- psorics; and that in some cases the higher these are given the more good they will do. Such is my own experience in very many cases. The disorders Avhich appear during gestation vary in almost every possible respect in different women; each individual, however, usu- ally suffering in the same manner whenever enceinte, and with the same comparative severity, unless relieved by appropriate homoeo- pathic medication. In some women these disorders appear Avith but slight intensity, and soon pass aAvay; while others declare they never 238 DISORDERS INCIDENTAL TO PREGNANCY. have such good health as they enjoy Avhen pregnant. Others, again, dread this condition as bringing Avith it for them a long train of vari- ous and distressing sufferings, by which their health is deteriorated, their strength exhausted, and their prospects in confinement rendered gloomy in the extreme. In some instances these disorders appear very soon after conception, and in different forms continue during the entire period of utero-gestation; in others they are relieved by the third, fourth or fifth month; while in other cases the difficulties make their appearance only during the later months, and continue to in- crease in severity till confinement. An I Avhile the disorders of pregnancy principally affect individual cases in one or more of their various forms, the entire range of these forms, as collected from the records of many cases, is found to cover every function and particular organized system in the female economy. The principal of these disorders may be classed under the following heads: Disorders of the digestive system and of the secretions and excretions; of circulation and respiration; of the uterus and Us appendages; of locomotion and innervation; and of the affections, emotions and feelings. Hygiene of Pregnancy. A few Avords on this subject, which is quite as important as the medical treatment of the disorders of pregnancy, inasmuch as it is intended to prevent such disorders from occurring. In order that this period may be gone through with in a thoroughly physiological manner, all unphysiological and unphilosophical habits must be laid aside and all pernicious practices abandoned. The pregnant Avoman should strive to cultivate for herself the utmost cheerfulness and tranquillity of mind ; she should strive to be at peace Avith all the Avorld and at peace with herself, for her mental and moral state Avill surely be engrafted upon her offspring, the education of the future being commencing while yet in utero. And in this effort she should be seconded by her husband, whose responsibility is very great at this period—whose conduct toward the wife of his bosom at this period, acting upon her mental organization, will be transmitted to their joint offspring, for weal or for avoc Medical men cannot be too particular in urging this point on all suitable occasions, as it falls to their lot not alone to cure diseases, both mental and physical, when they exist, but as Avell to prevent their occurrence when it is at all possible to do so. A pregnant woman, during the whole course of her pregnancy, will DISORDERS INCIDENTAL TO PREGNANCY. 289 require more sleep than at other periods, and an ample allowance of "tired Nature's sweet restorer" should always be indulged in. And yet, at the same time, habits of slothful ness are to be deplored and decried. " Early to bed and early to rise" applies Avith additional force at this juncture, and nine, or at the latest ten, o'clock at night should ahvays find her in bed, and six, or at the latest seven, o'clock in the morning should find her up. Habits of regularity in all things should be cultivated—regularity as to hours for sleeping and waking —regularity as to meals, exercise, stool, etc. As much exercise in the fresh air as is possible should be taken. Walking is indispensable, and every day should find her taking a Avalk leisurely and with the mind at ease; and this rule should be observed even in cold and, (xeteris paribus, unpleasant Aveather, excepting Avhen the Avalking is dangerous from snoAv or ice. A walk is often an excellent remedy for the slothfulness and heaviness that sometimes steals over the preg- nant Avoman like an incubus—a much better remedy than taking a nap, or even than a prescription from the doctor. Useful employment, reading or useful and agreeable conversation should engage the Avaking hours not otherAvise employed. In fact, the physician should enjoin upon his pregnant patients the importance of cultivating a proper condition of mental vitality as well as physical. Hoav important is it that the expecting mother, as a neAv thread of life is being spun within her, should think and do that alone which is good and right, for of a certainty her offspring will have Avoven into the tissue of its existence the resultant of what she is and does during her preg- nancy. It is a fact worthy of notice that as pregnancy advances the fluids of the body are increased in quantity, and of course an increase of circulating capacity is demanded. This has, in connection Avith other points, a decided bearing on the question of dress during pregnancy. Unusual looseness about the Avaist is requisite, and as Avell about the neck, wrists and lower extremities; even an elastic garter spanning the leg may be injurious, jand everything that can retard or in any way interfere with free circulation should be, if possible, avoided. The proper warmth of the clothing should be studied Avith great care. It should be composed of such fabrics as combine lightness with warmth, so that proper heat of body may be maintained Avithout the discomfort of oppressive clothing. In the later months, particularly, the clothing should not be tightened about the Avaist at all. The dress should be allowed to fall loosely and gracefully from the neck and shoulders, shoAving but little waist; and this will be found not 19 290 DISORDERS INCIDENTAL TO PREGNANCY. only most becoming, but far better for the mother and the fruit of her womb. One fact in connection Avith this question of dress is here noteworthy—viz., that women in the later months of pregnancy often complain of, and really suffer from, coldness of the abdomen, the protruding abdomen causing the clothing to set off to the extent of almost completely exposing that part of the body to direct contact with the air. In view of this, the clothing should be so adjusted, or an extra garment worn, to obviate the difficulty. Physicians will greatly benefit their patients by giving strict directions in regard to all these matters, which are so apt to be regarded as minor and insig- nificant points. The diet during pregnancy should be generous in meats, vegetables and fruits, and at the same time simple. The less tea and coffee are indulged in the better for both mother and foetus, as these have a tend- ency to produce nervousness and even convulsions. Sugar, salt and spices should be taken in moderation. Stimulants of all kinds should be most strictly and religiously avoided. Very many of the discomforts arising at this period may be promptly relieved or removed by a strict conformation to the laAvs of a rational mode of life. If, however, they should persist, and help seems neces- sary to adjust and properly balance the deranged vital forces, help is to be sought Avithin the pale of homoeopathic medication, and the law of the similars—here, as elsewhere, applicable—should be brought to exercise its wondrous health-giving powers. Thus pregnancy judici- ously managed prepares the way for the act of parturition, and, it may be remarked, just as pregnancy has been free or freed from sufferings and from complications, will, cceteris paribus, the act of parturition and its post partem consequences be likewise free from dangers and disorders.* Disorders of the Digestive System. The disorders of the digestive function and apparatus may be enumerated under the heads of variations of appetite and taste, gastric disturbances and intestinal affections. Under the first of these heads will be found anorexia, malacia or longing, and bulimy; under the second, nausea, vomiting and pyrosis; under the third, constipation, diarrhoea and fissure of the anus and rectum. I. Variations of Appetite and Taste. Anorexia, or Avant of appetite, and even disgust for food, very fre- * From a pamphlet by the author, entitled " Before, During and After Parturition." VARIATIONS OF APPETITE AND TASTE. 291 quently makes its appearance at the commencement of gestation ; less often it is seen only toAvard its close. In some cases there is a loath- ing for some particular kinds of food, especially meats; in other cases there seems to be simply a general loss of appetite. These symptoms are usually supposed to be the results of the sympathetic relations existing between the stomach and the uterus, but their deeper meaning, already referred to, will be particularly stated in connection with that of the other variations of appetite. Malacia or longing, another not uncommon affection of pregnant women, consists in a depra\Tation of taste, in which an almost univer- sal loathing is combined with an exclusive longing for some particular article of food. Where something injurious or not used for food is desired, the abnormity is termed pica. Chalk, charcoal, pepper, salt food, acids, alkalies, are sometimes very strongly and persistently craved and eaten. The desire for particular articles of food should be gratified to a reasonable extent. " The common tendency of the appetite in pregnancy is to prefer fresh vegetables, fruits and cooling drinks, and to avoid stimuli of all kinds. In this the taste of preg- nancy accords very Avell with all its requirements."—Smith. Bulimy, or inordinate and insatiable hunger, is another affection of pregnant Avomen; which here, as in other persons, generally indicates some disorder of nutrition or assimilation, although it may be due simply to sympathetic nerv^ous irritation. All these morbid condi- tions of the appetite are but indications of the various hitherto latent dyscrasia?, developed now by the pregnant state. And the careful ex- hibition of the appropriate remedies will not only relieve the suffer- ings of the patient, but will also greatly improve her general health, as already stated. We give the various remedies which have been found useful in these complaints. These should be compared Avith those more fully stated under Gastric Derangements, and carefully studied in the Materia Medica, in order to determine Avhich is the appropriate remedy in each individual case. Note.—In arranging these remedies for study* they have been classified and arranged in groups. Those in group 1 are most strongly indicated for the particular symptom or condition under which they are found. Those in group 2 come next in importance, and those in group 3 occupy the loAvest scale of relative importance. But while these indications of the relative prominence of particular symptoms in the confirmed pathogeneses of particular remedies are of great value, they will be found infallible only when they lead to the 292 DISORDERS INCIDENTAL TO PREGNANCY. determination of a medicine in accordance with the totality of the symptoms. And yet the totality of the symptoms will often be indexed by the characteristic symptom on the side of the patient and by the corre- sponding'key-note on the side of the remedy. Finally, and as elseAvhere observed in the present Avork, the charac- teristic symptom of a particular case may not be the most prominent or even the most distressing symptom: especially is this seen to be the case Avhere it consists in the time of aggra\7ation or other similar circumstance: nor yet will the key-note often be the most violent and painful of the pathogenetic results of the drug. The deepest streams are the most still and silent, and the true vital currents of the human frame are far more subtle, profound and spirituelle than the noisy rivers that rush through the arteries and the veins. Table of Remedies for Variations of Appetite and Taste. Anorexia—Want of Appetite.—1. Chin., Cycl., Nux v., Rhus tox., Sep., Sil. 2. Ant. cr., Am., Ars., Bar. c, Bell., Bry., Calc. c, Canth., Cic, Con., Ignat., Lye, Merc, sol., Natr. m., Op., Plat., Puis., Ruta., Sabad., Sulph., Thuj. Bulimy—Inordinate Appetite.—1, Calc. c, Chin., Cina, Jod., Lye, Nux v., Puis., Sil., Verat. a. 2. Ang., Aur., Bell., Bry., Coca, Kali c, Hell., Natr. m., Oleand., Nux m., Petrol., Phos., Puis., Rhus tox., Sabad,, Stann.,, Staph. Hunger without Appetite.—1, Natr.. m., Op., Rhus tox. 2. Agar., Ars., Bar., Bry., Chin., Dulc., Hell., Magn. m., Sil., Sulph. ac. Thirst—Too great.—1. Aeon., Ars., Bry., Calc. c, Cham., Chin., Merc, sol., Sulph. 2. Amm. mur., Ant. cr., Arm, Bell., Colch., Cupr. m., Hep., Hyos., Natr. m., Nitr. ac, Nux v., Rhus tox., Sec. corn., Sil., Stram., Veratr. a. ------ Want of—1. Apis, Hell., Merc, sol., Nux m., Puis. 2. Agn., Ars., Asaf., Camph., Con., CycL, Euphorb., Mang., Oleand., Sabad., Samb., Sep., Spig., Staph. ------ with aversion to drink.—1. Bell., Canth., Hyos., Nux v., Stram. 2. Agn., Lach., Natr. m., Rhus tox., Samb. Aversion to Acid Things.—1. Bell., Ferr., Sabad., Sulph. 2. Coca, Nux v., Ignat. ------Beer.—Coca, Nux v., Stann., Sulph. ------Brandy.—Ignat., Merc. sol. ------Bread.—1. Natr. m. 2. Con., Lye, Nux v., Puis., Sep., Sulph. variations of appetite and taste. 293 Aversion to—Broth.—Am., Ars., Graph. ----- Coffee.—I. Nux v. 2. Bry., Calc. a, Cham., Coff., Phos. -----Fat Food, Butter, etc.—1. Petr., Puis. 2. Ang., Bry., Carb. an., Carb. veg., Cycl., Natr. m., Sulph. -----Fish.—Graph., Zinc. -----Meats of all kinds.—1. Mur. ac, Petr., Sil., Sulph. 2. Calc. c, Carb. veg., Graph., Lye, Plat., Rhus tox., Sabad., Sep., Zinc. -----Meal and Flour {dishes made of).—Phos. -----Milk.—JEthayea, Bry., Calc. a, Guaj., Puis., Sep., Sil.,Sulph. -----Salt.—Carb. veg., Selen. -----Solid Food.—Ang., Bapt., Ferr., Staph. -----Sweets or Sweet Things.—1. Caust., Sulph. 2. Ars., Merc. sol., Phos., Zinc. ----- Vegetables.—Hell., Magn. m. ----- Water.—1. Bell., Calad., Nux v., Stram. 2. Bry., Natr. m., Caust., Canth. ----- Wine.—l. Merc, sol., SabacL 2. Ignat., Lach., Rhus., Sulph. Longing for Acids.—1. Veratr. a. 2. Ant. cr., Amm., Ars., Bry., Cham., Hep., Lach., Phos., Squill., Stram., Sulph. -----Bcer.—l. Bry., Merc. soL, Natr. a, Nux v., Petr., Puis., Sabad., Stront. 2. Caust, Coca, Lach., Op., Phos. ac, Spig., Sulph. -----Bitter Things.—Dig., Natr. m. -----Bread.—1. Ars., Plumb. 2. Natr. m., Stront., Aur. -----Brandy.—1. Op. 2. Ars., Hep., Nux. v., Selen., Sep., Sulph. -----Coal, Slate-pencils, Chalk, etc.—Cicuta, Nitr. ac, Nux v. -----Cakes.—Plumb. ----- Cheese.—Ignat. -----Coffee.—1. Ang. 2. Aur., Bry., Chin., Con., Selen. ■-----Fat Food.—Nux v., Nitr. ac. ■-----Fruit.—1. Verat. a. 2. Ignat., Sulph. ac. ----- Juicy Things.—Phos. ac. -----Liquid Food (soups, etc.).—1. Staph., Sulph. 2. Ang., Ferr. ----- Meat.—Magn. a, Merc, sol., Sulph. -----Meal and Flour (dishes made of).—Sabad. -----3Iilk.—l. Aur., Chel., Merc, sol., Sabad., Sil. 2. Ars., Bry., Calc. a, Phos. aa, Staph., Stront. -----Raw Potatoes and Flour.—Calc. c. -----Refreshing Tilings.—Caust., Phos., Phos. ac, Puis., Valer. ■---Salt Things.—Calc. a, Caust., Con., Nitr. ac, Veratr. a. -----Smoked Things.—Caust. 294 disorders incidental to pregnancy. Longing for—Saur Kraut.—Carb. an. -----Sweet Things.—1. Amm. a, Chin., Kali, a, Lya, Natr. a, Rhus., Sabad. 2. Ipec, Magn. m., Rheum., Sulph. ----- Vegetables.—Alum.,Magn. c. ----- Warm Food.—Ferr., Lye. ----- Wine.—1. Cic, Hep., Sep., Sulph. 2. Bry., Lach., Spig., Staph. Taste. Taste, Bitter.—1. Bry., Cham., Merc, sol., Nux v., Puis., Sep., Veratr. a. 2. Aeon., Am., Ars., Calc. a, Chin., Con., Dros., Ignat., Lye, Magn. m., Natr. a, Natr. m., Sabad., Stann., Sulph. ------Diminished or Lost.—1. Puis., Sil. 2. Calc. a, Sec. corn., Sulph. ------Metallic.—1. Cupr., Rhus tox. 2. Agnus, Nux v., Ran. bulb., Zinc. ------Putrid or Offensive.—1. Am., Merc, sol., Puis. 2. Ars., Bell., Bry., Calc. c, Carb. veg., Cham., Con., Jod., Merc, sol., Nux v., Rhus tox., Sep., Stann., Sulph., Valer., Zinc. ------Saltish.—Merc, sol., Phos., Puis., Sep. 2. Ars., Carb. veg., Chin., Jod., Lya, Natr. c, Rhus tox., Sulph., Tart, em., Veratr. a. ------Sour.—1. Bell., Calc. a, Chin., Nux v., Phos., Puis., Sulph., Tarax. 2. Cham., Ignat., Kali, c, Lya, Merc, sol., Natr. m., Petrol., Stann. ------Sweetish.—1. Phos., Plumb., Puis., Sabad., Squill. 2. Aeon., Alum., Dig., Stann., Zinc. II. Gastric Derangements. Nausea and Vomiting—Morning Sickness.—In many women nausea and vomiting set in at an early period of pregnancy, and are simply the result of a peculiar reflex irritation of the stomach : in these cases this affection usually continues but a short time. Those forms of nausea and vomiting which principally appear in the later months result, not from sympathetic irritation or reflex action, but from the direct irritation of the stomach, and perhaps also of the diaphragm, by the upward displacement. Next to the cessation of the catamenia, and especially in conjunction Avith it, morning sickness becomes one of the earliest as well as one of the most reliable original signs of pregnancy; while for all those who have eA7er before experienced it there is little room for mistake in regard to its nature; for in each individual in whom it occurs it has a uniform type and well-remem- bered character. The nausea may occur at an early period in the morning with un- GASTRIC DERANGEMENTS. 295 varying regularity, or in the evening, or at any period of the day, or even of the night. For each individual it maintains also its uniformity as to the date of its first appearance: in some it begins very soon after conception, in others it appears toward the third or fourth month, and in others again it comes on only toward the close of gestation: in these latter cases it may have appeared also for a short time soon after conception. In the duration of this affection there is also the same general variety and individual uniformity. Thus in some Avomen it lasts but a few Aveeks, from six to eight at most; in others it continues for four or five months; while in some few most distress- ingly severe cases this difficulty assumes the form of a formidable disease, and persists through the entire period of utero-gestation, un- less relieved by art. And this unfortunate condition has sometimes been still more fully developed and aggravated by sea-sickness, so that even life itself has been lost Avhere the voyage was tedious, homoeopathic treatment not being accessible. The nausea and vomiting of pregnancy, as already stated, are most apt to occur on first rising in the morning ; sometimes these symptoms disappear in a few minutes, sometimes they last through the greater portion of the day. In some the vomiting is very easy; in others it is attended with very severe retching, and even Avith other painful symp- toms. Those Avho vomit upon Avaking or rising in the morning usually throw up some viscid, glairy matters, which are generally colored with a little bile, especially if the retching has been very severe. Others vomit only after eating, occasionally after only one of the daily meals, but sometimes after all of them. Again, in some un- fortunate cases the vomitings continue even in the intervals of the re- pasts, everything taken into the stomach, whether liquid or solid, being immediately rejected. There are cases, finally, in which the mere thought of food, or the sight or the smell of it, is sufficient to induce the vomiting.—Cazeaux. In some cases nearly all the food ingested seems to have been thrown up, even for months in succession, and yet a good delivery succeeds at full term; the repeated and severe vomitings seemino- to exert comparatively little influence upon the general health. In like manner, pregnant Avomen may rise from the breakfast-table, vomit and return to their food as if nothing had happened. Such characteristics, so different from vomiting arising from any other cause, almost con- clusively indicate the presence of pregnancy. Important complica- tions, however, arise in the greater number of more severe cases, and the health of both mother and child is often greatly injured through 296 DISORDERS INCIDENTAL TO PREGNANCY. the marasmus and cachectic conditions Avhich ensue. Among the most serious of the symptoms which appear in connection with severe emesis is to be reckoned the sense of tenderness at the epigastrium. This may be attended by considerable pain, which is increased bv pressure. This epigastric soreness and tenderness, whether observed in the earlier or in the later stages of pregnancy, is due to the pro- found irritation of the ganglia or plexuses of the sympathetic nervous system which are located in this vicinity. And in this centre of organic life, in the very constitution itself, are planted the psoric ele- ments Avhose active development in pregnancy occasions these suffer- ings and innumerable others, Avhose duration and severity but too well indicate the gravity of the sources from which they are derived. The stomach itself is in no such direct sympathetic relation Avith the uterus, but the latter organ is in profound sympathy with the organic nervous system which is centred near the stomach, and which entirely controls the compound functions of digestion and nutrition. Hence the ma- rasmus and cachexia which succeed severe cases of morning sickness in the old practice; hence, too, the brilliant successes which in the new school follow the exhibition of arsenicum and other powerful and particularly indicated antipsorics. Hence, too, while under the allopathic regime these cases became worse and worse with each suc- ceeding pregnancy, under homoeopathic treatment they become better and better, until the Avoman finds she can pass through the formerly so much dreaded period of gestation Avith little or no suffering, and terminate her labor in a delivery as easy as it formerly was difficult and painful. Some of the remoter consequences of the nausea and vomiting, or rather of that morbid condition of the constitution itself which pro- duces these symptoms—such as chlorosis, anaemia and albuminuria— will be more fully described in a subsequent section. In the same connection it will be shown hoAV the disturbance of digestion, nutri- tion and assimilation is followed by important changes in the consti- tution and character of the blood and of some of the most important secretions; and hoAV dropsies and other forms of structural disease necessarily supervene. The diet and regimen of the pregnant Avoman should be carefully attended to: such articles as best agree should be advised in each individual case, and equal care taken to avoid every unwholesome or irritating influence. It has sometimes been found that the exces- sive irritability of the stomach in pregnancy is due to the presence of fumes from some neighboring manufactory, Avhich, although in- GASTRIC DERANGEMENTS. 297 sufficient to induce any unpleasant symptoms in the ordinary condition of. the woman, very powerfully affect her Avhen enceinte. Homoeo- pathic remedies may antidote the effects of these noxious vapors if they are not too poAverful, but in the greater number of such cases a temporary removal from the neighborhood may be necessary. The folloAving medicines Avill be found to cover the principal forms of gastric derangements of pregnancy; and the indications given should be confirmed by finding in the Materia Medica a full corre- spondence with the totality of the symptoms and accompanying con- ditions. Aconite. Nausea and perhaps vomiting, with thirst; fear of being in crowds or of being in busy places; fear of death, or fear that something untoAvard will happen. Everything tastes bitter except water. Pain in the stomach after every meal, headache, burning sensation extending from the stomach all the Avay to the mouth, and along the dorsum of the tongue. Decided tingling in the tongue or fauces, or in other parts. Especially adapted to young, full-blooded and active Avomen. Acetic acid. Sour eructations, sour vomiting, with profuse water- brash and salivation, day and night. Agaricus. Gastric derangements, with itching, burning and redness of various parts of the body, as if frost-bitten—of the ears, nose, cheeks, fingers or toes. Much hunger, but no appetite. Constipa- tion; the first part of the stool is very hard, the latter part liquid. Alumina. Gastric derangements Avith inactive state of the rectum, so that even a soft stool has to be urged with much force to cause it to pass off; at the same time a condition often prevails in the oesopha- gus, somewhere in its course, it may be in the chest, as though it were constricted, even small portions of food are swallowed with difficulty. She has to strain at stool in order to urinate. Tingling itching on the tongue; she must scratch it. Potatoes particularly disagree Avith her. Loss of taste; heartburn; eructations. The peculiar alumina constipation may characterise the whole case. Angustura. Nausea Avhen walking, as if she Avould faint; she has to sit doAvn. Stitches in the tip of the tongue, painfully aggravated on moving; it. Antimonium c. Nausea and vomiting, or only nausea, Avith Avhite- coated tongue. Watery stools, with occcasional hard lumps. Fright- ful vomiting, Avith convulsions. Belching, Avith taste of what has been eaten. Thirst at night. Painful sense of fullness of the stomach, Avhich is sore on pressure. 298 DISORDERS INCIDENTAL TO PREGNANCY. Apis mel. Irritable heartburn, extending up into the throat. Sen- sitiveness of the pit of the stomach to pressure, and burning therein. Dyspnoea, with feeling that each breath drawn Avill be the last. Very scanty secretion of urine. Constipation or diarrhoea. Absence of thirst or great thirst. Argentnm n. The head sympathizes with the gastric disturbance, and there are pain, vertigo, etc. Time seems to pass very slowly. The stomach seems as if it would burst from flatulence accumulated therein, accompanied Avith great desire to belch, which is accomplished Avith difficulty and the flatus is emitted Avith great violence. Belching after every meal. The bowels are usually regular. Arnica. The derangement is the result of concussion. The motion of the fcetus gives rise to pain. Bruised and sore feeling throughout the stomach and abdomen. Belching, as of rotten eggs. Frequent eructations. Vomiting of blood. At night the head is very hot, Avhile the trunk and extremities are cool. Arsenicum. Very great debility and exhaustion; the least effort causes exhaustion. Very pale, white look. Bitterness in the mouth, particularly after eating or drinking; sensation as of a stone in the stomach. Cold water seems to lie in the stomach as if it did not as- similate, therefore she cannot drink it, although she desires it. Nightly vomiting. Vomiting of fluids as soon as she takes them. Lienteria; exhausting diarrhoea. Feels cold, and wants to be in a warm room, or to be covered up warmly. Very uneasy and restless. Fluids do not agree with the stomach, and cause nausea. Vomiting of blackish or greenish matter. Belladonna. Face flushed or very pale, eyes red ; throbbing of the carotids; dread of light and of noise. A putrid taste arises from the fauces, also while eating and drinking, although the food tastes nat- ural. Nausea in the throat. Vomiting of bile. The symptoms become AArorse in the afternoon and evening. Sour vomiting. Thick coating on the tongue. Borax. Dread of a doAvnAvard motion. Everything tastes bitter, even the saliva. Distension of the stomach after every meal. Vom- iting of food and mucus. Symptoms are worse in very warm Aveather. Bryonia. Nausea on waking in the morning. Her nausea is usually relieved by keeping quiet. Dry, parched lips, dry mouth and tongue. Splitting headache. Vomiting of food immediately after eating. She desires to keep still. The gastric derangement is ameliorated by keep- ing quiet. Stool of hard dry feces as if burnt. Worse on sitting up, even sitting up in bed, after being angry, in warm air, from Avarm GASTRIC DERANGEMENTS. 299 weather or from warm food. Better in cool weather or from taking cool food. Calc. carb. She cannot sleep after three in the morning. Heartburn and food eructations. Vertigo on running up stairs or ascending. Leucophlegmatic temperament. Soreness of the tongue, either on the tip, sides or dorsum, so that she can scarcely talk or eat. She can- not bear tight clothing around the hypochondria. Stitches in the liver during or after stooping, or at other times. Sensation as if the feet were cold and damp. Vomiting of sour matter. Feels better from warmth, and cannot bear cold air. Cantharis. Gastric difficulties, accompanied Avith very frequent mic- turition, Avith cutting and burning pains, only a feAv drops being emitted at a time, and sometimes Avith blood. Sensation of fullness, extending into the chest and abdomen, after taking coffee. Burning in the region of the pylorus. Vomiting with violent retching and severe colic. Carbo veget. She has to eructate frequently, which affords only tern- ■ porary relief of her many sufferings. Sensation as if the oesophagus were contracted or entirely closed. Even the most innocent kind of nourishment disagrees Avith her. Sensation as if the stomach and ab- domen would burst when eating or drinking. Varices of the rectum, vagina, vulva or lower extremities. Itching of the genitals, perineum and anus. Causticum. Phlegm in the throat, AAmich she is unable to hawk up, and Avhich sickens her. She sits doAvn to the table with some appe- tite, but can eat scarcely a morsel. Constant sensation as of lime being burned in the stomach, Avith rising of air. Stitches in the liver for hours in the afternoon. Haemorrhoids, Avhich cause great suffer- ing on Avalking. Her upper eyelids are nearly paralyzed, she can hardly keep them open. Fatty taste. Constipation. Stools tough and shining, or hard and in pieces at first and aftenvard soft. Chamomilla. The existing pain is increased by eructations. Nausea as if she would faint. Great irascibility of temper—she «an hardly return a civil ansAver. Burning across the stomach into each hypo- chondria. The epigastrium is painfully bloated in the morning, with a sensation as if its contents were passing into the chest. The belch- nig of Avind is painful. She cannot compose herself to sleep; she imagines she hears the voices of absent persons. Cnelidonium. There is a constant pain under the lower inner angle of the right shoulder-blade; this pain may extend into the chest or stomach, or even cause severe gastralgia, nausea and vomiting. Her 300 DISORDERS INCIDENTAL TO PREGNANCY. nausea causes great heat of the body. Great desire for milk, the drinking of which ameliorates all her symptoms. China. The abdomen feels full and tight as if stuffed—eructations afford no relief. There may be diarrhoea and dejection of much flatus, but no relief is obtained. In connection Avith the tightness about the abdomen, she often feels as if her garters Avere too tight, and loosens them, and as if her Avaist were too tight; she must loosen that, etc. Bitter taste in the back part of the throat, bitter taste of everything. She craves dainties, but hardly knows Avhat. Flat or sour taste. Cina. Grinding of the teeth, tumbling and tossing during sleep. Diarrhoea always after drinking (compare Arsenic). Inclination to vomit, Avith a Aveak, hollow, empty feeling in the head. Constant pressure in the stomach at night, causing restlessness. Itching of the nose, occasioning boring or rubbing of it. Always hungry. Cross or peevish. Cocculus. Burning in the oesophagus extending into the fauces, with •a taste of sulphur in the mouth. She is scarcely able to raise herself in the morning from nausea and inclination to vomit, it makes her so faint. Metallic taste in the mouth. Sensation in the abdomen as if sharp stones rubbed together on every movement, and the lower ex- tremities seem almost paralyzed. Yellow-coated tongue, with aver- sion to food. Fetid eructations. Worse from riding in a carriage or from sailing. Painful sensation of fullness in the stomach. Frontal headache. Nausea which is felt in the head. Conium. Vertigo, particularly on turning over in bed. The urine intermits at every emission. Stinging in the neck of the uterus; scirrhus of any part. Terrible nausea and vomiting during pregnancy in Avomen having scirrhosities. Where the history of the case of nausea and vomiting reveals the fact of SAvelling and soreness of the breasts with each menstrual period, and the patient ahvays feels worse after going to bed, so much so that she is obliged to sit up or to Avalk about to get relief. Bitter taste. Eructations with heartburn. Crocus. Sensation of fermentation in the stomach, or of motion up- Avard and downward, hither and thither. Feeling of nausea in the chest and throat as if she would vomit. Very Ariolent heartburn. Cuprum met. Violent vomiting of frothy mucus. Sometimes green. When drinking the fluid descends Avith a gurgling noise. Sensation in the stomach as if she had something bitter in it. The violent nausea and vomiting are relieved by drinking cold Avater. Intense coppery taste. Profuse salivation. Cyclamen. After eating the least quantity, disgust and nausea in the GASTRIC DERANGEMENTS. 301 mouth and throat. Much dimness of vision, with fiery specks and sparks before the eyes. Intermittent thirst. Violent hiccouo-h. Fatty taste; fat food disagrees. Digitalis. Nausea as if she would die. Very sIoav pulse. Light- colored stools. Intermittent pulse. Very persistent nausea and vom- iting—nausea even after vomiting. Burning in the stomach extend- ing up the oesophagus. Want of appetite, Avith clean tongue and empty stomach. Very much nausea in the morning. Drosera. Nausea after eating fat. The nausea is worse after mid- night till morning. The mouth seems in a bitter state when eating. Nausea with inclination to vomit. Vomiting of slimy matter. Dulcamara. The sufferings are made worse by every cold change in the weather. Empty eructations, with throbbing as from disgust. Frequent eructations while eating. Sensation of retraction in the pit of the stomach, Avith burning. Ferrum. Vomiting of food, with a fiery red face. Renewed vomit- ing after eating. Vomiting at midnight. Everything she vomits tastes sour and acrid. Vomiting of blood. Graphites. Itching blotches here and there over the body. Vesicular eruptions, from which oozes a glutinous watery fluid. Sore varices. Constipation or diarrhoea. Feces very large and difficult of passage' Nausea with vertigo, so that she is afraid to walk. Rancid heart- burn, particularly after eating. Taste in the mouth as of rotten eggs every morning, which nauseates her. Gossypium. Great distress, weakness and prostration. Has been useful in very bad cases. Helleborus. Urine scanty, dark and depositing a coffee-ground sedi- ment. Nausea, yet hungry; still the food is repulsive although the taste is natural. Intensely painful burning in the stomach, extending into the oesophagus. Hepar. Itching rash in the bend of the arms and under the knees in the popliteal space. Frequent and momentary attacks of nausea. Vomiting every morning. Inclination to vomit, Avith flow of saliva from the mouth. Constant sensation of water rising in the oesophagus, as if she had eaten sour things. _ Ignatia. Great sense of emptiness at the pit of the stomach, with sighing and great depression of spirits. Full of suppressed grief as it were. Sensation as if she had been fasting a long time, with flat taste and languor in the limbs. Hiccough. Flat, sour or bitter taste. Ipecac. One continual sense of nausea all the time—not a moment's relief. Vomiting of large quantities of mucus. Diarrhoea and colic. 302 DISORDERS INCIDENTAL TO PREGNANCY. Disgust for food, empty retching; vomiting of food, slime or blood; sour vomiting. Cutting pains about the umbilicus. Jodium. Continual empty eructations from morning till evening, as if every particle of nourishment were turned into gas. Nausea and vomiting of saltish-tasting substances. A continual taste of salt in the mouth. Offensive taste. Symptoms relieved for a short time by eating. Kali bich. Discharge from the stomach, throat or mouth, or from any of the mucous membranes, of a tough, stringy mucus, inclining to stick to the parts and draAving out in long strings. Kali carb. Very sleepy during a meal, Avith strong desire to sleep. Nausea as if she would faint, relieved by lying doAvn. Vomiting, with a swoonlike failing of strength; with much colicky pain in the ab- domen of a stitching character. Disgust for food. "Sickness of pregnancy Avithout vomiting, coming on only during a walk, with a feeling as if she could lie down anywhere and die." Laurocerasus. Attacks of suffocation, with palpitation and a sort of gasping for breath—a feeling as if she were not going to breathe again—she must sometimes lie down to find relief. Eructations tast- ing of bitter almonds or prussic acid. Violent pain in the stomach, with loss of speech. Disgust for food. Lycopodium. Much rumbling and working in the abdomen; gurg- ling in the left hypochondrium. Sensation of satiety, on account of Avhich she cannot eat. Red sand in the urine. Great pain before urinating and relief as soon as the urine begins to flow. Immedi- ately after a meal sensation as of fasting, but no hunger. Much heat in the face after eating, particularly in the left cheek. Heartburn from the stomach, the acidity rising into the throat. After eating pain in the region of the liver and palpitation of the heart. Vomit- ing of sour matter or of bile. Aversion to bread. Bitter, fatty or sour taste. Magnesia carb. Much sour taste and sour vomiting. All her symp- toms are aggravated every third week. Much roughness or stinging or burning in the throat, with desire to vomit. Much loathing Avith- out desire to vomit. Magnesia mur. Constipation of large, difficult stools, which crumble as they leave the verge of the anus. A continual rising of white froth into the mouth. Eructations tasting like onions. Fainting nausea, succeeded by coldness and weakness in the stomach and gulping up of water. Loss of taste or bitter taste. Mercurius. Much salivation, ulcerated gums, sore and elongated GASTRIC DERANGEMENTS. 303 teeth. Mucous stools, followed by tenesmus. Rancid heartburn after a simple supper. Heartburn all night. Ptyalism with nausea, Avak- ing her from sleep, particularly after twelve at night. The pit of the stomach is very tender to the touch. Taste bitter, offensive, saltish or sour. Eructations and heartburn, vomiting of bile or of food. Moschus. Violent eructations tasting like musk, sometimes of garlic. The sight of food makes her sick. Eructations with hot saliva in the mouth. Heartburn with palpitation. Natrum mur. Waterbrash like limpid mucus, profuse and constant. She always awakens in the morning Avith headache. She craves salt. Has a strong aversion to bread. Clawing in the pit of the stomach. Feeling of great hunger, as if the stomach were empty, but no appe- tite. She ahvays has heartburn after eating. Very much nausea, particularly in women using much salt food. Dreams at night of robbers being in the house; she must have the house searched in order to be satisfied. Loss of taste or flat, bitter or sour taste. Much belch- ing. Heartburn and palpitation of the heart. Vomiting of food. Nitric acid. Much nausea and gastric trouble, relieved by moving about or riding in a carriage. Constant nausea with heat in the stomach, extending to the throat. Fat food causes nausea and acidity. Exceedingly strong and offensive urine, smelling like that of horses. Nux mosch. Mouth, tongue and throat very dry, so that they " stick to one another," particularly at night. Sensation of fullness of the stomach, with tightness of breathing; very useful for this symptom in the last months of pregnancy. Disposition to faint. Great sleepi- ness. Nux vom. Thinks she woulcj feel better if she could vomit. Nausea and vomiting every morning, with constipation; large, difficult feces. Putrid taste Ioav down in the pharynx when hawking up mucus. Food and drink have a fetid smell to her. She cannot bear the odor of tobacco. Stools very small and frequent, with frequent and pain- ful urging. Not much appetite; restless sleep, particularly after three A. m., Avith nausea and vomiting in the morning and great depression of spirits. She cannot enjoy reading or conversation. She is irrit- able and wishes to be alone. Canine hunger; aversion to water and bread. Longing for beer, brandy, etc. Bitter or sour taste. Belch- ing, eructations, hiccoughing, heartburn. Vomiting of food, of bile, of black or sour matter. Opium. Constipation. Stool consists of round, hard, black balls. Longing for brandy. Petroleum. In women affected with diarrhoea only in the daytime; 304 DISORDERS INCIDENTAL TO PREGNANCY. nausea when riding, she cannot ride in a carriage. Flat or sour taste. Vomiting of bile. Aversion to fat food and to meat. Particularly applicable in all gastric troubles of pregnant Avornen. Phosphorus. Constipation with narrow, long, hard, dry feces, which are difficult to evacuate. Very weak feeling in the abdomen. Heat up the back. Profuse watery diarrhoea, pouring away as if from a hydrant. Sour eructations and sour vomiting. Very sleepy all the time. Saltish, sour or SAveetish taste. Vomiting of blood, of food or of sour matter. Phosphoric acid. Sensation as if the stomach were being balanced up and down. Bread tastes bitter. Nausea, as if in the palate or throat. She frequently rises at night to pass large quantities of color- less urine. Much debility. Pulsatilla. Pulsations in the pit of the stomach. Vomiting of mucus. Bad taste in the mouth every morning on aAvaking; she has to wash it out soon, it is so bad she cannot bear it. Nothing tastes good to her. Absence of thirst; she does not relish as much water as usual. Nightly diarrhoea, stools very changeable. Loss of taste, or bitter, fatty, saltish, sour or sweetish taste. Eructations. Nausea. Rhus tox. Putrid taste after the first mouthful. Pain between her shoulders on swallowing food. Very restless at night, particularly the latter part of the night; she must turn frequently in order to find an easy position. No appetite, or hunger without appetite. Un- natural or metallic taste. Eructations and nausea, with inclination to vomit. Sabadilla. No relish for food till she takes the first morsel, when she makes a good meal. A kind of. heartburn, the heat commen- cing in the abdomen and extending upward to the mouth. Much nausea and vomiting with heat in the abdomen. Vomiting of ascarides. Horrid burning in her stomach, as if it would burn up through into her throat. Aversion to meat. Sweetish taste. Salivation. Selenium. Violent beating of the pulse in the whole body after eating, particularly in the abdomen. Sepia. Vomiting of milky water or milky mucus. Sense of emptiness at the pit of the stomach; the thought of food sickens her; a sense of weight in the anus. Eructations tasting like spoiled eggs. Taste as of manure. Aversion to meat. In the morning, nausea as if all the viscera were turning inside out. Inclination to vomit in the morning when rinsing her mouth. She cannot take her accus- tomed ride in the morning on account of nausea. Want of appetite. GASTRIC DERANGEMENTS. 305 Taste bitter or saltish. Eructations. Disgust for all kinds of food. Vomiting of food and bile. Constipation. Silicia. Hungry, but she cannot get down food, it is so nauseous. Prolonged after-taste of food. Nausea, with violent palpitation of the heart. Nausea after every exercise that raises the temperature of the body. Constipation, as if from inactivity of the rectum, the stool receding after partial protrusion. Taste of blood in the morning. Aversion to meat. Loss of taste. Nausea and vomiting. Staphysagria. Sensation as if the stomach were hanging doAvn relaxed. Shortly after a full and substantial meal she feels very hungry. Extreme hunger even when the stomach is full of food. Flat taste. Constant accumulation of water in the mouth. Very sensitive to all moral or physical influences. Stramonium. Troublesome thirst, even with very much saliva Every kind of food tastes like straw; in fact, she has no taste! Nausea, with flow of very saltish-tasting saliva. Sulphur. Profuse salivation, the taste of which causes nausea and spells of vomiting. All the trouble seems to be caused by the nauseous salivation. Flashes of heat; heat on the top of the head; cold feet; short sleep at night—she Avakes very frequently. Profuse waterbrash. Aversion to meat and craving for brandy. Bitter, saltish or sour taste. Belching; eructations; sour vomiting. Sulphuric acid. Coldness and relaxed feeling in the stomach; loss of appetite and great debility. Belching; eructations; vomiting Tremulousness; the Aveaker she feels the greater the sensation of tremulousness. Is impelled to do things hurriedly. Tartar em. Vomiting of large quantities of mucus. Belching; disgust for food; nausea; salivation. Valerian. Heartburn, with gulping up of rancid fluid, which, how- ever, does not rise into the mouth. Nausea, as if a thread were hang- ing in the throat, exciting attempts to vomit. She feels nauseated, faint, Avith white lips and body icy cold. Fatty and offensive taste J heartburn; risings into the throat; nausea in the throat. Veratrum. Much thirst for cold drinks. Craves fruits and juicy articles of food. Wants everything cold. Violent retching. Canine hunger Craving for acids and salt food. Taste bitter or saltish. Eructations; heartburn; nausea; inclination to vomit. Violent retching and vomiting; vomiting of bile. Cold sweat on the fore- head, with all the sufferings. Zinc. Taste of blood in the mouth and sweetish risings from the stomach. Terrible heartburn after taking sweetish things. Great 306 DISORDERS INCIDENTAL TO PREGNANCY. greediness when eating; she cannot eat fast enough, from canine hunger. Much nausea and vomiting. Fidgety feet. Aversion to meat. Metallic taste. Pyrosis—Acidity—Heartburn.—These distressing forms of gastric disturbance sometimes make their appearance soon after con- ception, Avhile in other cases they may not appear until after the fourth month. Some women are remarkably subject to these symp- toms Avhen enceinte; in others they are manifested with less violence; in others not at all. There may be merely a burning sensation- heartburn in the throat—which indicates sympathetic irritation; or the severer forms of pyrosis, with acidity, which arise from more fully-developed gastroses. As in the nausea and vomiting of preg- nancy, so in pyrosis, heartburn and acidity, every degree of intensity and variety of manifestation and complication may be seen in different individual cases. Sometimes these disturbances are found accom- panied Avith and greatly aggravating the nausea and vomiting; at other times they seem to appear instead of the vomiting. As in ordinary cases of dyspepsia, these sufferings are worse after taking particular articles of food or drink, such as meats, fat meats or gravies, milk, fruit. In the more severe cases nearly everything that is ingested becomes but an added fuel to the burning of the pyrosis and acidity. Still, a careful avoidance of all those articles Avhich, wrhether solid or liquid, are found most to disagree, and a careful administration of the truly-indicated homoeopathic remedy, Avill, as in cases of nausea and vomiting, go very far to remove the most distressing symptoms, and eventually to secure a great improve- ment in the general health. For these difficulties, when not merely the aggravations by pregnancy of already existing forms of chronic gastritis, are but the developments of constitutional dyscrasia? hitherto latent, as explained in the case of morning sickness. And while the classes of hereditary dyserasise are but few, still, modified as they are in their actual developments by individual peculiarities, they require a great variety of remedies for their proper treatment. Not indeed many remedies for each individual case—for the more skillful the physician the fewer Avill be the remedies which he will be obliged to administer in any given case, and the greater the number of cases which he will cure with a single remedy, sometimes even with a single dose—but a variety of remedies will be necessary to correspond to the variety of disorders which result in different persons, even from the same cause. gastric derangements. 307 The doctrine of individual specifics is based upon the most pro- found analysis of the human system and of the laAV of cure, and is confirmed by the radical and constitutional improvement—an im- provement which is found to be the more radical and permanent the higher the potencies of the remedies Avhich are administered. The doctrine of individual specifics is therefore truly scientific, since it harmonizes the results of practical experience with well-established principles, and even Avith those profounder explorations of our being in Avhich matter is seen to fade into spirit, and physiology to be re- placed by psychology. The doctrine of general specifics leads to just the reverse of all this, as well in principle as in the ratio and extent of actual success. For our allopathic and eclectic brethren, and even those of the so-called physiological school among the homoeopaths, are so manifestly blind that they totally ignore in therapeutics that predominance of mind over matter which they do not hesitate to admit in all other branches of scientific inquiry. They prove them- selves materialists and chemists—anything but true physiologists; while as to psychology, or the doctrine of the connection of the body with the soul, and of the influence of the latter over the former, they seem to regard it as entirely beneath their attention. Hence, what do we see in the practice of all these classes alike but temporary expe- dients—Avhich often result in manifest disaster, and which always oc- casion more injury than they are capable of discerning—instead of radical cures ? We see chemical antidotes which, if they sweeten the streams, do it at the expense of the fountains ; and mechanical ap- pliances which not only fail to assist Nature, but in many cases effect- ually prevent her from helping herself. Those who thus pride themselves in indulging in allopathic and eclectic modes of thought are greatly to be pitied; they know not what they do. All the advancing progress of modern scientific thought is against them, and the more enlightened of those Avhom they profess to admire despise them as foolish rejecters of the higher light held up before them. Table of Remedies for Gastric Disturbances. {Compare with the General Indications given on pages 292-294, as well as with the Materia Medica.) Belchings or Eructations. Am., Bell., Bry., Coca, Con., Merc, sol., Natr. m., Nux v., Phos. Puis., Rhus tox., Sarsap., Sep., Sulph. ac, Sulph., Verat. a., Tart. em. 308 disorders incidental to pregnancy. Hiccoughing. 1. Amm. mur., Cycl., Hyos., Ignat., Nux v. 2. Agar., Bell., Bry., Puis., Ran. bulb., Veratr. a. Pyrosis—Heartburn. 1. Calc. a, Con., Caust., Croc, Nux v. 2. Amm. a, Caps., Carb. a., Carb. v., Chin., Jod., Lya, Merc, sol., Natr. m., Phos., Puis., Sep., Valer., Veratr. a. Risings into the Throat. 1. Asaf., Merc, sol., Lach., Plat. 2. Con., Phos., Spig., Valer., Veratr. a. Disgust for Food. 1. Ipec, Kali a, Sep. 2. Ant. cr., Bell., Bry., Puis., Sil., Tart. em. Nausea ("Sick at the Stomach"). 1. Ars., Caust., Cham., Hell., Ipec, Natr. m., Nux v., Puis., Rhus., Sil., Sulph., Sulph. ac, Tart, em., Valer., Veratr. a. 2. Aeon., Angust., Ant. cr., Argent, nit., Asar., Bell., Bry., Caps., Cham., Cyclam., Calc. a, Carb. v., Chin., Con., Cupr. m., Graph., Kali a, Lya, Merc, sol., Mosch., Natr. m., Nitr. ac, Phos., Squill., Sep., Stann., Sulph., Sulph. ac, Valer., Tart. em. ------felt in the Throat.—1. Cycl., Phos. ac, Stann. 2. Cupr. m., Puis., Staph., Valer. ------felt in the Chest.—Aeon., Croc, Merc, sol., Rhus tox. ------felt in the Abdomen.—Bry., Puis. Empty Retching, Gagging. 1. Bell., Ipec, Veratr. a. 2. Arm, Asar., Bry., Chin., Nux v., Puis., Sulph. Vomiting. Vomiting of Bile, Bitter Vomiting.—1. Ars., Bry., Cham., Ipec., Merc, sol., Nux vom., Puis., Sep., Veratr. a. 2. Aeon., Bell., Chin., Con., Cupr., Dulc, Ignat., Lya, Petrol., Plumb., Sec. corn., Stann., Sulph. ------of Black Matter.—1. Ars., Nux v., Chin. 2. Petr., Phos., Plumb., Veratr. a. ------of Blood.—1. Am., Ferr., Ipec, Phos. 2. Aeon., Canth., Chin., Nux v., Plumb., Puis., Sep., Sulph. intestinal affections. 309 Vomiting of what has been Drunk.—1. Ars., Phos., Veratr. a. 2. Bry., Cham., Dulc, Ipec, Nux v., Sil., Tart. em. ------of what has been Eaten.—1. Ars., Bry., Ferr. Nux v. Squill. 2. Amm. a, Ant. cr., Calc. a, Cina, Cupr., Dros., Hyos., Ignat., Ipec, Lya, Natr. m., Phos., Plumb., Puis., Sep., Stann., Sulph., Veratr. a. ------of Fetid Matters.—1. Sep. 2. Ars., Coca, Cupr. m., Ipec, Nux v., Op., Stann., Sulph. ------of Slimy Matter.—1. Dros., Puis., Tart. em. 2. Ars., Bell., Cham., Chin., Con., Dig., Hyos., Ignat., Ipec, Merc, sol., Nux v., Sec. corn., Sulph., Veratr. a. ------of Sour Matter.—1. Calc. c, Chin., Lya, Nux v., Phos., Sulph. 2. Ars., Bell., Cham., Ipec, Puis., Veratr. a. ------of Watery Matter.—1. Bry., Caust., Veratr. a. 2. Arm, Bell., Cann., Chin., Con., Cupr., Ipec, Nux v., Stann., Sulph., Sulph. ac. ------of Worms.—1. Aeon., Cina, Ferr., Sabad., Sec. corn. 2. Hyos., Sil., Spig., Veratr. a. III. Intestinal Affections. Constipation.—This is so frequent an attendant of pregnancy that by some it has been deemed almost its natural consequence. But it is much more apt to occur, and is at the same time much more trouble- some and inveterate, in pregnant women who from habits of life and constitutional peculiarities are predisposed or subject to it in their ordinary condition. The mechanical pressure exerted upon the rectum, by which its calibre is diminished and its action paralyzed, and the habits of inac- tivity in which many pregnant women indulge, especially in cities, combine to produce costiveness. And as a final result of the consti- pation, haemorrhoids, either blind or bleeding, appear in many cases. And the very great amount of vital force consumed in the womb may also tend to draw away from the intestinal canal some of the energy that might have sustained its regular and daily evacuations. The indications for hygienic treatment will be suggested by the more apparent causes of the difficulty. Not only will the constipa- tion .itself be avoided in many cases by suitable and active exercise in the open air, but many of the attendant complications and conse- quences, such as headache and rush of blood to the head, may in the same Avay be escaped. The remedies will be indicated by the nature of the discharges and by the accompanying symptoms and totality of 310 DISORDERS INCIDENTAL TO PREGNANCY. the patient's condition. The constipation being but one of the forms of development of the constitutional dyscrasia in many instances— Avhether the most prominent symptom or not—requires a careful, radical treatment, by which not only Avill the present difficulty be re- lieved, but the general health improved, so that this trouble Avill not appear in succeeding pregnancies. The folloAving remedies, as well as those detailed under gastric disturbances, should be carefully studied and compared with the totality of the patient's symptoms: Aconite. Where there is much thirst, a general dryness of the skin, a constant restlessness, and where the same fears appear that are men- tioned in this remedy under gastric disorders. Alumina. Constipation from inactivity of the boAvels; much effort must be employed for the expulsion even of a soft stool, so great is the apparent inaction of the rectum. Agaricus m. Loud rolling and rumbling in the bowels. The stool is very hard and knotty at first, then it becomes soft, and finally diar- rhoeic, especially if there are red, itching and burning frost-bite look- ing places on the feet, hands or face. Anacardium. Frequent and ineffectual urging, the rectum feeling as if stopped up Avith a plug; if the stool does not pass soon, she feels colicky pains in the abdomen. Inactivity of the bowels. Antimonium c. Sensation as if a copious stool Avere going to pass when only flatus comes forth, but finally a very hard stool is evacu- ated. Incarcerated flatus. Apis. Stools seldom and very difficult, with stinging pains and sen' sation in the abdomen, as if of something tight, Avhich Avould break if too much effort Avere used. Heartburn. Scanty urine. Arnica. In cases where an obstinate constipation has remained ever since some severe concussion. Inactivity of the boAvels. Flatulency; colic ; loud rolling and rumbling in abdomen; foul-smelling flatus; stool seems to be unsatisfactory and insufficient. Belladonna. Flatulency. Obstruction of the bowels. Much tend- ency of blood to the head; flushed face; red eyes; throbbing of the carotids; heat in the head ; intolerance of noise and of light. With belladonna, high, I have succeeded in cases like this, when the most violent doses of the allopathic school had utterly failed. Bryonia. The stool is mostly dark, dry and hard as if burned, and is evacuated with much difficulty. The lips are parched and cracked; much thirst. Stinking flatulency ; rumbling and rolling in the abdo- men. Obstruction of the bowels from hardened stool. Stool too large to be evacuated without pain. CONSTIPATION. 311 Calc C. Indicated in leucophlegmatic temperaments. Stools very large, hard; sometimes in part undigested. She does not sleep after three A. m. Stinking flatulency. Constipation from indurated stool, Avhich is too white. Sour-smelling stool. Carbo V. Tough, scanty, not properly cohering stool; it seems to break off, and in consequence to become interrupted and rendered more difficult of expulsion. Stinking stool. Flatulency, Avith colic and rumbling of gas in the boAvels. Incarcerated flatus, smelling very badly Avhen emitted. Patient attributes all her troubles to " the wind." Obstruction from inactivity of the boAvels. Causticum. Constipation, in which the effort to effect a passage causes heat, redness and perspiration on the face. Flatulency, loud rolling and rumbling in the bowels. Obstipation of hardened feces. Stool knotty like sheep-dung, too small in size. Stool shining like grease. Chelidonium. In cases accompanied by pain under the inner and lower angle of the right shoulder-blade. Stool like sheep's dung. China. Hard, intermitting stool, with sensation of tightness and fullness in the abdomen; also with burning and heat in the head. Flatulence with colic; loud rolling and rumbling; black stools; ob- struction from inactivity of the bowels. Cocculus. Hard stool every other day, expelled with great difficulty. The loAver extremities are nearly paralyzed. Incarcerated flatus; ob- struction of the boAvels. Conium. Frequent and ineffectual urging, or a small quantity is evacuated each time; much vertigo, particularly on turning in bed. The urine intermits in its Aoav at each emission. Flatulency; colic from incarcerated flatus. Graphites. Large, hard, knotty stool, the knots being united by mucous threads, and much mucus after the stool. Itching blotches about the body, Avhich emit a glutinous fluid. Sometimes the stools are only the size of lumbricoides. Incarcerated flatus; colic; obsti- pation from hardened stool or from inactivity of the bowels. Stool knotty and too large. Hepar. Constipation resembling that of alumina: hepar may be given in preference where the skin-symptoms or others seem to indi- cate it more particularly; for instance, if eruptions appear on the bend of the elbow and on the popliteal space. Ignatia. Difficult stool, causing prolapse of the rectum. Empty feeling at the pit of the stomach; sighing and full of grief. Flatu- 312 DISORDERS INCIDENTAL TO PREGNANCY. lency, incarcerated, rumbling and rolling about. Constipation from inactivity of the bowels. Jodium. Constipation Avith ineffectual urging, but the stool passes with great facility soon after drinking some cold milk. Kali c. Unsuccessful desire for stool, with a sensation as if the rec- tum Avere too Aveak to expel it. She feels very strangely and badly an hour before stool. Itching pains in and about the anus and rec- tum during and after stool. Flatulency. Obstipation from hardness of stool or from torpor of the boAvels. Laurocerasus. Frequent attacks of suffocation about the heart, so that she must gasp for breath. Simple obstruction of the bowels. Ledum. Great Avant of vital heat; she can hardly keep warm even with much Avrapping; in constipation, AArhere this state of the system prevails, this remedy will be found useful. Lycopodium. She says her abdomen is like a yeast-pot, so great a fermentation goes on there. Borborygmus and gurgling, especially in the left hypochondrium. Much red sand in the urine. Distressing pain in the back before urinating. Incarcerated flatulence; sharp, shooting pains from right to left across the abdomen. Constant feeling of satiety; but a small quantity of food seems to fill to repletion. Magnesia mur. Large stool, passed with difficulty, and crumbling as it passes the verge of the anus. Obstipation, of hardened feces. Knotty, crumbling, insufficient and unsatisfactory stool. Mercurius. Constant and ineffectual desire for stool. Scorbutic con- dition of the gums. Salivation, sore throat, soreness of the gums and other mercurius symptoms. Constipation from hardness of the stool, blood Avith the stool. Natr. m. Hard, difficult stool, and inactivity of the rectum. Bad headaches always on waking in the morning. Craves salt. Aversion to bread. Very vivid and fearful dreams. Sore places in the mouth, which are very painful, sensitive even to liquids. Constipation from inactivity of the bowels. Rumbling and incarceration of flatus. Nitric acid. Hard, difficult, scanty stool. Urine exceedingly offen- sive, like horses' urine. She sleeps badly in the latter part of the night. Great feeling of Aveakness after a stool. Much flatus, incar- cerated, stinking Avhen emitted. Bloody stool. Nux mosch. Great dryness in the mouth and tongue, Avhich sticks to the palate. SIoav and difficult stools. Colicky pains from incar- cerated flatus. Constipation from inactivity of the bowels. For Avomen disposed to faint or Avho " bolt" their food. CONSTIPATION. 313 Nux vom. In women of sedentary habits, accustomed to the use of much coffee, wine and rich and high-seasoned food generally. Stools large and difficult, or small, frequent and painful. Flatulence, colicky pains, incarcerated flatus, or loud rumbling and rolling in the bowels. Constipation from torpor of the bowels, or in persons Avho have been in the habit of using cathartic pills or other purgatives. Knotty or bloody stools. Insufficient stool. Rush of blood to the head during stool. Oleander. First diarrhoea, then hard, difficult stool. Opium. Stools ahvays in round, black, hard balls; in such cases opium in the higher preparations never fails. Constipation occurring either from accumulation of hard, dry feces or from torpor of the bowels. Phosph. Stools narrow, dry, long, and difficult to expel—very like a dog's stool. Blood with the stool. Rumbling in the abdomen. Constipation from hardened feces. Phosph. acid. She is obliged to rise frequently at night to pass off large quantities of colorless urine. The stools are hard and in pieces. Flatulency. Phytolacca dec. Constipation habitual; the patient says the boAvels will not move without the aid of purgative medicines. Feeling of fullness in the abdomen before stool, which remains after stool as if all had not passed. Constipation from torpor of the rectum. Per- sons Avho are subject to rheumatic pains on change of weather, espe- cially in the hips and thighs. Platina. The stools adhere to the parts like soft clay, and pass off with difficulty on that account. Obstinate incarceration of flatus. Plumbum. Constipation, with violent colic. The stools are usually composed of little balls, compacted together like sheep's dung. Sen- sation as if of a string drawing the abdomen in toAvard the back. Flatulency, colic, commotion in the abdomen. Pulsatilla. Obstinate constipation in mild, gentle, tearful women, with very nauseous, bad taste in the mouth in the morning—so very bad that she must wash her mouth immediately on waking. Gastric disturbance; cannot bear the smell of food. Hard, bloody stools. In- carceration of flatus, emissions of foetid flatus, borborygmus. Ratanhia. Most obstinate and long-continued constipation, with urging feelings in the small of the back, as if a stool would come doAvn. Rhododendron. She is rheumatic, and all her pains reappear at the approach and during the continuance of rough, stormy and Avindy 314 DISORDERS INCIDENTAL TO PREGNANCY. weather. The stool is not so hard, but it is very tardy, requiring a good deal of urging. Flatulent and colicky patients. Rhus tox. She is rheumatic, has restless nights on account of not being able to lie long in one position, although she feels quite com- fortable for a short time after every change. She has almost constant tenesmus, Avith nausea and tearing in the intestines. Ruta. Difficult expulsion of stool, Avith a large protrusion of the .rectum; in fact, the rectum is very liable to protrude before the stool immediately on attempting to go to stool. Constipation from either inactivity of the bowels or from impaction of feces. Sabadilla. Very difficult stools, Avith much burning in the abdomen, and a sensation as of something alive in the abdomen. Colic, with violent urging to stool and borborygmus. Sabina. Hard, difficult, painful stools, Avith pain extending from the back directly to the pubes. Sarsaparilla. Obstinate constipation, Avith violent urging to uri- nate. Great desire, with contraction of the intestines and excessive pressure from above doAvnward, as if the bowels would be pressed out, when a small stool is passed, and then the same phenomena recur again. Sepia. Sensation of a weight or of a heavy lump in the anus; this is a very characteristic indication. The stool is very difficult, covered Avith mucus, and sometimes impossible to pass even Avith terrible, in- voluntary strainings. Flatulency, with loud rolling and rumbling in the abdomen. Obstipation from hardened stool. Knotty and insuf- ficient stool. Sepia200 was stated many years ago to be specific in the constipation of pregnant women. Silicia. Very much urging, the stool often receding after having been partially expelled. The stool is composed of hard lumps. In- carcerated and offensive flatus. Stannum. It exhausts her to talk much or to read aloud. It is more difficult and tiresome for her to descend than to ascend, to sit down than to rise up. Although the stool has been fully accomplished, she does not feel relieved. Staphysagria. The more trouble she has with her gums and teeth the more constipated she becomes. Colic from incarcerated flatus in the boAvels, offensive flatus. Constipation from inactivity of the boAvels or from impaction. Sulphur. The first effort to stool is often very painful, compelling her to desist. Flushes of heat, heat on the top of the head, coldness of the feet, faintness from eleven to twelve at noon, she can scarcely DIARRHCEA. 315 wait for her dinner. Bloody, knotty, hardened, insufficient stool. Loud rolling and rumbling in the abdomen, with emission of offen- sive flatus. Sulph. acid. Hard stool, consisting of small black lumps mixed with blood, accompanied by such violent prickings in the anus that she has to rise up on account of the pain. Sensation of tremor all over the body, without trembling. Thuya. Very violent pain in the rectum during stool, so violent that she can hardly pass the stool, Avith sensation as if she could not live any longer. Veratrum a. Flatulency, colic and borborygmus. Costiveness, owing to the hardness and size of the feces, as Avell as to the inactivity of the rectum. Cold swreat on the forehead during the movement of the boAvels, with exhaustion and faintness aftenArard. Verbascura. Stool like sheep's dung, scanty, very hard, and expelled with great effort. Zinc. This remedy is particularly indicated where there is remark- able dryness of the stools, Avhich are insufficient and difficult of expul- sion, and when the bowels, particularly the rectum, seem to be so very inactive, as if all peristaltic and expulsive poAver was lost. Diarrhcea may be developed during pregnancy, like constipation or haemorrhoids, from some constitutional dyscrasia, which is called into action by the profoundly vital function of gestation. Or it may be developed in consequence of some imprudence of diet or by taking cold. The condition of the bowels in which diarrhoea makes its appear- ance is more like actual disease than where constipation is present. The diarrhoea may alternate with constipation, and this is quite a common complication. Or it may be of that character Avhich natu- rally accompanies acidity of the stomach and great weakness of the digestion. Sometimes it assumes the form of lienteria or discharge of undigested food. In other cases the liver seems involved, and the stools have a bilious appearance ; such attacks of diarrhoea may occur in consequence of violent emotions of the mind, to which pregnant women are peculiarly liable. The discharge may be easy and pain- less, or accompanied by severe suffering, soreness, cutting pains and even tenesmus, as if of actual dysentery. This latter form, approach- ing inflammation of the bowels, is apt to come on after exposure to the night air, especially if the woman be not clad with sufficient warmth. 316 DISORDERS INCIDENTAL TO PREGNANCY. It is not necessary to detail all the symptoms of the various forms of diarrhoea which may appear in pregnant Avomen; the most im- portant of them may be found among the indications and character- istics of the various medicines. There are three directions which should be insisted upon in pre- scribing for cases of diarrhoea in pregnancy : First, the patient should carefully abstain from every unsuitable article of food; those which are found by experience to be indigestible or to occasion distress, Avhether immediately followed by aggravation of the diarrhoea or not, should be particularly interdicted. Second, the patient should take care that her Avhole body is amply protected from the cold and clamp, but especially her feet and abdomen. The former should be Avarm and dry as a matter of course ; the latter will often—from becoming so prominent—require extra covering, as of flannel. Third, perfect quiet is absolutely essential in cases of diarrhoea in pregnancy. This condition should indeed be ahvays enjoined in the treatment of diarrhoea, whether it extend to dysentery or inflammation of the bowels or not. But in the case of pregnant women it is if possible still more indispensable. Rest, repose, especially in a horizontal position, Avill enable the patient to recover her health and strength, under the influence of the homoeopathic remedy, in a very short time, when if she continued moving about those cases of diarrhoea which at first were mild and painless might become inveterate and greatly aggravated in character. Again, it is to be borne in mind that a diarrhoea long continued may bring about abortion or premature labor, and hence the importance of early and judicious treatment and of the due observance of dietetics and rest. Sometimes the diarrhoea, not very severe and apparently of no great consequence, which makes its appearance in pregnancy, is but the insidious forerunner of phthisis pulmonalis, othenvise held in abey- ance by the influence which the state of pregnancy exerts upon the entire economy of the female system. "We give the chief indications for the remedies which are oftenest called for in the diarrhoea of pregnancy. The remedy should always be made to correspond to the totality of the symptoms; and if the simile is not found in one of those here given, a more extended search must be instituted in the Materia Medica. Compare the indications here given with those laid down for the same remedies in gastric derangements and constipation. By such comparison a remedy may be chosen with great accuracy. DIARRHCEA. 317 Agaricus m. The diarrhoeic stools are accompanied with abundance of flatulency, with painful drawing in of the abdomen. The itching, burning and red places upon the skin fade away as the diarrhoea improves. Aloes. Sensation of weight or heaviness in the rectum, and frequent passage of accumulations of mucus of large or smaller size, sometimes with very distressing tenesmus. Morning diarrhoea, Avhich necessitates expedition in attending to the call, not so much on account of the urgency, as because of a feeling as if the stool could not be retained, but must drop involuntarily. Rumbling and rolling in the bowels previous to stool. Alumina. Diarrhoea with tenesmus; stools bloody and scanty. She has to strain at stool in order to pass water; she cannot pass her urine without straining at stool. Ammon. mur. Diarrhoea, with soreness of the anus, several pustules are discovered near it. Angustura. Diarrhoea, with shivering over the face and goose-flesh. Antimonium C. Diarrhoea at night and early in the morning, with white tongue. Watery diarrhoea, containing hard lumps. Acrid diarrhoea. Arnica. Involuntary stools, with sore and bruised feeling all through the body. Mucous, offensive or purulent stools. Argentum nit. Very offensive eA^acuations, with very profuse emis- sion of flatus, sometimes with noise. Stools watery or of green mucus. Often there is much colicky pain. The diarrhoea occurs more frequently at night. Arsenicum. Exhausting diarrhoea, the stools containing undigested food. The patient is very weak, the least motion occasioning a sense of great fatigue. The diarrhoea is reneAved after eating and drink- ing. Very offensive diarrhoea. Sharp, cutting or burning pains with the diarrhoea. Painless diarrhoea. Stools acrid, bloody or involuntary. The pain is greatest during the stool, and is relieved after stool. Asafoetida. Watery, liquid stools of the most disgusting smell imaginable. (Also the same in infants and children.) Colic with the diarrhoea. Aurum. Nightly diarrhoea, with much burning in the rectum. Of- fensive, painful diarrhoea. Belladonna. Involuntary diarrhoea. The diarrhoeic stool is followed by frequent urging, no more stool being passed. Flushed face; red eyes; throbbing carotids, etc. 318 DISORDERS INCIDENTAL TO PREGNANCY. Borax. Frequent, soft, light yellow, slimy stools, Avith faintness and weakness. Bryonia. Burning diarrhoea. The diarrhoea is worse or aggravated by Avarm Aveather. Lips dry and parched; thirst; nausea after eating; nausea on sitting up in bed. The patient Avishes to remain very quiet, as every motion aggravates her symptoms. Calc c. Much crawling and itching, as from ascarides, in the anus. Leucophlegmatic temperament. Does not sleep after three in the morning. Cantharis. A constant desire to urinate, with cutting, burning pain. Dysenteric diarrhoea. Stools Avhich resemble scrapings of the intes- tines or Avater in Avhich meat has been washed. Capsicum. Much burning and smarting in the anus, as if from cay- enne pepper. Pain in the back continuing after the stool. Carbo V. Much flatulency, with belching, which affords only tem- porary relief. Causticum. Haemorrhoids or fissures, rendering walking almost intolerable. Much suffering after each evacuation. Cham. Hot diarrhoeic stool, smelling like rotten eggs. The stools excoriate the parts. Painless, green, Avatery diarrhoea, a mixture of feces and mucus. Nightly diarrhoea with colic, causing her to bend double. In all chamomilkt cases the moral symptoms are about the same—i. e. quarrelsome, obstreperous. Chelidonium. Diarrhoea, with pain under the inner and lower angle of the right shoulder-blade. China. Diarrhoea of yellow, watery stools, undigested, and with much flatulence. Sensation of distension in the abdomen, which is not relieved by eructations or dejections. Painless diarrhoea. Lien- teria. Very offensive black or yelloAvish-brown stools. Prostration after each evacuation. Cocculus. Diarrhoea, Avith a sensation in the abdomen as of sharp stones rubbing together. Vomiting of bilious matter. Numb sen- sation in loAver limbs, as if paralyzed. Colocynth. Diarrhoea, with colic drawing one double, and which is very distressing, causing restlessness, Avrithing and twisting about; pain is relieved someAvhat by bending nearly double, and by making hard pressure upon the abdomen. The abdomen and thighs must often be approximated as much as possible during the stool. Aggravation after eating or drinking. Conium. Heat and burning in the rectum during the stool, and tremulous Aveakness afterward. Frequent stitches in the anus between DIARRHOEA. 319 the stools. Painful diarrhoea. The urine intermits during its flow. Vertigo, particularly on turning in bed. Crocus. Long, dull stitches near the anus from time to time, con- tinuous, and painfully affecting the whole nervous system. The stool contains dark stringy blood. Cuprum met. Violent diarrhoea, with cramps in the stomach and chest, the cramps extending upward. Much flatus escapes with the stool. Digitalis. Violent diarrhoea, the stools being ash-colored or very light. Very sIoav pulse. Accompanying the diarrhoea is violent beat- ing of the heart—not rapid, but too violent. Nausea. Despondency. Vomiting of food. A very depressing sensation of sinking at the stomach. Drosera. Loose stool almost continually, but rather worse after midnight. Bloody, mucous or offensive stools. Dulcamara. Stools yellowish, greenish, whitish, mucous or bloody; often attended Avith prostration or Avith colicky pains around the um- bilicus. Worse after every cold change of the weather or after taking cold. Euphorbium. Stools like glue prepared for use, painful and flatulent. Ferrum. Frequent diarrhoeic stools, corroding the anus, the face being fiery red. Lienteria. Painless diarrhoea. Vomiting of food soon after eating. Debility and emaciation. Gelseminum. Diarrhoea occasioned by fright. Disposition to go to stool Avhenever anything startles her. Graphites. Diarrhoea, with varices, and a smarting, sore feeling after the stool when wiping. Stool brown, very fetid, often undi- gested. In the morning taste in the mouth as of spoiled eggs. Ab- domen distended, often with a sensation of fullness and hardness. Much flatulency. Helleborus. In cases of diarrhoea in which the urine is found to be scanty and to contain a deposit like coffee-grounds. Stools of Avhite mucus, often tenacious or jelly-like. Hepar. Diarrhoea, with tenesmus, and an itching rash in the bends of the elboAvs. Stools of a lightish color, often undigested and of a sour smell. Sour regurgitations of food. Empty sinking feeling in the stomach, relieved by eating. The diarrhoea is Avorse during the day, after eating, or after drinking cold water. Hyoscyamus. Diarrhoea, with involuntary jerks of the muscles im- mediately before, during or immediately after the stool. Involuntary stools.' Yellow, watery, painless diarrhoea. 320 DISORDERS INCIDENTAL TO PREGNANCY. Ignatia. Empty, Aveak feeling at the pit of the stomach, Avith dispo- sition to take a long breath frequently, a sort of sighing inspiration. Ipecac. Diarrhoea, with one continual sense of nausea—not a mo- ment's respite. Fermented stools, looking like yeast. Sometimes the diarrhoea is accompanied Avith vomiting of mucus or of grass-green substance. Iris versicolor. Gastric disturbance and headache. Severe burning at the anus during and after liquid stools. Burning extending from the mouth to the stomach. Diarrhoea worse at night. Emissions of very fetid flatulence, accompanied with slight discharge of liquid fecal matter. Jodium. Diarrhoea of watery, foaming, Avhitish mucus, Avith pinching around the navel and pressive pain in the vertex. Kali c. Diarrhoea, with sharp, shooting and stitching pains all over the abdomen. Stools of a light gray color. Persistent stitching pain in the region of the liver. Suitable to cachectic persons Avith sacu- lated SAvellings over the eyes. Lachesis. Diarrhoea ahvays worse after sleeping, and Avith frothy urine. Laurocerasus. Diarrhoea, with peculiar suffocating spells about the heart. She is often obliged to lie down on account of this peculiar sense of suffocation. Green, liquid stools. When drinking the fluid rolls down the oesophagus Avith a peculiar rumbling noise. Ledum. Diarrhoea, Avith a sensation of great coldness; she has great want of vital warmth, and can hardly keep warm. Between the anus and coccyx a red humid spot, smarting, sore and itching. Leptandria. Black, fluid stools; great urging, with difficulty of re- taining the stool. Cutting about the umbilicus after stool. Stools like tar in color and consistency, very fetid, and worse in the after- noon and evening. Lycopodium. Diarrhoea, Avith a constant sensation as of fermentation in the abdomen like yeast working. Sensation of fullness up to the throat after eating even a small quantity. Rumbling of flatus re- sembling a loud croaking. Magnes. c. A green, watery diarrhoea occurs regularly every three Aveeks. The stools appear sometimes like the green scum coA^ering a frog-pond. Sometimes white masses, like pieces of tallow, are found floating in the green stools. Sharp pain in the abdomen before stool. Mercurius. Morning diarrhoea, composed mostly of slime and fecal matter, with tenesmus before and during the stool. Diarrhoea pre- ceded by a faint sickish pain in the abdomen, entirely relieved by DIARRHOEA. 321 stool. The stools are often mixed with slime and blood, and are at- tended with tenesmus. YelloAV stools of the color of sulphur. Saliva- tion, sore, ulcerated gums, loose and sore teeth, aching of the jaw-bones, etc. Frequent urging to stool, a small quantity only being passed at a time, often of green or bloody mucus. Mouth and tongue moist, and plenty of saliva, yet great thirst for cold water. Disposition to remain at stool, as if she " could not get done." Mezereum. Diarrhoea, with prolapse of the rectum; the anus becomes constricted about the prolapsed rectum, which is very painful to the touch. Muriatic acid. Diarrhoea, with intolerable itching of the anus, which is sometimes so sore that it can scarcely be touched. Dark purple- colored varices, excessively painful to the touch. Very weak and languid. Great tenderness of the anus after stool—so great that the slightest touch or pressure is very painful. Natr. mur. Diarrhoea, like Avater. Disgust for bread. Severe head- ache on waking in the morning. Very vivid dreams; they seem like a living reality. Nux mosch. Chronic diarrhoea during pregnancy, with unusual slug- gish flow of ideas, so much so that it takes her a long time to answer any simple question. Diarrhoea, with fainting. Nux vom. The stools are very frequent, but small in quantity, with sore pain in the anus. She often feels as if something yet remained to pass, although a fair quantity may have been evacuated. Stools usually dark. Alternation of constipation and diarrhoea. Irritable, morose and sullen; apt to be quarrelsome if disturbed. Sleeplessness, particularly toward morning. Want of appetite. Opium. Black, Avatery diarrhoea, sometimes frothy. Diarrhoea in consequence of a fright. Drowsiness, but refreshing sleep cannot be obtained. Petroleum. Diarrhoea only in the day-time. Phosph. Watery diarrhoea, pouring aAvay as from a hydrant, with great sense of weakness in the abdomen, and general debility. Stools of green mucus or of whitish fluid; little grains like boiled kernels of rice are seen with the stools. Sharp shooting pains in the abdomen. Phosph. acid. White, gray diarrhoea; copious, yellow, watery diar- rhoea, with rumbling in the abdomen. Diarrhoea painless, but not exhausting. Mental state characterized by decided indifference to ex- ternal influences or surroundings. Podophyllum. Morning diarrhoea, or diarrhoea occurring in the 21 322 DISORDERS INCIDENTAL TO PREGNANCY. latter part of the night; profuse, frequent, gushing, and painless or not very painful. Pulsatilla. Watery diarrhoea, only or usually at night—sometimes unconsciously evacuated. She has no thirst; a bad taste in the mouth, nothing tastes good. Blue eyes, tearful disposition. Stools very changeable in appearance, so that no two are alike. Rheum. Sour diarrhoea, Avith cutting and colicky pains about the navel. The emanations from the body are all sour-smelling. Re- pugnance to food as soon as a small quantity has been eaten. Rhus. Diarrhoea, with drawing and tearing down the legs with every eA^acuation. Stools reddish, bloody. Restlessness, frequent change of position, wdth temporary relief. Sabina. Diarrhoea, with pain extending from the back to the pubes. Secale c. Painful diarrhoea, Avith great prostration. Putrid, fetid, and colliquative diarrhoea. The patient does not wish to be covered up Avarm or to be near the heat, but prefers to be in the air or Avishes to be fanned. Involuntary diarrhoea. Sepia. Sense of weight in the anus, and an empty, sore feeling at the pit of the stomach; much burning at the anus and rectum. The diarrhoea soon becomes exhausting. Jerking pains from the anus upAvard through the rectum. Stramonium. Diarrhoea, the stools having a cadaverous smell; great thirst; food tastes like straw. The mental symptoms are Avorse in darkness and solitude. Great loquacity. Sulphur. Diarrhoea in the morning, driving her out of bed; has to hurry, and barely escapes soiling her clothing. Very hungry about eleven o'clock in the morning; she cannot wait for her dinner, she is so faint and hungry. Very sleepy during the day-time; aAvakens often during the night; gets Avide awake, as though she had not slept at all. Sulphuric acid. Diarrhoea, with great debility; sensation of general trembling without any actual trembling. Cannot do anything delib- erately, hurries as if impelled to do e\rerything hastily. Tabacum. Diarrhoea, the stools consisting of yelloAvish or greenish slime; sudden attacks of extreme faintness, often with cold perspira- tion. Beclouded condition of the mind, she cannot read or study satisfactorily. Feeling of oppression around the cardiac region. Tartar em. Colliquative diarrhoea, Avith meteorism. Nausea, with faintness; warm perspiration on the forehead and head from efforts to vomit and vomiting. Veratrum alb. Very exhausting diarrhoea, she feels very weak after REMEDIES FOR INTESTINAL AFFECTIONS. 323 every movement of the bowels, Avith cold sweat on the forehead, and sometimes cold general perspiration. Table of Remedies for Intestinal Affections. Incarcerated Flatulency. 1. Carbo veg., Cham., Coca, Graph., Ignat., Kali c, Lya, Nitr. ac, Nux v., Plumb., Puis., Staph., Tart. em. 2. Ant. cr., Arn., Asar., Canth., Chin., Coloc, Con., Natr. a, Natr. m., Nux m., Phos., Phos. ac, Plat., Rheum., Squill., Veratr. a. BORBORYGMUS. 1. Caust., Chin., Hell., Lye, Nux v., Phos., Phos. ac, Puis., Sulph. 2. Aloes, Agar., Arn., Bry., Canth., Carb. veg., Cham., Ignat., Natr. m., Plumb., Sassap., Squill., Sep., Spig., Staph., Tart. em., Veratr. a. Flatulent Colic. 1. Carb. veg., Chin., Lya, Nux v., Puis., Rhod., Staph., Veratr. a. 2. Anac, Arn., Asaf., Aur., Cham., Con., Graph., Hyos., Ignat., Nux m., Phos., Plumb., Rheum., Squill., Tart. em. Constipation (Simple). 1. Bry., Calc. a, Coca, Lya, Nux v., Op., Phytol., Plumb., Sil., Graph., Sulph. ■ 2. Alum., Bell., Canth., Carb. veg., Con., Creos., Dulc., Graph., Kali a, Laur., Meny., Merc, sol., Nitr. ac, Phos., Plat,, Sabad., Sep., Stann., Sulph., Sulph. ac, Veratr. a., Verbas. -----from Inactivity of the Bowels.—1. Alum., Hep., Kali a, Natr. m., Nux v. 2. Anac, Am., Camph., Carb. veg., Chin., Coca, Staph., Ignat., Natr. c, Nux m., Op., Phytol., Petr., Puis., Ruta, Staph., Sulph., Thuj., Veratr. a., Zinc. •-----from Induration of the Stools.—1. Bry., Magn. m., Op., Plumb., Verb. 2. Amm. a, Aur., Carb. an., Caust., Chel., Graph., Kali a, Magn. a, Merc, sol., Nux v., Petrol., Ruta, Sep., Sil., Sulph., Sulph. ac, Thuj. Diarrhoea (Simple). 1. Ant. cr., Cham., Chin., Merc, sol., Phos., Phos. ac, Puis., Rhus tox., Sulph., Veratr. a. 2. Aeon., Amm. mur., Ars., Asaf., Bor., Bry., Calad., Calc. a, Carb. v., Dig., Hyos., Lach., Natr. m., Nitr. ac, Petr., Rheum, Sep., Sil. -----Painful.—1. Rheum, Rhus tox. 2. Ars., Bry., Caps., Cham., Dulc., Merc, sol., Nux v., Petrol., Puis., Sec. corn., Sulph., Veratr. a. 324 DISORDERS INCIDENTAL TO PREGNANCY. Diarrhoea, Painless.—1. Chin., Ferr., Hyos., Lya, Phos., Phos. ac., Podoph., Stram. 2. Ars., Bell., Cham., Chel., Op., Plat., Sulph. Stools. ------Knotty, like Sheep's Dung.—I. Magn. m., Merc, sol, Op., Plumb., Sulph., Verb. 2. Amm. a, Carb. an., Caust., Chel., Graph., Nux v., Sep., Sulph. ac, Thuj. ------Acrid.—I. Ars., Chin., Ignat., Merc, sol., Puis., Sulph. 2. Ant. cr., Cham., Dulc, Ferr., Graph., Kali a, Lach., Nux v., Phos., Staph., Veratr. a. ------Bilious.—1. Cham., Puis. 2. Ars., Dulc, Ipec, Leptand., Merc, sol., Podoph., Veratr. a. —----Black-colored.—1. Ars., Bry., Chin., Leptand., Sulph. ac. -,---^.Bloody—1. Canth., Merc, sol., Ipec, Nux v., Puis., Sep., Sulph. 2. Apis., Arn., Ars., Asar., Bry., Calc. a, Caps., Carb. veg., Chin., Dros., Ferr., Led., Lya, Merc, sol., Merc, corr., Nitr. ac, Phos., Rhus tox., Sabin., Sassap., Sil. ------Frothy.—1. Chin., Coloc, Magn. m., Merc, sol., Rhus tox. ------ Green.—1. Cham., Phos., Puis., Rheum, Sulph. 2. Dulc, Merc, sol., Phos. ac, Stann., Veratr. a. ------ Whitish.—1. Dig. 2. Calc. a, Lach., Spong., Sulph. ------Involuntary.—1. Phos., Phos. ac, Veratr. a. 2. Ars., Bell., Mur. ac, Natr. m., Sulph. ------Mucous.—1. Asar., Bor., Caps., Cham., Nux v., Phos., Puis., Sulph. 2. Arn., Ars., Carb. veg., Graph., Hell, Ipec, Kali c, Magn. in., Merc, sol., Petrol., Rheum., Rhus tox., Ruta, Sep., Spig. ------Purulent.—1. Merc, sol., Sil. 2. Arn., Canth., Lye, Puis., Sulph. ------of a Sour-Smell—1. Calc. a, Cham., Graph., Hep., Merc. sol., Natr. a, Rheum., Sulph. ------Stinking^ or of a Putrid Smell.—1. Ars., Asaf., Carb. veg., Puis., Sil., Sulph. 2. Arn., Aur., Bry., Calc. a, Cham., Chin., Dulc, Graph., Nitr. ac, Nux v., Oleand., Plumb., Squill., Staph., Stram. ------too Large.—1. Bry., Kali c. 2. Graph., Ignat., Veratr. a. ------too Small.—1. Caust,, Merc, sol., Pbos., Sep., Sulph. -——^ Undigested.—1. Ars., Chin., Ferr., Oleand. 2. Ant. cr., Bry., Meny., Phos., Phos. ac, Sulph. ac. ----.— Insufficient.—1. Am., Cham., Magn. m., Natr. a, Nux v., Sulph. 2. Alum., Coleh., Hyos., Sabad., Sep., Staph. ------Tenacious.—1. Merc, sol., Plat. 2. Asar., Caust., Plumb., Sassap. FISSURE OF THE ANUS. 325 Stools, with Ascarides.—1. Calc. a, Chin., Cina, Ferr., Ignat., Sulph. 2. Asar., Merc, sol., Nux v., Phos., Plat., Squill., Sil., Spig., Spong. ------with Lumbrici.—1. Cina, Sabad., Sil., Spig., Sulph. 2. Aeon., Anac, Calc. a, Cham., Cic, Graph., Natr. m., Ruta, Sec. corn. ------with Taenia.—1. Calc. c, Graph., Plat, Puis., Sabad., Sil., Sulph. 2. Carb. A-eg., Chin., Kali a, Nux v., Petr., Phos., Sep. Fissure of the Anus. This very painful and distressing disorder occurs more frequently in women than in men, and is often an accompaniment of pregnancy. In milder cases the fissure is limited to the mucous membrane, but in the severer forms it involves also the sub-mucous tissues. The fissure is usually about a quarter of an inch in breadth and from a quarter of an inch to an inch in length, situated immediately Avithin the anus, Avith its inferior extremity corresponding to the margin of the sphincter ani. In recent cases the edges of the fissure are soft and pliant, but in cases of long standing they are indurated and promi- nent. Fissure of the anus should be distinguished from haemorrhoids, though they often coexist in the same individual. Haemorrhoids are almost ahvays attended Avith constipation, Avhich acts as a provoking cause, but fissure of the anus is as often accompanied by looseness of the boAvels as other\Aase. The fissures are always very painful during and after an evacuation—sometimes even before. They are accom- panied by a constriction of the sphincter ani in many cases, which renders the evacuation of the boAA'el still more difficult and painful, and in some instances almost impossible. The pain is increased by forced expirations, as in coughing, sneezing, and by urinating ; every effort to discharge flatus or feces is attended Avith excruciating torment, which continues for one or more hours, attended Avith Aaolent spasm- odic action of the sphincter ani: so violent is the agony that most persons thus afflicted put off the calls of nature and retain the recum- bent position. This diseased condition results from some constitutional dyscrasia. Its cure should not be attempted by surgical means. Its homoeo- pathic treatment results in a cure; Avhile its surgical treatment is merely temporizing, and may be folloAved by disastrous consequences; just as the cure of anal fistula by operative procedure is sometimes lolloAved by pulmonary disease. What have been termed rhagades or cracks of the anus appear to be a milder form of fissure of the anus. 326 DISORDERS INCIDENTAL TO PREGNANCY. iEsculus hip. This remedy has been successfully employed in some cases. The boAvels are costive, although they are moved daily. Face pale and haggard, as though from great suffering. Lameness of the back and hip, so that walking is not only painful, but Avellnigh im- possible. Itching, stinging, burning and feeling of fullness at the anus. Haemorrhoids. Arsenicum. On going to stool painful constriction immediately above the anus, AAdiich extends toAvards the sacrum. After stool the anus burns like fire, causing intense agony, restlessness and exhaustion. Heat and pain in the rectum, with a kind of tenesmus, as in dysentery, Avith continual pressure. Causticum. There is great difficulty in walking, for the pain in the anus aud rectum becomes intolerable. Much pain in the perin- eum. Large, painful pustule near the anus, discharging pus, blood and serum. BoAvels are usually very costive. Gratiola. After stool, painful pressure in the abdomen Avhen walk- ing, relieved by sitting doAvn. Sticking pain about the umbilicus. Tearing in the rectum or prickling in the anus. Painful cramps in the os coccygis. Ignatia. Painless contraction of the anus for many days. Soon after stool, pain in the anus, shooting far up into the rectum, or con- striction and smarting like touching a wound. Very easy prolapsus of the rectum. Pain in the anus returning at the same hour each day; Avorse walking and still worse standing, but relieved on sitting doAvn. Lachesis. On going to stool the anus feels as if closed. Internal, cramp-like pain in the anus before and after passage. Prolapsus of the rectum, which is thick and tumefied, and Avhen it returns it con- tracts spasmodically. Mezereum. Painful constriction, tearing and drawing at the anus, in the perineum, and from thence through the urethra. After stool the anus contracts upon the prolapsed rectum, Avhich remains stran- gulated, causing, when touched, a pain like a Avound.' Natrum mur. On going to stool the rectum seems contracted, then is voided, after great effort, only a small quantity of hard feces, with tearing, bleeding and smarting at the anus, and finally some soft mat- ter. Ripping-up sensation in the anus after stool. Much sticking and sharp pains in the anus and rectum between the stools, and at night in bed. Nitric acid. This remedy is used more frequently than any other. The symptoms Avhich indicate it are: On going to stool, pain in the FISSURE OF THE ANUS. 327 rectum as if something Avere torn away, or twitchings in the rectum and spasmodic contraction of the anus many hours aftenvard. Smarting more in the rectum than in the anus immediately after stool, and continuing tAvo or three hours. Sometimes prolapsus of the rectum or discharge of much blood accompanies some of the above symptoms. Nux vom. Painful stools, either much too large and difficult or too small and insufficient, with a sensation as if something remained in the rectum still to be discharged, but with an entire inability to void it. Phosphorus. The pains for phosphorus are mostly lancinating, in the anus and up the rectum—sometimes attended Avith smarting. After stool, strong desire to urinate. Acute smarting pains after a soft stool, extending into the abdomen. Plumbum. A sensation as if a rough body were traversing the rectum during stool. Sensation as if the anus were draAvn strongly upAvard. Much trouble with the urine in not being able to pass it —apparently from want of sensation to do so; the will to do so can- not effect it, as if from paralysis. Sepia. Constrictive pain in the rectum, extending to the perineum and into the vagina. Pain in the rectum on going to stool,and Avhich persists for a long time after sitting down, and finally an imperfect stool is voided Avith sore, smarting pain. There is a sense of Aveight in the anus, like a constant drag. Silicia. Painful effort to stool for some time, and finally the stool recedes into the rectum; such efforts are repeated several times before a passage is effected, with sore, sticking, shooting pains. Sulphur. Tenesmus for an hour after having been to stool. On attempting to sit down for stool the pain in the anus prevents her from doing so. After stool a pulsating pain continues in the rectum the whole day. Lancinating pains from the anus upAvard after stool, so violent as to cause syncope. At night there is much difficulty in lying in bed from lancinations and uneasiness in the rectum, tenes- mus, etc. Thuja oc. During an attempt at stool the pain in the anus and rec- tum is so great that she has to desist. Violent contraction in the anus and rectum, folloAved by tearing as if in the bowels. Burning pricking in the anus between stools. Violent burning in the anus while Avalking. The remedies laid down under the head of haemorrhoids, varicose veins, constipation and diarrhoea, with their indications, should like- wise be consulted. 328 DISORDERS INCIDENTAL TO PREGNANCY. Disordered Secretions and Excretions. Ptyalism. The profuse flow of saliva Avhich sometimes occurs in the earlier months of pregnancy usually lasts but two or three months, although cases are recorded in Avhich it continued during the whole period of gestation. Where this discharge is excessive it must necessarily prove very exhausting. Its source must be found in some peculiar constitutional dyscrasia, which ultimates itself in this direction under the stimulus of pregnancy. Hence the homoeopathic remedies are found to relieAre the difficulty, and at the same time benefit the whole system of the patient, This is just the reverse of the experience derived from the allopathic use of astringent gargles. Tavo cases are referred to by Cazeaux, in one of Avhich the sudden suppression of the ptyalism was folloAved by apoplexy, in the other symptoms of suffocation appeared. This eminent authority is unwilling to admit that these results were the actual consequences of such suppression, but the intelligent homceopathist would expect nothing less. The salivation, if unattended by other symptoms, may require mercurius, but in most cases there are other gastric disturbances, all of which must be duly considered. For remedies, therefore, con- sult those mentioned in the preceding sections. Spitting of blood sometimes exists in connection with pregnancy, but in ordinary cases need give rise to no alarm. It is usually due to the general congestion consequent on the condition of pregnancy, and con- sists of a mere exudation from the mucous membrane of the air-pas- sages or fauces. Such remedies as Aeon., Bell., Creos., Hamara., Ipec, Lachesis. Elaps., Mur. ac, may be indicated. Urinary Difficulties and Derangements. As gestation advances, the increasing size of the uterus causes it to press more and more upon the bladder. Thus the capacity of the latter organ is diminished by the lateral pressure, Avhich necessitates a much more frequent discharge of urine. The same frequent mictu- rition results also from the direct irritation of the neck of the bladder. Thus there may be hourly calls to pass water, Avhich are sometimes but partially relieved by the Aoav of a few drops only at a time, or the irritation may amount to dysury, an actual strangury, or even to a complete retention of urine. These difficulties may arise in the earlier stages of pregnancy, espe- cially Avhere the unusual size of the pelvic cavity allo\ys the fcetus to URINARY DIFFICULTIES AND DERANGEMENTS. 329 remain too long Avithin it, or they may appear in consequence of some displacements, such as prolapsus, anteversion or retroversion of the uterus. Where some displacement appears to be the cause—which may sometimes be knoAvn by the suddenness of the onset of the diffi- culty, especially if it follows some accident or over-exertion—the case should receive the treatment recommended in a succeeding chapter for uterine displacements. If it prove to be retroversion, the use of the elevator may be necessary to replace the organ. The other varieties of displacement scarcely ever require manual assistance, since perfect rest in the horizontal position and the exhibition of the homceopathi- cally indicated remedy Avill, in most cases, readily relieve the uterine and the urinary difficulty at the same time. The catheter may some- times be required, in order at once to relieve the patient of the great distress under which she may be laboring from enormous accumula- tion of uriue. Incontinence of urine sometimes appears, especially in the later stages of pregnancy. When it appears in the early months it may re- sult in part from the pressure of the Avomb upon the neck of the blad- der before it rises out of the pelvic cavity, causing a loss of tone of the part. This difficulty will often yield to the indicated remedy, but if not, Avhere it comes on in the early stage of pregnancy, it may be ex- pected to disappear upon the emergence of the uterus from the cavity of the pelvis. For the medical treatment of these difficulties the following reme- dies should be carefully studied according to the indications here given, and compared in the Materia Medica with reference to any concomitant and constitutional symptoms which may also be present in the case. It is to be noted, likewise, that these remedies should be consulted, and may be required for urinary difficulties occurring not only during pregnancy, but before, during, and after parturition as well. Aconite. Retention of urine, with stitches in the region of the kid- neys. Difficult and scanty emission, with pinching around the um- bilicus. Bright-red, hot urine. Enuresis, accompanied with profuse perspiration. Desire to urinate, accompanied Avith great distress, fear and anxiety. Worse from exposure to cold dry air. Apis. Burning smarting pain before and after urination. Stitching pain in the urethra during micturition; must urinate often. Arnica. After passing a little urine she Avishes to pass more, but is unable to do so at that time. Brown urine with brick-red sediment. 330 DISORDERS INCIDENTAL TO PREGNANCY. Sense of fullness of the bladder, Avith inability to urinate. A bruised and sore feeling exists if haemorrhoids complicate the case. Arsenicum. Considerable burning is experienced at the commence- ment of the flow, Avhich ceases upon the full establishment of the stream; restlessness, cold sweat. Sometimes the urine Avill not flow at all, and, although the bladder be full, there is yet no desire to uri- nate, as though there Avas paralysis of the viscus. Discharge of mucus and blood Avith the urine. Belladonna. Great difficulty in passing a small quantity of urine; it floAvs in a very feeble stream or in drops. The urine is often of a golden-yellow color. Constant involuntary dribbling of urine. Enu- resis with profuse perspiration. The region over the bladder is very sensitive to pressure, the slightest jar causing pain. Blood-red urine. Urine, at first clear, becomes turbid on standing. Retention of urine. Camphor. Retention of urine, with constant pressure on the bladder and desire to urinate. Burning in the urethra during emission of urine. This remedy will prove very useful if the urinary difficulty is the result of the injudicious use of cantharides, balsam copaiba, tur- pentine, etc. Cannabis. Burning during and after emission, particularly after cantharis has failed to relieve. Cantharis. Very frequent urination, even sixty times an hour, with violent cutting pain, so severe as to make her scream. The urine is often bloody. Strangury, with frequent urging. The urine does not flow in a stream, but dribbles away or passes drop by drop, Avith cut- ting and burning. Cutting and burning pains in and through the bladder. Tenesmus of the bladder, Avhich is agonizing in severity. Capsicum. Burning smarting after micturition, as from the applica- tion of cayenne pepper. Causticum. Frequent desire to urinate, a small portion passing in- voluntarily. Involuntary passing of urine at night. Also Avhere there are signs of paralysis of the bladder from prolonged retention of urine and over-distension. Coccus cacti. The urine does not form the usual jet, but runs down over the surrounding parts. Does not cut or burn. Colocynthis. Tough mucous sediment in the urine which can be drawn out into strings. Conium. The urine flows and stops, and flows and stops again, and so on. There are cutting pains during the Aoav, and burning or smarting afterward. Strangury, with vertigo, particularly on lying doAvn. URINARY DIFFICULTIES AND DERANGEMENTS. 331 Dulcamara. The urine on standing and becoming cooled, has an oily consistence, Avith a jelly-like sediment, intermixed Avith specks of blood. The urinary difficulty is increased at every cool change of the weather. Graphites. Urinary troubles, Avith burning in the urethra between the acts of micturition. Very frequent nightly micturition. Pain in the sacrum when urinating. Cutting and doAvnward pressure in both kidneys before urinating. Helleborus nig. In bad cases where the irritation at the neck of the bladder threatens to run into inflammation. Almost constant desire to urinate, very little being passed, of a dark color and depositing a coffee-ground-like sediment; the bladder at length becomes paralyzed and greatly distended. On straining to pass a small quantity of urine some drops of blood come away. Nausea and distended abdomen sometimes attend. Hepar. Intense soreness in the urethra during the emission of urine. Very slow but painless emission of urine, apparently from feeble con- traction of the bladder. Greasy and opalescent pellicle on the urine. Blood-red urine. Painful micturition. Lachesis. Stitches in the kidneys, extending doAvnward and appar- ently through the ureters. Frequent emission of a foamy urine, some- times dark and scanty, sometimes profuse. Dull pain in the bladder, occasionally with a sensation as though a ball were rolling about in there. Laurocerasus. Acrid urine, corroding the labia. Urinary difficulties, with palpitation of the heart and gasping for breath, coming on by spells. Very slow flow of urine; sometimes the bladder seems to be completely paralyzed, so that not a drop can be voided. Thick, red- dish or mahogany-colored sediment, Avith Avhite jelly-like flocks float- ing through it, Pain in the region of the stomach when urinating. Lycopodium. Much pain in the back previous to the emission of urine, so that she even screams out. Itching in the urethra during and after micturition. Violent jerking, sharp-shooting, tearing or cutting pains in the urethra not long after urinating. Red crystals are deposited in the urine, the urine itself being clear. Foaming urine. Stitches in the bladder, neck of the bladder and anus at the same time. The Aoav is delayed, Avith pain in the back, which, however, is relieved as soon as the flow begins. Urine turbid, milky, deposit- ing a thick sediment of a nauseating odor. Merc. sol. Constant desire to urinate, the desire not lessened by urinating. Pieces of filaments, flocks and hard pieces of mucus re- sembling pieces of flesh are passed in the urine. Burning and scald- 332 DISORDERS INCIDENTAL TO PREGNANCY. ing sensation of the urine from raw surfaces and otherwise. Very great tenderness over the bladder. Sour-smelling urine. Prolapsus of the vagina or swelling of the external genitals accompanies the urinary difficulty. Nitric acid. Painless retention of urine. Desire to urinate, with cutting in the abdomen. Urine Avith an intolerable odor. Very thin stream, as if from contraction of the urethra. Stitching pain in the abdomen when urinating. Burning in the urethra, and desire to urinate with the hope of relieving the burning, Avhich, however, is in- creased by the act. Nux vomica. She wishes to urinate very frequently, only a little at a time being passed, Avith a sore burning pain, usually accompanied with constipation. Strangury. Bloody urine. Spasmodic retention of urine, only a few drops passing at a time, Avith scalding sensation; reddish brick-dust sediment. Phosphoric acid. Frequent calls to urinate at night, a large quantity of colorless urine being passed each time. Creeping in the urethra between the acts of micturition. White, jelly-like flocculi in the urine. Pulsatilla. Retention of urine, with redness, heat and soreness of the vesical region externally. Continued pressure on the bladder, Avithout desire to urinate. Desire to urinate, with drawing in the abdomen. Involuntary emission of urine when sitting or Avalking. After uri- nating, spasmodic pain in the neck of the bladder, extending to the pelvis and thighs. Frequent and almost ineffectual urging to urinate, Avith cutting pains. Great urgency of the call, it seems impossible to delay. The urinary difficulties are increased by taking cold, and at such times the urine may deposit a tough, slimy sediment. Rhus tox. Involuntary urination, particularly Avhen at rest. Dysu- ria, Avith discharge of drops of bloody urine. SnoAV-\\diite sediment in the urine. Retention of urine, with great restlessness and uneasi- ness, no position being comfortable except for a few moments. Belch- ing of Avind while urinating. Ruta. At every step after micturition she feels as if the bladder were full and moved up and doAvn. She feels as if she could not retain the urine, so urgent is the desire, although she can pass but a very small quantity. Involuntary emission of urine whether at rest or in motion. Sepia. The urine deposits a sandy, sometimes pinkish sediment, which becomes firmly attached to the vessel and is with difficulty re- moved. Frequent urging at night, the urine voided often having a ALBUMINURIA. 333 putrid odor in the morning. Sensation as though urine were passing through the urethra, Avhich is not a fact. Burning and smarting in the urethra. Violent itching about the vulva accompanies the urinary difficulties. Stramonium. The urine dribbles aAvay very sloAvly and feebly. Re- tention of urine, or it flows feebly or in drops, though painlessly, as though there existed a spasmodic stricture of the urethra. Sulphur. Very frequent desire to urinate day and night, in fact al- most constant urging; the pain caused by the act of micturition scarcely ceases until the patient is again obliged to urinate, Avhich gives rise to a renewal of the pain. Very urgent call to urinate; she is unable to wait even for a moment. Fetid urine, Avith a greasy pellicle on its surface. The urine is emitted Avith great force. The urine occasions an acrid or corrosive sensation when voided, as though it were strong lye. Albuminuria. Albuminuria, or the presence of albumen in the urine, constitutes one of the most interesting of the pathological changes induced by pregnancy. Healthy urine contains no albumen, and the urine of healthy women in the pregnant state is equally destitute of this element. This change in the urine is not ahvays constant or equal in amount: in proportion as women are constitutionally healthy, they will be found free from albuminuria in pregnancy. And in proportion as their systems are affected by some dyscrasia, the derangement of the vital fluid will be greater; for it must be borne in mind that albumen must be diminished in the blood in the same ratio that it is increased in the urine. Cases of albuminuria might be cited illus- trating all the different degrees, from the slightest and scarcely per- ceptible trace of albumen which appears in the urine for a brief period only of pregnancy, up to those forms of anasarca which involve the entire system, and in which the urinary secretion, almost totally suppressed, is so loaded with albumen as to become entirely solid on boiling.* Albuminuria may be either temporary or permanent. In the former case it may arise from a great variety of morbid influences and in connection Avith various forms of disease. And it may be occasioned by pregnancy, which, although not itself a morbid con- dition, seems to develop in some form or other any latent dyscrasia which may have been lurking in the system, just as scarlatina de- * Am. Horn. Review, vol. v., p. 492. 331 DISORDERS INCIDENTAL TO PREGNANCY. Arelops any scrofulous taint Avhich may belong to the constitution of children whom it attacks. And, in fact, scarlatina does actually develop an albuminuria in post-scarlatinal dropsy, which must be deemed a purely psoric affection, since it appears only in a particular variety of constitution, although the presence of the albumen is par- tially accounted for by the temporary failure of the functional action of the skin during desquamation. Permanent albuminuria is principally found in connection with chronic disease of the kidneys, whether in the pregnant or in the un- impregnated condition. In that form of hypertrophied degeneration in which the kidneys become white and enlarged, the urine is greatly diminished in quantity and contains a large amount of albumen. This nephritic affection never proves fatal without the previous occurrence of dropsy, which is one of its most usual and prominent symptoms. Such cases belong to strongly-marked psoric diatheses, of which in- stances have been observed in three successive generations in which the albuminuria, morbid affection of the kidney, almost total suppres- sion of the secretion of the urine and general dropsy were the un- avoidable attendants of every pregnancy. This intimate connection of albuminuria Avith psora is Avell illustrated in the report, by an allo- pathic physician, of the treatment with arsenic of this disease compli- cated with psoriasis and lichen.* The arsenic chanced to be the true homoeopathic similimum to the entire case, and, although given in allopathic doses, both albuminuria and skin disease were thoroughly cured. The prompt disappearance of the albuminuria at the termination of pregnancy in many cases, gives rise to the belief that some local in- fluence, such as pressure of the gravid uterus upon the emulgent veins, may be an important cause of this condition. But, as already stated in the case of varices and haemorrhoids, such results can occur from local pressure only in persons constitutionally predisposed to this af- fection. Thus, in the milder cases particularly, we see all the abnor- mal symptoms removed by the recuperative energy of nature alone on the discontinuance of the provoking cause. Thus, too, even during the continuance of pregnancy, the homceopathically indicated remedies are so far capable of antidoting the constitutional dyscrasia that the albuminuria in many instances may be made to disappear entirely in spite of the persistence of the provoking cause. And these remedies may even then have been selected under the prevailing influence of other (sensational) symptoms—remedies perhaps in which we have * Brailhwaite's Retrospect, July, 1862, p. 95. ALBUMINURIA. 335 hitherto discovered neither pathogenetic nor clinical evidences of their adaptation to albuminuria. The important relation which albuminuria bears to puerperal in- sanity and convulsions ought not to be overlooked in this connection. " Albuminuria precedes arid attends the first access of puerperal in- sanity in a large proportion of cases, but not perhaps so frequently nor so constantly as it precedes and attends upon attacks of puerperal convulsions. The coagulability of the urine generally disappears within a short time after an attack of puerperal insanity commences. When the insanity recurs in the form of successive attacks or explo- sions, each attack is connected with a neAv attack or advent of albumi- nuria." The albuminuria mostly appears in the later months of pregnancy, and its presence, especially if accompanied by anasarcous conditions, will serve to place the physician on his guard agajnst puerperal con- vulsions. And while on the one side the albuminuria seems to pre- dispose to severe nervous affections, on the other excessive nervous excitement appears to cause albuminuria. Where from collateral symptoms there is reason to suspect the presence of albumen in the urine of a pregnant Avoman, the urine should be subjected to the usual qualitative tests, that its presence or absence may be ascertained with certainty, and the presence of albu- men having been discovered, its quantity should likewise be made out. At the same time in treating the case the attention of the practitioner should not be diverted from the general symptoms by the presence of the albumen, but, as in all other cases, the subjective symptoms should have equal weight with the objective symptoms, and the remedy chosen should be as nearly in accord with the totality of the case as possible. These cases are amenable to treatment, and it is feared that failures to cure sometimes result from the entire at^ntion, in choosing the remedy, being directed to the albuminuria. Uraemia, or retention of the urea in the blood, Avhich usually forms a part of the albuminuria, is probably the direct cause of the convul- sions and other nervous affections that sometimes result. And it is remarked that these difficulties are more apt to occur in primiparse than in multipara. This affection has been mentioned as a powerful and frequent cause of abortion, of premature labor and of the death of the foetus. This, however, is more apparently than really correct; for the presence of albumen in the urine forms but a single one of the symptoms of a general dyscrasia Avhich pervades the entire system, the radical cure 336 DISORDERS INCIDENTAL TO PREGNANCY. of Avhich forms one of the most gratifying results of homoeopathic practice. The ansemia, oedema, ascites and anasarca which appear in connec- tion Avith albuminuria will be subsequently considered. The follow- ing medicines, together with those mentioned under the head of urinary difficulties and of dropsy, should be considered, as Avell as the general table of remedies appended to this section, and, above all, the Materia Medica should be carefully studied. Allium cepa., Amm. carb., Apis., Ars., Aurum mur., Bell., Bry., Cinnabaris, Cobalt, Colch., Cupr. m., Dig., Dulc, Eupat. purp., Glo- noine, Lachesis, Natr. mur., Ononis sp., Phos., Phos. ac, Squill, Terebinth. Remedies for Urinary Difficulties and Derangements. Urine acrid.—1. Hepar., Merc. sol. 2. Cann., Caust., Clem., Par., Rhus tox., Thuja. ------smelling like ammonia.—1. Asaf. 2. Mosch., Nit. ac., Phos. ------hot or scalding.—1. Ars., Canth., Hepar. 2. Aeon., Caps., Cham., Colch., Dig., Merc, sol., Phos. ac, Squill. ------bloody.—1. Canth., Puis. 2. Ars., Calc. a, Caps., Ipec, Lya, Merc, sol., Mezer., Nux v., Phos., Sec. corn., Sep., Sulph., Zinc. ------with greasy or variegated pellicle on its surface.—1. Paris. 2. Calc. a, Hepar., Jod., Lya, Petrol., Phos., Puis. ------dark.—1. Aeon., Bell., Bry., Colch., Merc, sol., Sep., Tart. em., Veratr. a. 2. Ant. cr., Arn., Calc. a, Canth., Carb. veg., Dig., Hell., Hepar., Ipec, Puis., Selen., Staph., Sulph. ------flaky.—1. Canth., Mezer. 2. Cham., Cann., Sassap., Zinc. ------frothy.—1. Lach., Lye. ------greenish.—1. Camph. 2. Rheum., Veratr. a. ------milk-colored.—1. Aur. mur., Cina, Phos. ac. ------mucous.—1. Natr. mur., Puis. 2. Ant. crud., Canth., Coloc, Dulc, Merc, sol., Valer. ------pale.—1. Con., Nitr. ac, Phos. ac. 2. Agar., Alum., Ang., Arn., Bell., Colch., Coloc, Ignat., Puis., Rhus tox., Sassap., Squill., Sec. corn., Stram., Stront. ------purulent.—1. Canth., Clem. 2. Lye, Puis., Sabin., Sil., Sep. ------stinking.—1. Dulc. 2. Ars., Carb. veg., Natr. mur., Nitr. ac, Phos. ac, Puis., Sep., Viol. tr. ------with urinous odor in excess.—1. Benz. ac. remedies for urinary derangements. 337 Urine turbid or cloudy when voided.—1. Cina, Con., Merc. sol. Sabad. 2. Ambr., Cann., Chin., Dulc, Ignat., Phos., Puis., Rhus tox., Sep. -----becomes turbid or cloudy on standing.—1. Bry., Cham., Phos. ac. 2. Caust., Merc, sol., Seneg., Valer. -----sticky or viscous.—1. Coloc. 2. Creos., Cupr. met., Phos. ac. Sediment, reddish.—1. Canth., Natr. mur., Puis., Sep., Valer. 2. Aeon., Ambr., Ant. crud., Arn., Chin., Lye, Nitr. ac. -----whitish.—1. Phos., Rhus tox. 2. Coloc, Con., Hepar., Nitr. ac, Oleand., Petrol., Phos. ac, Sep., Spig., Sulph., Valer. -----yellow.—1. Cham., Phos., Sil., Spong., Sulph. ac, Zinc. -----bloody.—1. Canth., Phos. ac, Puis., Sep. 2. Aeon., Dulc, Lye, Phos., Sulph., Zinc. -----clay-like.—1. Sassap., Sep., Sulph., Zinc. -----cloudy.—1. Bry., Nitr. Phos. ac, Seneg., Thuj. -----flaky.—1. Canth., Mezer., Zinc. -----like flour.—1. Calc. c, Graph., Natr. mur. -----like pus.—1. Canth., Cham., Lye, Puis. 2. Calc. a, Con., Kali c, Sep., Sil. -----mucous.—1. Dulc, Natr. m., Puis., Valer. 2. Ant. crud., Aur., Bry., Caust., Coloc, Con., Merc, sol., Natr. a, Phos. ac, Sassap., Seneg., Sulph., Sulph. ac. -----sandy, gravelly.—1. Ant. crud., Calc. a, Lya, Phos., Ruta., Sassap., Sil., Zinc. 2. Ambr., Arn., Chin., Meny., Natr. m., Nitr. ac, Nux m., Nux v., Puis., Thuj. Desire to Urinate, ineffectual.—1. Canth., Dig., Sassap. 2. Arn., Camph., Caust., Coloc, Hyos., Kali a, Nux v., Phos., Phos. ac., Plumb., Puis., Stram., Sulph. Discharge, too copious.—1. Arg. nit., Mur. ac, Rhus tox., Squill., Verb. 2. Agnus., Bar. a, Bism., Canth., Guaj., Ignat., Merc, sol., Nitr., Phos. ac, Seneg., Tarax., Viol. tr. -----scanty.—1. Canth., Colch., Dig., Graph., Hell., Op., Ruta., Staph. 2. Aeon., Arn., Bell., Bry., Caust., Chin., Dulc, Hep., Hyos., Kali c, Laur., Nitr. ac, Nux v., Phos., Plumb., Puis., Sulph., Veratr. a. ■----- too frequent—1. Agar., Bar., Canth., Caust., Merc, sol., Nitr. ac, Rhus tox., Squill., Staph. 2. Bry., Creos., Ignat., Kali a, Lach., Mur. ac, Natr. c, Phos. ac, Selen., Spig., Thuj. -seldom.—1. Canth. 2. Aeon., Arn., Ars., Aur., Camph., Hepar., Hyos., Laur., Nux v., Op., Plumb., Puis., Ruta., Stram. 22 338 disorders incidental to pregnancy. Discharge by drops, dribbling.—1. Canth., Sulph. 2. Am., Camph., Clem., Dulc, Petrol., Staph., Stram., Thuj. ------involuntary.—1. Caust., Puis., Rhus tox. 2. Bell., Creos., Dulc, Lye, Merc, sol., Natr. m., Petrol., Ruta., Sep., Sil., Spig., Sulph. ------involuntary at night, " wetting the bed."—1. Ars., Bell., Bry., Caust., Cham., Merc, sol., Op., Puis., Rhus tox., Sep., Sil., Stram., Staph. 2. Aeon., Arn., Bar. a, Calc. a, Chin., Cina, Creos., Dulc, Hep., Hyos., Ignat., Kali c, Lye, Natr. m., Nux v., Petrol, Phos., Phos. ac, Rheum., Ruta., Spig., Zinc. ------ interrupted.—1. Clem., Con. 2. Agar., Caust., Dulc, Sulph., Zinc. Retention.—1. Aeon., Arn., Ars., Canth., Hepar., Hyos., Laur., Lye, Plumb., Puis., Ruta., Stram. 2. Aur., Bell., Caps., Caust., Chin., Cic, Coloc, Con., Cupr. m., Dig., Graph., Nux v., Op., Sec. corn., Sulph., Veratr. a. Complaints before urinating.—1. Bor., Coloc, Lye, Nux v., Puis. 2. Arn., Bry., Dig., Phos, ac, Rhus tox., Sulph., Tart. em. ------when beginning to urinate.—1. Canth., Clem., Merc. sol. ------while urinating.—1. Cann., Canth., Hepar., Lye, Merc. sol., Phos. ac, Puis., Thuj. 2. Aeon., Clem., Colch., Con., Ipec, Nitr. ac, Nux v., Phos., Sassap., Sep., Sulph., Veratr. a. ------on cessation of flow.—Bry., Canth., Sassap., Sulph. ------after urinating.—1. Canth., Coloc, Hepar., Merc, sol., Natr. m., Sassap., Thuj. 2. Anac, Arn., Bell., Calc. c, Cann., Caps., Chin., Con., Dig. Natr. a, Nux v., Par., Puis., Ruta., Staph., Sulph., Zinc. Remedies acting especially on the Bladder.—1. Canth., Hyos., Lye, Nux v., Puis., Ruta. 2. Aeon., Ant. crud., Am., Bell., Calad., Caps., Dulc, Mur. ac, Petrol., Sassap., Squill., Sep., Staph. Remedies acting especially on the Urethra.—1. Cann., Canth., Caps., Clem., Merc, sol., Phos., Thuj. 2. Aeon., Bry., Calc. c, Caust., Chin., Colch., Con., Mezer., Natr. m., Nitr. ac, Nux v., Phos. ac, Puis., Sabin., Sep., Sulph., Zinc. Disorders of Respiration. cough and dyspnoea. These are the principal forms of disorders of the respiratory organs which occur in connection with pregnancy. There may also be oppres- DISORDERS of respiration. 339 sion of the chest, palpitation of the heart, and other similar symptoms; but these belong rather to disordered circulation than to disordered respiration. Yet so intimate is the connection between these two vital functions that it Avould be difficult in any given case to de- termine whether the disturbance of the respiration affected the cir- culation, or whether the disturbance of the circulation affected the respiration. For our purpose it is sufficient to remember that both these functions are under the immediate and absolute control of the nervous system of organic life, which, as has already been explained, is most intimately connected with the uterus and sustains all the development of utero-gestation. From reflex, sympathetic irritation of the pneumogastric, either in connection with gastric disturbances or in lieu of them, the cough of pregnancy may arise in the earlier months, or it may be the direct result of irritation of the diaphragm from the upward displace- ment in the later months. In either case tlie cough is short, frequent, irritating, and it may be perfectly dry or attended with some expecto- ration. Influenza may also set in as a complication, in which case prompt attention should be rendered and a cure effected at once, since otherwise abortion itself may result. A certain spasmodic form of cough sometimes makes its appearance, resembling hooping-cough, and arising from an apparently similar irritation of the pulmonary nerves. Such cough as may be connected with a tuberculous condition of the lungs, as in cases of incipient phthisis, is more apt to disappear under the influence of pregnancy. Should the pulmonary difficulties be so far developed that a purely phthisical cough maintains itself during the period of gestation, the state of the patient will require the most serious attention, since the phthisical symptoms usually appear with far greater intensity after delivery. Another most important indication of this condition in pregnancy is to be found in the chills, which haA^e been known to occur every day, and which in the entire absence of cough or expec- toration Avere belieA^ed to he due to some miasmatic influence. Such a patient was readily delivered of an apparently healthy and full-sized child, but was herself found upon examination to be in the last stage of consumption, never being able to leave her bed or scarcely to speak. She lived but a few weeks after her confinement. Dyspnoea in its various forms, panting respiration, shortness of breath, oppression of the chest, is a not unfrequent accompaniment of pregnancy. The symptoms of this class, as well as those con- nected with cough, are more apt to appear in persons whose chests 3 40 disorders incidental to pregnancy. are naturally weak, Avho are constitutionally predisposed to phthisis pulmonalis, or Avho have a similar predisposition to hydrothorax. A very sad case of a fatal complication of all these difficulties recently came under observation. A young woman, aged about thirty, of scrofulous constitution, rather short in stature, inclined to hydrothorax, Avho probably had some small accumulation of water about the heart for a considerable time, was married in the fall, and found herself enceinte in the winter; she consulted her physician, at a dis- tance, for a severe cough with great shortness of breath. She reported herself very much relieved by the remedies advised, but soon after taking, as was stated, " a cold on her lungs," she died in a feAv days, suffocated by the copious pulmonary effusion. Plethora has also been mentioned as one of the causes of dyspnoea in pregnancy, for which of course venesection is the allopathic remedy. But a more sound physiological view, which denies that there is ever too much pure blood, leads also in this instance to a more accurate pathology, which attributes the dyspnoea to irregularity or obstruction of the circulation—to congestion perhaps in the more aggravated cases—but never to plethora. The local congestions which arise in such cases from the obstruction of the general circulation, or even from constitutional predisposition to pulmonary apoplexy, are connected with palpitation of the heart and rush of blood to the face and head. These local difficulties, Avhether dependent upon constitutional dyscrasia or not, are insepa- rably connected with the other forms of disorder Avhich occur in the pregnant condition ; since every part of the system sympathizes with the Avhole and the Avhole Avith every part, the remedy which will cure any one must also be the one which more or less accurately corre- sponds to them all. Hence, too, the radical cure of such cases is seen to be a work of time; the disturbance of the harmony of the system by pregnancy becomes gradually relieved, as the circulation and play of the vital forces are equalized by eliminating from the interior of the organization those subtle hereditary miasms which poison the springs of life in their original fountains. For the treatment of the cough, dyspnoea, and other disturb- ances of the respiratory system in gestation, we recommend there- fore no particular medicines, but advise the thorough study of those already detailed under the various forms of gastric disturbance, and more particularly a reference to the most copious and reliable works on Materia Medica that can be procured. The leading symp- toms of the case may be found in connection with the pulmonary derangements of circulation. 341 difficulties, Avith the gastric derangements, or with some abnormal condition of the secretions or excretions; and the remedy at first in- dicated by the principal symptoms, if it do not in time remove the entire train of morbid conditions, will remove some of them; at which time a new prescription may require to be made for the case as it then presents itself. But it will sometimes be found that the remedy which is indicated at the first, being homoeopathic to the particular form of constitutional dyscrasia in the patient, and given at intervals and in higher potencies, will eventually remove all the various forms of trouble and restore the patient to complete health.* Derangements of Circulation and of the Circulatory Apparatus. plethora, hydremia, anaemia, etc. Plethora, in pregnancy, means principally that increased activity of the circulation which corresponds to the increased activity of the nervous system. The volume of the blood may be increased, and this increase may sometimes be obtained at the expense of the quality of the blood itself. Thus, as the bulk of the circulating fluid is aug- mented, it becomes more thin and watery. And this condition is ex- pressed by the term hydrozmia or Avatery blood. Plethora alone is insufficient to account for the vertigo, giddiness, flushes of the face, dimness of vision, ringing in the ears, flashes of heat all over the body and attacks of fainting which often annoy pregnant women. Some of these conditions it should, however, be remembered, may arise from the opposite or anajmic condition of the blood. Even in plethora, while some few of the symptoms may be due to the pressure of the apparently augmented quantity of the blood, the greater part must doubtless arise from the influence of the vitiated character of the blood itself rendered more serous, since it is evi- dent how similar symptoms, as of debility, may appear to spring from too much and also from too little blood. The same thing is seen in cases of severe haemorrhage, where the other fluids in the body are rapidly called upon to replace the quantity Avhich is requisite for the flow of the current. The intimate connection of this hydremic con- dition of the blood, which often appears in the latter part of the period of gestation, with the various forms of dropsical accumulation, will be obvious. It is sufficient to remark here that the common source of all these morbid conditions of the blood, and of the subsequent effu- Consult also Dr. Carroll Dunham's Bonninghausen on Hooping-Cough, and Dr. B. Simmons' Cough Repertory. 342 DISORDERS INCIDENTAL TO PREGNANCY. sions and cedematous infiltrations is to be found in the psoric dyscra- sia developed and aggravated by the constitutional excitement of pregnancy. Anaemia constitutes a still greater degree of depravation of the blood under the prolonged influence of many of the other morbid con- ditions of pregnancy. The failure of nutrition from the severe nausea and vomiting which sometimes persist even through the Avhole course of pregnancy, and from other gastric disturbances and intestinal diffi- culties, in addition to some original morbid tendency in the system itself, sometimes reduces the pregnant woman to a very feeble, almost cachectic condition. This condition is still further aggravated by the constantly-increasing demand made upon it for the support of the growing fcetus. And the exhaustion in such cases may prove fatal, either before or after delivery, unless the very root of the difficulty is reached and removed by the appropriate remedy. Among the more active consequences of such impoverished condi- tion of the blood in pregnancy-—as in chlorosis—should be noticed certain local congestions. These are developed in different parts of the body, according to the direction of the constitutional Aveakness; thus in some persons we see epistaxis, in others haemoptysis, in others still hsematemesis, and in others, finally, certain forms of uterine hsemorrhage, to be afterward described more particularly in connection with the other principal causes of abortion. For each of these forms of local congestion the appropriate remedy must be selected in accord- ance Avith all the conditions present. Uremia, or the retention of the urea in the blood, has been men- tioned in connection with albuminuria, with which it is usually a com- plementary symptom. All these forms of dilution, depravation or poisoning of the blood may be cured by the exhibition of the reme- dies indicated by all the attendant circumstances, symptoms and con- ditions ; not by any means failing to consider the mental and moral states and symptoms, Avhich latter may constitute the most important indications to guide us in the selection of the curative remedy even for such pathological changes. The same deep-seated constitutional influence that disturbs the harmony of the circulation and the propor- tions of the constituents of the blood, most powerfully and much more palpably affects the intellectual faculties, the sensibilities, and even the affections. 03DEMA. 343 (Edema—A nasarca—Ascites. These various forms of dropsical affections may occur during preg- nancy, either resulting entirely from the condition of pregnancy itself, or complicated and in great part caused by serious diseases of the heart, kidneys or liver. Some women when pregnant are invariably more or less dropsical, while others, on the contrary, do not show even the slightest evidence of simple oedema. And again, a dropsical condition of considerable magnitude may give rise to no inconveni- ence during pregnancy save that of causing clumsiness, and disappear promptly after parturition, AArhile in another case it may be very fruitful of suffering and of peril, not only to health, but even to life. What at the first is merely an cedematous enlargement of the feet and ankles may be developed as gestation advances into a general dropsy, the primary infiltration into the cellular tissue being finally accompanied by extensive effusion into the great serous cavities. (Edema of the Lower Extremities is a very common attend- ant of pregnancy, often occasions no great inconvenience, and is usually confined to the seventh, eighth and ninth months. It is sup- posed to arise in most instances from mechanical pressure alone, and to be entirely independent of constitutional disease. This may be true in those cases where it is not accompanied by other dropsical af- fections. Standing and Avalking serve to aggravate this condition; it becomes Avorse towards evening, gradually increases as pregnancy advances, and is often combined Avith a varicose state of the veins. In some instances the oedema becomes A^ery great, the integuments of the lower limbs become enormously distended, and a certain angry redness appears, as if erysipelas would set in. In such cases there is reason to suspect the presence of some more deeply-seated cause than mechanical pressure upon the veins, or even upon the lumbo-sacral nerves, nor will the dropsical infiltration be restricted to the inferior extremities. (Edema of the vulva will nearly always be present Avhen that of the lower limbs is so largely developed; and this will often cause much suffering in the latter months of gestation, and even render the patient unable to lie on either side. Cases are on record in which the oedema of the external genitals was so enormous that the patients were obliged to lie on their backs Avith their loAver limbs widely separated. In the worst forms of this affection the tumefaction may occasion considerable difficulty in the dilatation of the perineum and passage of the child's head. Acupuncture has sometimes been re- 344 disorders incidental to pregnancy. sorted to in advance of parturition, with considerable relief of the pain arising from the excessive distension of the delicate and sensitive tissues. Anasarca represents the extension of the oedema from its original local seat in the lower extremities over the entire surface of the body. Both oedema or partial dropsy of the cellular or areolar tissue, and anasarca or general dropsy of the same tissue, belong to the class of infiltration, as contradistinguished from ascites and hydrothorax, Avhich are effusions respectively into the abdominal and thoracic cavities. The more the oedema comes to resemble anasarca, the more we realize the existence of general constitutional causes of the affection, and are thus led to look for the means of curing it in corresponding constitutional remedies. The attendant symptoms in each case will aid us in the selection of the remedy, since we must prescribe for the patient, not for a particular pathological condition alone, however distressing it may be, or however thoroughly we may understand it. Much experience proves the truth of this. Ascites, or dropsical effusion into the cavity of the abdomen, may make its appearance in the first half of pregnancy, although it is more usually developed about the fifth or sixth month, and then con- tinues during the remainder of the period of gestation. This affection is attended with more or less oedema of the inferior extremities, of the labise, and infiltration of the abdominal Avails. The accumulation of fluid in the abdomen may be slow and gradual, or it may be very rapidly effused, especially after a certain degree of general oedematous infiltration has been reached. In pregnant Avomen this disorder cannot fail to cause much greater inconvenience, and even positive suffering, than in other persons, since it will cause greater obstruction of the movements of the thorax. So great is the dyspnoea in the advanced stages of pregnancy from this cause that the respiration becomes as difficult and distressing, and the erect posi- tion is almost as necessary, as in ordinary cases of hydrothorax. There are frequent attacks of faintness and a constant sense of suffo- cation from the insufficient aeration of the blood. And these suffer- ings are often aggravated by difficulty of sleeping, headache, thirst and disgust for food. The presence of Avater in the abdomen may be determined by per- cussion, the fluctuation being usually more perceptible in the left ascites. 345 hypochondrium just below the false ribs. The existence of any large accumulation of water in the cavity of the abdomen will usually prevent conception, by impeding the action of the fimbriated ex- tremities of the Fallopian tubes; and the same cause tends to prevent the full and healthy development of the foetus, although women with dropsy are said to have had often very lively and healthy children. Ascites should be treated by homoeopathic physicians with medicines alone if possible, since tapping, either in the earlier or in the later months of pregnancy, is very apt to be folloAved by the expulsion of the fcetus. The severity of' the dropsy itself, and the consequent danger of its interfering with gestation, may be measured by the earlier or later period in which it makes its appearance. When the effusion is evident in the first half of the pregnancy, if its increase cannot be arrested or the disease removed by the use of the appro- priate remedies, it may even be necessary to resort to paracentesis. The causes of ascites, and in fact of all forms of dropsical dis- order, except perhaps the most trifling, Avhich may be considered to result from pressure and general AA^eakness, must be found in the constitutional dyscrasise that haAre already been referred to in con- nection with disorders of the blood and its excretions. The mor- bidly serous condition of the blood forms but a single link in the chain that terminates in cellular infiltration and dropsical effusion. Still farther back Ave may trace the fault of nutrition, by which the blood is impoverished, rendered watery and the receptacle of urajmic poisons. It is important to be familiar with these pathological changes so far as they can be detected, and some of their objective manifestations may afford valuable aid in selecting the appropriate remedy. Espe- cially, if not only, is this true where the pathogenesis of the remedy has furnished us with similar pathological symptoms. But that physician will be most successful in his prescriptions who carefully avoids encumbering his mind with theoretical generalizations, most patiently studies his Materia Medica, and never allows himself to rest satisfied till he has found the remedy which constitutes the most com- plete simile to the mental, moral, sensational and physical symptoms of the case. For the remedies which may be indicated in the various forms of dropsical affections liable to appear in pregnancy, consult those de- tailed in the article on Dropsy of the Uterus. Dropsy of the Amnion and Hydrorrhcea are treated of under the bead of Disorders of the Uterus and its Appendages. 346 disorders incidental to pregnancy. haemorrhoids, or plles. Hemorrhoids may make their appearance in the earlier or in the later months of pregnancy. In the first instance they may result in part from pressure exerted directly upon the internal iliacs by the expanding uterus before it has emerged from the pelvis. In the latter case the gravid uterus exerts pressure upon the common iliacs. Still this affection of the hsemorrhoidal veins is by no means entirely caused by such mechanical pressure, otherwise it would be much more com- mon than it iioav is, if not indeed universal. In women predisposed to constipation, or in whom some dyscrasia develops itself in such obstruction of the boAvels, haemorrhoids are an almost necessary consequence of this condition in pregnancy; and the inactive habits that aggravate the constipation at the same time augment the hsemorrhoidal enlargements. But whether due to the inactive state of the circulation, which is a necessary attendant of in- active habits, to mechanical pressure, to constipation, to dyscrasia, or, as is generally the case in greater or less degree, to all these influences combined, the piles constitute a very painful condition in pregnancy. They may be blind, that is, never bleed, and inAvard, never protrud- ing, and still occasion much suffering. They may protrude with each evacuation, sometimes become strangulated and difficult of re- placement, and by their exhausting haemorrhages may greatly weaken the strength. The constipation greatly aggravates the hsemorrhoidal condition, and at the same time the pain accompanying an evacuation is so great that the woman dreads going to stool, and hence by delay- ing causes increased atony of the boAvels and aggravates the constipa- tion. This circumstance should be borne in mind by the practitioner, and should lead him to urge upon his patient the necessity of not neglecting the alvine evacuations, and at the same time lead him to suggest a suitable diet, such as would have a tendency to produce rather a relaxed condition of the bowels. Most of these cases are en- tirely amenable to treatment, and even the worst may be so modified that the suffering may be almost entirely removed. Under allopathic treatment the constipation is attacked by purga- tives, which are incapable of removing either the cause or the conse- quences ; Avhile the indicated homoeopathic remedy exerts a beneficial influence equally upon the obstruction of the bowels and upon the en- largement of the hsemorrhoidal veins. The following medicines should be studied, and that one selected which best corresponds to all the con- ditions and symptoms of the patient, Avho should carefully abstain from coffee, wines and liquors, and from food too much concentrated, and •- HEMORRHOIDS, OR PILES. 347 take as much daily exercise as her circumstances and situation will allow with comfort to herself. The medicines mentioned under Con- stipation may likeAvise be consulted Avith advantage. Aconite. Shooting and constant pressure at the anus, pain in the back and sacrum as if bruised, feeling of fullness of the abdomen, colicky pains, great uneasiness; the piles occasion great annoyance. ^Isculus hipp. Sensation in the loAver portion of the back, across the sacro-iliac symphyses, as of great Aveakness; she "gives out" there Avhen walking. Bleeding piles, or purple-colored piles which do not bleed; constipation, great pressure in the rectum. Aloes. The varices protrude and resemble clusters of grapes, fre- quently feel hot and sore. When urinating, sensation as though something had passed or Avould pass from the bowels. Feelino- of heaviness or weight Avithin the pelvis. Large masses of mucus are sometimes discharged per anum. Alumina. Evacuations look like laurel-berries, and are passed with much difficulty and with cutting pains. Occasional discharge of blood from the rectum, followed by sore pains. The urine cannot sometimes be passed except when straining at stool. Ammon. carb. The varices protrude during stool, and even between the e\'acuations, and feel raAv as if excoriated. Burning and itching in the anus. Discharge of blood during and after stool. Ammon. mur. Continual sore smarting in the haemorrhoids. Sore pustules on the verge of the anus. Pain in the perineum, especially when Avalking. Particularly useful if hsemorrhoids occur after the suppression of a leucorrhoeal discharge. Antimonium C. Diarrhoea and constipation alternate, the evacuations while diarrhoea exists consisting of a Avatery fluid with hard lumps. General gastric disturbance Avith the hsemorrhoids. Excretion of large quantities of mucus, Avith burning, tingling and itching so great that she can scarcely keep still. Apis. Constipation. Scanty urine. Much stinging pain in the anus and rectum ; the stinging is followed by severe burning sen- sation. Arsenicum. Burning, like fire, and shooting pains in the varices; heat, agitation, and sometimes a feeling of great Aveakness and rest- lessness. Fissures in the anus, which burn and render urination diffi- cult, Pain or a painful stiffness in the back, making stooping diffi- cult. Belladonna. Bleeding piles, accompanied Avith a sensation as if the 348 DISORDERS INCIDENTAL TO PREGNANCY. back Avere breaking or Avould break. The varices sometimes become strangulated from spasmodic constriction of the sphincter ani, at Avhich time they are excessively sore and sensitive. Dysuria and congestion of blood in the head are frequent accompaniments of the hsemorrhoidal condition AAdien this remedy is indicated. Calcarea c. The piles often bleed profusely, to the extent of blanch- ing the patient. The pain occasioned by the piles is aggravated by walking. Very great pain in the anus after stool. Sleeplessness in the early part of the night. Acrid and offensive sweat from the feet, Avhich makes them raw and sore. Feet are cold, as if from damp stockings. When not pregnant the patient menstruates too frequently and too profusely. She is very sensitive to cold air. Capsicum. Burning and smarting in the varices, as though pepper Avere sprinkled on them. Bleeding piles, the Aoav of blood causing a burning pain in the anus. Carbo veg. The hsemorrhoidal tumors are large and blue, with shoot- ing pains in the loins, stiffness in the back, burning and rheumatic pains in the limbs. Burning feces. Frequent congestion to the head; epistaxis; flatulence. There may also be much burning mucus from the rectum. Discharge of an acrid, offensive humor from the anus, particularly at night. Much itching about the anus and perineum. Cascarilla. The bowels are evacuated with difficulty, and the feces are covered with much mucus, or the feces are mixed with quantities of mucus. Frequent and profuse bleeding from the anus during or after stool. Causticum. Large and painful hsemorrhoids, which burn Avhen touched and seem to hinder the passage of the feces; the suffering is much increased by walking. Sometimes in connection with the hsemorrhoids we find a large and painful ulcer near the anus, con- stantly discharging blood and pus. Chamomilla. In painful, bleeding, burning hsemorrhoids; but the mental symptoms will particularly indicate this remedy. She is rest- less, can hardly control herself; gives short answers; she can hardly endure her slight sufferings. Irritable and spiteful. China. Hsemorrhoids, with burning, itching, tingling or creeping, extending into the urethra. They sometimes bleed profusely. The patient is very sensitive and debilitated, and the piles and her general symptoms are worse every other day. Collinsonia. A jagging sensation is felt in the lower part of the rectum and anus, as though sticks or gravel had lodged there. The symptoms get worse in the evening, and continue so till late at night. HEMORRHOIDS, OR PILES. 349 Blind or bleeding piles. Constipation or diarrhoea. Weight or pres- sure in the rectum, with intense irritation or itching there. Colocynth. Pricking at the anus, Avith constant discharge of mucus. Darting in the rectum, alternating Avith stitches through the bladder. Blood flows continuously from the hsemorrhoids for a long time. Emission of large quantities of flatus per anum. Persons Avho are subject to violent attacks of cramp colic. Graphites. Easy prolapse of the rectum, as though the parts had lost their tonicity; it becomes prolapsed without even a desire for stool. SAvelling of the anus. The varices feel very sore after an evacuation. Painful burning fissures betAveen the varices. The patient menstru- ates scantily, and has itching blotches on the face and other parts of the body. Hamamelis. The varices bleed very profusely, with sensation of soreness, Aveight and burning in the rectum. The varices protrude, and the anus feels sore as if raw. The stools are covered with mucus; the back feels as if it would break; restlessness at night; dryness of the mouth. Ignatia. When the piles are attended with pains shooting deep into the rectum, seemingly up into the abdomen. Itching and tingling in the anus, and prolapsus recti during an evacuation. Sensation of excoriation and contraction in the rectum. The pain in the anus and rectum continues for hours after an evacuation. Kali carb. Stitching and cutting pain in the varices, which become greatly swollen and enlarged. The feces are large and hard, and the stools are followed by bleeding from the varices. Lachesis. The anus feels as if it Avere entirely closed by the varices, and as if nothing could pass; the bowels are very costive, apparently on this account. (Hsemorrhoids, which make their appearance at the climacteric, when the menstrual flow becomes scanty.) Lycopodium. Much rumbling in the abdomen; red sand or red sediment in the urine; itching eruption around the anus; great tendency to excoriations, which bleed easily. The varices protrude, and are particularly painful when sitting. Cutting in the rectum and bladder. Tearing in the rectum, so sharp that it arrests the breathing. Mercurius sol. Piles which bleed during stool and Avhile urinating. The bloody stool causes an acrid, painful sensation in the anus. Prolapsus of the rectum, the fallen gut having a dark and bloody appearance. Inflammation and suppuration of the hemorrhoidal tumors. 350 DISORDERS INCIDENTAL TO PREGNANCY. Muriatic acid. Exceeding tenderness of the parts; she cannot bear the least touch upon them, not even of the sheet. The piles bleed profusely; there is much itching of the parts, which is not relieved by scratching. Great debility. Prolapse of the rectum when uri- nating. Involuntary discharge of a small' quantity of feces while urinating, which seems unavoidable. Natrum mur. A moisture constantly oozes from the varices, which are very painful, stinging, smarting and throbbing. Herpetic erup- tions about the anus, with itching and burning. Stitches in the rectum from beloAV upward occasionally during the day. Hard, difficult and painful stool followed by a liquid stool, the pain lasting a long while afterward. Nitric acid. Old hsemorrhoidal tumors, secreting much slime and bleeding profusely at every fecal evacuation. Smarting in the rec- tum a long time after a stool; also sharp cutting pains Avhich last a long time. Nux vom. This remedy should be thought of for all persons of sedentary habits, and for those who use spirituous liquors or coffee in excess. It is especially indicated when there are shooting and shocks in the loins; contused pains which hinder from rising up; consti- pation, with frequent and ineffectual effort to evacuate, and sensation as if the anus were closed or contracted; no appetite; sleepless in the latter part of the night; headache; loss of energy. Sensation in the rectum after an evacuation, as though something remained which should be passed; or a frequent or even continual inclination to stool, Avith a sensation as though the rectum contained a small quantity of feces which must be passed, although nothing passes. Petroleum. Hsemorrhoids, Avith itching about the anus, which compels her to rub and scratch till the part becomes raw and sore. A moisture constantly oozes from the vulva, with violent itching. Phosphorus. The hsemorrhoids are accompanied with a sensation of weakness or sinking in the abdomen; they protrude very easily, coming down even during the emission of flatus. Relaxation of the sphincter ani; constant discharge of mucus from the varices. Podophyllum. Piles, with prolapsus ani; prolapsus uteri; consti- pation or morning diarrhoea; too frequent but natural passages. Pain in the lumbar and sacral regions, worse during a stool and still Avorse afterward. Constipation with headache. She is subject to " bilious attacks." Pulsatilla. Discharge of blood and mucus during stool; pallid coun- tenance and disposition to faint; dysuria; tearful disposition, mild and HEMORRHOIDS OR PILES. 351 gentle; bad taste in the mouth in the morning. She cannot bear to be in a close or warm room; generally feels worse in the evening, and is better from going into the fresh open air. Feels worse after partak- ing of rich or greasy food. Absence of thirst. Rhus tox. Protrusion of blind hsemorrhoids after every stool, Avhich feel sore. Drawing in the back from above downward, which sensa- tion seems to be due to the piles, and with a feeling as though every- thing would come through the rectum. Constant restlessness and fidgetiness. Sabina. The piles discharge bright red blood, and cause pain in the back from the sacrum to the pubes. Biting, sore pain in the varices, especially during the morning stool. Sepia. The patient is subject to a painful sensation of emptiness in the epigastric region; has delicate and sensitive skin. Protrusion of the varices and of the rectum, attended Avith difficult micturition. Heat, burning and SAvelling of the anus when the piles do not pro- trude, and defecation is then excessively painful, the stool being rather small, narrowed down by the diminished calibre of the anus. Sometimes the fecal mass is triangular in form and very painful. Constant oozing of moisture from the anus. Stitches and jerkings from the anus upward into the rectum and abdomen. The symptoms are usually aggravated by partaking of milk. Silicia. If the varices protrude ever so little they are apt to become strangulated and painful, and are returned with much difficulty. Difficult stool, the fecal mass receding into the rectum several times when on the point of being discharged. The hsemorrhoidal tumors inflame and suppurate easily. Sulphur. Much itching and soreness of the anus on account of the varices, Avhich bleed during stool. Prolapse of the rectum during a hard stool. The indications for this remedy are to be found rather in general characteristics than in local symptoms. Heat on the top of the head, general flushes of heat, weak, fainting feeling; very hungry and faint about eleven o'clock A. M.; awakens frequently at night, and feels very weak and faint in the morning; very cold feet, sometimes burning in the soles of the feet at night in bed. Inclina- tion to stoop forward when walking, or even when sitting. Desire to sleep late in the morning. Despondency and sluggishness of the mind; she finds it difficult to do anything. Thuja occ. The hsemorrhoidal tumors are excessively sensitive to even the slightest touch. Fig-warts around the anus or elsewhere are an accompaniment. 352 DISORDERS INCIDENTAL TO PREGNANCY. Varicose Veins. Varicose veins often appear during the latter months of utero-ges- tation, and are commonly supposed to be caused by the pressure of the gravid uterus upon the iliac vessels and inferior cava. But this local pressure can be but a single one of the exciting causes, since varices are seen in some who are not pregnant, and they do not make their appearance in the larger proportion of those who are. If the pressure Avere the main cause, all or nearly all pregnant women should have more or less of this varicose condition before they are confined, which is far from being the case. The constitutional condition of the system in general, and perhaps of the organs of venous circulation in particular, which gives rise to varices under the influence of exciting causes, is no doubt similar to that which produces hsemorrhoids. In each affection, constipation seems to exert no small provoking influence, although it may be that the same deep-seated disorder of the constitution may at the same time cause the varicose and the constipated condition. The varicose and the hsemorrhoidal enlargements are alike liable to rupture and to occasion serious hsemorrhage. And both these disorders are equally amenable to homoeopathic medication. The appropriate remedies, taken in season, will entirely cure the varicose condition, or, if re- sorted to only after the enlargement has already become very exten- sive in the latter months of utero-gestation, will at least prevent its further increase. And as on the one hand homoeopathic treatment perseA^eringly employed will entirely remove the constitutional pre- disposition to varix, so, on the other hand, the highest allopathic authority states that " this condition of the veins gradually increases in amount and severity with every succeeding gestation." * The various and severe pains, and all the attendant symptoms and conditions of varices below the knee, in the thighs, in the labia, vagina, and even in the os uteri itself, the appearance of the enlarged veins themselves, their color, inflammation or rupture, and the concomitant and constitutional symptoms and seasons and occasions of aggrava- tion, will enable the attentive physician to prescribe in such cases, with the certainty of greatly ameliorating the general health, and so of improving the prospect in parturition, as well as of removing the varicose diathesis itself. The vascular nature of much of the substance of the external geni- tals predisposes them to varices. They may occur in the veins of the vulva or in those of the vagina. * Churchill, Diseases of Women, chap. vi. varicose veins. 353 These enlargements of the veins are scarcely less common during pregnancy than are hsemorrhoids, but, except they appear in the vulva or vagina, are usually less painful. They should be treated upon general homoeopathic principles, all the attendant and constitutional symptoms being taken into account in prescribing. The following medicines are more particularly useful, and the indications given for their use under the head of Hsemorrhoids or Piles, together with those of the other medicines there given, may be consulted with advantage: Apis mel. Burning and stinging pains in the varicosed veins, either with or without constipation. Arnica. The varices are very sore, with a bruised feeling. Espe- cially useful for varicose veins of the vulva or vagina. Arsenicum. If they burn like fire. Carbo veg. Painful discharge or complete suppression of urine at- tends the varicosed condition of the vagina. The varices have a blue appearance. Causticum. If they become much more painful when the patient is walking. Ferrum met. In weakly persons, with fiery-red face. Fduoric acid. In obstinate cases and in those of long standing, espe- cially in women who have borne many children. Graphites. The varicosities itch very much, and have little pimples on the surface of the integument over them. Itching blotches on various parts of the body. Hamamelis. The varicose veins are hard, knotty, swollen and painful. Lycopodium. Varicose veins of the lower limbs, extending nearly to the feet; they seem very large, and hard under pressure of the finger. Red sandy sediment in the urine. Borborygmus and constipation. Nux vom. In women who habitually use wine and rich and highly- seasoned food, who keep late hours and suffer from habitual consti- pation. Pulsatilla. Especially suited to women of mild disposition, Avho are easily moved to tears. The pain from the varicosed veins and the general symptoms are aggravated toward evening. The varices pre- sent a blue appearance. Sulphur. This remedy will often be found useful when indicated by its well-marked and well-known characteristics. It will be especially useful to women who suffer from hsemorrhoids as well as varicose veins of the extremities or vulva. 23 354 disorders incidental to pregnancy. Zinc. Varicose veins which give rise to fidgetiness of the feet and limbs. External treatment for this affection, such as bandaging, is of far less value than internal medication. In extreme cases, however, Avhere there appears to be danger of rupture of the vessels, a roller or a laced stocking may be applied to support the veins until the remedies have time to act. In such cases, also, placing the limbs Avhen they are the seat of the affection upon a stool or chair relieves the over-distended vessels from the downward pressure of gravity. Perfect rest and quiet are indispensable in the treatment of these worst forms of varicose veins. CHAPTER XVII. DISORDERS INCIDENTAL TO PREGNANCY—CONTINUED. Affections of the Uterus and its Appendages. THE morbid affections to which the uterus is liable in the pregnant state may be arranged in three classes : I. those which are prin- cipally sensational, such as cramps, pains and excessive sensibility; II. displacements; III. abnormal secretions, such as leucorrhcea, dropsy of the amnion and hydrorrhcea. I. Pains ; Cramps ; Sensibility of the Uterus.—The uterus in pregnancy, even if it does not experience an enlargement of its nerves corresponding to that of the arteries and veins, still partakes in a remarkable manner of the increased sensibility of the nervous system in general. Hence all influences, from within or from Avithout, are very acutely felt—many of them very painfully—which in the unimpregnated condition would scarcely be noticed. In addition to this excessive sensibility, there are actual uterine pains, seated appar- ently in the walls of the uterus, which are doubtless the result of the contraction of the uterine muscles. These may appear at any time after the first three months of utero-gestation; they may return at intervals in paroxysms, and increase in severity as the pregnancy advances. These pains may even become so severe as to resemble uterine cramps. The excessive sensitiveness of the uterus renders the ordinary motions of the fcetus very painful to the mother, Avhile at the / AFFECTIONS OF THE UTERUS AND ITS APPENDAGES. 355 same time the morbid irritability of the mother's state in general ren- ders the movements of the fcetus much more active and violent. All these morbid conditions may be greatly ameliorated by the exhibition of appropriate homoeopathic remedies, thus rendering the patient more comfortable, and at the same time removing influences which mio-ht otherwise terminate in abortion. II. Displacements of the Uterus.—Conception may occur in women Avho are subject to prolapsus uteri in cases where the Avomb is temporarily replaced, or the already gravid uterus may become subject to either of the different forms of displacement under the influence of accidental causes connected with its OAvn weight or Avith the disproportionate size of the pelvis. In the former case the pro- lapsus, while it affords no bar to conception, greatly endangers the safety of the fcetus until after it is established above the superior strait. In the latter case the already gravid uterus may be projected so far over the pubes as to constitute anteversion, or turned back in such a manner as to undergo retroversion by its fundus being lodged beneath the promontory of the sacrum. Prolapsus uteri in pregnancy, as in the unimpregnated condition, may come on gradually or suddenly; it may also be a partial descent or a complete procidentia. This is especially apt to be the case when the pelvis is Unusually large. In all cases of prolapsus uteri in preg- nancy, whether the result of a previous habit or of more recent influences, it is simply necessary for the patient to remain quiet and take the remedy indicated, according to the conditions and symptoms of her case. The appropriate remedy, together with the increasing size of the ovum, Avill in a short time remove the prolapsus and render its return impossible. Anteversion chiefly occurs in the more advanced stages of pregnancy when the uterus has become very heavy, although some few instances are recorded in which this accident happened in the second and third months of pregnancy. In the slighter forms of this displacement the term obliquity is more applicable, Avhile in complete anteversion the fundus uteri may even be engaged below the symphysis pubis. Perfect quiet, a recumbent position, and the judicious exhibition of the remedy indicated by the symptoms of each case, will almost always suffice to effect a complete cure. In cases where the fundus is actually engaged beneath the symphysis, manual assistance will be needed in order to secure reposition, the patient lying on her back. Retroversion, in the pregnant as in the unimpregnated condition of the uterus, forms a very serious complication, whether it occur 356 DISORDERS INCIDENTAL TO PREGNANCY. suddenly or sloAvly. In many cases the symptoms will scarcely lead us to suspect the presence of this form of displacement until the fundus is actually engaged beneath the promontory of the sacrum. In this condition the use of the uterine elevator, described in another chapter, may be found necessary. Retroversion is most apt to occur in the third and fourth months, but it may occur in the fifth, or even as late as the seventh month, of gestation. It may take place very sloAvly, so as to become complete by the third month of pregnancy, aided very much by the gravity of the ovum when once it has be- come deflected from its proper position. This first beginning of the mischief may result from a too great and too long-continued distension of the urinary bladder. The complete or partial retention of the urine forms one of the most characteristic indications of the retroversion itself. In order to facilitate the restoration of the retroverted uterus it may be necessary to place the patient prone upon her face; thus, as soon as the fundus uteri is disengaged from beneath the promontory of the sacrum, its OAvn gravity will enable it to resume its proper place in the pelvis. It Avill be necessary to distinguish this form of displacement from extra-uterine pregnancy, since very disastrous con- sequences must otherAvise speedily result. And this will be best accomplished by a careful study of the conditions and symptoms of the case, and of the causes which have apparently produced the mis- chief, in addition to the most careful exploration per vaginam, and, if necessary, per anum. Retention of urine in the bladder, from want of opportunity to discharge it, as sometimes in traveling, violent strain- ing to lift a heavy Aveight, a fall backAvard, bloAvs or other accidental pressure upon the navel, may occasion the retroversion. A previous retroversion is no doubt the most frequent cause of the retroversion of the uterus in pregnancy. In such cases the trouble is at first entirely unsuspected, as in the first weeks of gestation the increased size of the uterus scarcely occasions any more inconvenience than before conception. But after a while the cervix uteri begins to press upon the bladder and hinder its evacuation. Then the sudden and severe symptoms, Avhich are really the consequences of the gradual enlargement of a previously retroverted uterus, are supposed to result from a sudden displacement. Careful attention to the calls of nature, as well in respect to the boAvels as to the bladder, Avill be important, in order to obviate any disposition to this displacement, particularly in persons Avho have suffered from it in former pregnancies. And where retroversion has either suddenly set in, as in consequence of AFFECTIONS OF THE UTERUS AND ITS APPENDAGES. 357 an accident, or gradually developed from partial displacement of this kind existing previously to conception, it may be necessary to evacuate the bladder and rectum before any progress can be made in restoration. Then, after the womb has been replaced, perfect rest in a recumbent posture, for a longer or shorter time, according to circumstances, will greatly aid the proper remedy to effect a complete cure. The various pessaries proposed and used in such cases we consider entirely unne- cessary, and in many cases positively injurious. With the aid of the appropriate remedies, and of such favorable circumstances and hygienic conditions as are indispensable under any plan of treatment, Nature may be enabled to hold the uterus up; which she can never learn to do as long as it is propped up and the muscular structures are thereby weakened. The medicines appropriate for these various forms of uterine dis- placements existing during pregnancy, as well as explicit directions for their treatment, will be found elsewhere, in the chapter on Dis- placements of the Uterus. III. Abnormal Secretions.—Leucorrhoea may exist during preg- nancy, especially in persons constitutionally predisposed to this affec- tion. The discharge is usually of a mild character, thick and white in its appearance, and sometimes profuse in quantity. The increased activity of the circulation of the uterus and its appendages, incident to pregnancy, extends to the muciparous glands of the vagina and cervix uteri, and an excess of the secretion which closes the cervix may occasion a constant discharge. In connection Avith the discharge may occur irritation, itching, heat and burning in the vulva and parts adjacent. Where the leucorrhoea is very profuse, symptoms of debility may follow. The treatment required for all these cases will be found under appropriate headings in another part of this work. Hydrorrhea is the name given to such discharges of water from the womb as occur in the course of gestation without rupture of the mem- branes. It is probable that this accumulation of fluid—false waters —takes place between the inner surface of the uterus and the mem- branes, the latter being stripped off as the fluid accumulates and forms tor itself a pouch. This pouch gradually increases in size in the direction of the os, and Avhen that outlet is reached the flow of false waters takes place. This phenomena may deceive the accoucheur, and [cad him to believe that the membranes are ruptured and that labor is about to set in, Avhereas careful examination will discover the mem- branes intact, and there may be no signs of labor present. 358 DISORDERS INCIDENTAL TO PREGNANCY. Iii the later months of pregnancy this affection is not uncommon, the uterus from time to time relieving itself of the undue accumula- tion Avithout special muscular effort, very much as the urinary blad- der does. An examination of the os uteri in such cases will satisfy the practitioner that the discharge does not come from within the true Avater-sac, and that therefore there is no cause for alarm as from a threatened miscarriage. The Aoav appears at irregular intervals, and without any especial provoking cause; neither does it occasion any re- markable symptoms. The concurrence of other dropsical conditions, such as oedema of the limbs, the fact that the discharge arises spontaneously, and the almost entire absence of pains or uterine contractions, will enable the physician to diagnose the hydrorrhcea with sufficient certainty. The false waters may make their exit without any noticeable provoking cause, and Avithout any more than the very slightest constitutional dis- turbance ; Avhile the membranes which enclose the true amniotic waters can only be broken by some great bodily exertion, some special acci- dent or posith^e effort, and their discharge of these Avaters cannot but be followed by strongly marked symptoms indicating the approach or actual existence of labor. Perfect quiet, freedom from excitement or anxiety, and the exhibition of the remedies indicated by all the at- tendant symptoms and conditions, will be all that is requisite to pre- vent serious mischief from this condition, and to remove as fur as possible its constitutional causes. Dropsy of the Amnion.—The determination of the existence of this disorder of pregnancy is not so easy as that of hydrorrhcea, since there may be an excessive amount of amniotic liquid without any very re- markable distension of the abdominal parietes, and since also the normal amount of the liquid itself is capable of very considerable variation. But generally speaking, dropsy of the amnion is an acute disease, and the rapidity of its development, together Avith the dis- tressing constitutional symptoms, affords our best means of diagnosis. This is the more especially the case since also ascites almost always complicates this affection. There does not seem to be any change in the specific gravity or con- stitution of the liquor amnii, only an excess of production. The nor- mal quantity may be estimated at three or four pounds, according to the state of pregnancy, but from forty to fifty pints haA^e been found present in dropsy of the amnion. Thus at the fifth or sixth month the uterus may be more distended than usually at full term. The uterus is rounded; fluctuation is more obscure; there is not much DROPSY OF THE AMNION. 359 thirst; the urine is natural except in cases complicated Avith general dropsy, and there is sometimes little or no cedematous enlargement of the inferior extremities. Among the most important diagnostic signs are to be found, therefore, the disproportionate size of the tumor to the period of pregnancy, the feebleness of the movements of the child, and the great size of the abdomen, evidently dropsical, which is less apt to be accompanied by oedema of the thighs and legs than in ascites. Dropsy of the amnion may occasion severe suffering to the mother, sensations of suffocation and hindrance of the circulation: these are probably due in part to the rapidity of the enlargement itself, and in part to the general constitution of the patient. But this difficulty very rarely becomes dangerous, since its very excess tends to self- relief by producing abortion. The most important results of this dropsical affection are found in the injury to the foetus, whose nutrition is enfeebled by such excessive secretion; in the total destruction of the fcetus, which is sometimes almost entirely dissolved in the amniotic fluid; and in the premature expulsion of the fcetus at a period when its insufficient age, its enfee- bled condition, or both together, render it incapable of viability. As has been already remarked, ascites usually accompanies and complicates dropsy of the amnion. But ascites may exist during pregnancy Avithout amniotic dropsy, and the reverse may likewise occur. It is therefore a matter of importance to be able to make a correct diagnosis. Cazeaux gives the following points for their differ- ential diagnosis: " In ascites complicating pregnancy the urine is small in quantity, whitish and turbid, the thirst great and constant, and the lower extremities and genital parts mostly much infiltrated. It is difficult, and sometimes even impossible, to distinguish the shape and fundus of the uterus, on account of the irregular form of the belly and the enormous distension of the hypochondriac regions. Percus- sion produces an undulation or sort of fluctuation, Avhich is much more perceptible at the upper than at the lower part of the abdomen. " In dropsy of the amnion the size of the belly approaches much more nearly that of a uterus at term, although the pregnancy may not have existed more than five or six months. The uterus is so rounded as to be almost spherical. Fluctuation is more obscure, thirst slight or absent, urine natural, and in some cases little or no infiltration of the loAver extremities. The umbilical tumor is rarely present, and when it exists has not the transparency observed in ascites." The treatment of dropsy of the amnion must be principally pro- phylactic, and based upon attendant symptoms and such constitu- 360 DISORDERS INCIDENTAL TO PREGNANCY. tional indications of predisposition to general or particular forms of dropsy as may be discovered, aided and confirmed by the sensational symptoms which may especially characterize the individual case. For Avhen dropsy of the amniotic cavity has become so extensively developed as to be clearly diagnosed, there will be small hope of eventually saving the product of conception. But even if perfect success may not be thus obtained in the first instance, there will still be reason to hope that in a subsequent pregnancy a constitutional treatment begun at an earlier period, and more intelligently directed by ampler knowledge of the case, its tendencies and its dangers, may enable the practitioner to obtain a decided improvement in the health of the mother, and at the same time secure the safety and the health- fulness of her child. Dropsy of the amnion is always the result of some constitutional dyscrasia, Avhich, under the stimulus of preg- nancy, develops itself usually in other directions and in other forms also. For the remedies for this affection consult therefore those men- tioned under other varieties of dropsy, and such as may be par- ticularly indicated by the sensational symptoms, such, for example, as the sense of suffocation. With regard to the propriety of inducing premature delivery in extreme cases of this kind, see the subsequent chapter on Abortion. Affections of the Appendages of the Uterus. Pruritus of the vulva forms one of the most distressing disorders to Avhich women are liable in pregnancy. This affection consists in an incessant and intolerable itching of the external genitals. The immediate cause may be found sometimes in an irritated, inflamed condition of the parts involved, or, as described by another, "it com- monly depends on follicular irritation of the vulva, Avhich, if un- checked, passes to aphthous ulceration." Sometimes there may be found no abnormal appearance of the vulva, except such as must arise from the violent rubbing and scratching to Avhich they have been sub- jected ; but on examination, congestion and even superficial granular ulceration of the cervix uteri may be detected. This affection is most apt to occur in young Avomen. Churchill relates a case the symptoms of Avhich are very strongly marked: Avhen about four months pregnant she Avas attacked by the most intense and incessant itching of the vulva; she had no rest, day or night; could scarcely ever sleep, but was obliged to walk up and down all night; she was kept in such an irritated condition by thin distress and loss of sleep that she became \rery cross and irritable. PAINS. 361 In this case no relief Avas obtained until after delivery, Avhen the pruritus disappeared of itself. In her next pregnancy this woman suffered in a similar manner, the pruritus returning at about the same period of gestation; but it Avas removed by local applications directed to the cervix, Avhich was found greatly congested, with superficial granulations around the edge of the os uteri. This affection is sometimes accompanied by sexual excitement, or it may have a periodic character, coming on or being aggravated at certain times of the day. The homoeopathic treatment of this disorder should always be constitutional rather than local; for, Avhether the pathological seat of irritation be found in the parts immediately affected or in the cervix uteri, the true cause of it must consist in the disturbance of the system Avhich is occasioned by pregnancy. For the remedies consult those mentioned in a future chapter under Pruritus. Pains. Pains, fixed or Avandering, irregular or constant, are often experi- enced by women during pregnancy, and are frequently so severely felt as to cause them to become the subject of complaint to their physicians. These pains are principally felt in the abdominal, lumbar and inguinal regions; they may be considered as myalgic, Avhether characterized by cramps or not, when they result from fatigue of the muscles; and they may be deemed purely neuralgic when they are caused by (reflex) irritation of the nervous centres. The pains which are experienced in the lumbar and inguinal re- gions, especially in the early stages of pregnancy, when they cannot be attributed to the size or weight of the gravid uterus, are usually the manifestations of some disordered condition of the uterus itself Pains felt in the loins in the advanced stages of gestation may be purely myalgic, or the result of strain of the muscles so constantly exerted to maintain the equilibrium by bearing the body backward. Pains felt in the breasts, and the excessive tenderness and sensibility of these organs, are due to sympathetic nervous irritation, and are therefore properly called neuralgic. Those Avhich are felt in the abdominal parietes usually appear in the more advanced stage of pregnancy, and may be attributed to over-distension of the muscles and tension upon the nerves. Certain pains in the interior of the thighs, numbness and cramps of one or both legs, have been supposed to result from pressure upon the sacral nerves. But even these may be caused by the severe dragging upon the various ligaments, and 362 disorders incidental to pregnancy. consequent irritation of the nervous centres in different parts of the abdomen and back. Where these pains are aggravated by exercise or movement, perfect quiet should be enjoined. But it is believed that with the help of the appropriate homoeopathic remedies these pains can be so far re- lieved as to admit of as much exercise as may be necessary for the general health of the mother, and consequently for the greater vigor of the child. There is no doubt that the greater susceptibility to these various pains witnessed in some individuals, like the predisposition to many other morbid affections in pregnancy, is in a great measure due to constitutional peculiarity, just as we see in certain constitutions a remarkable facility of straining and laming the muscles and tendons and of suffering dislocation of the joints from comparatively slight causes. At any rate, the following remedies, or others that may be especially indicated, are capable of affording very marked relief in these cases, whether the symptoms appear in the earlier part of gestation, and so threaten to result in abortion, or whether they occur principally in the latter part of pregnancy, and tend to increase the immovability and helplessness of the patient. The same may be said of those pains regarded as the results of a certain constitutional Aveak- ness of the muscular organs or of a corresponding irritability of the nervous system. Aconite. If the sufferings seem to be developed immediately after an exposure to cold air or to a draught. Sensation of soreness, with restlessness and uneasiness, although each movement causes pain. Fear of approaching evil. Distressed and unhappy. Thirst, with more or less feverishness. Argentum nit. Almost constant belching of wind after eating, which continues until the time for the next meal has nearly arrived. Pains in the back and lower extremities. Time seems to pass very slowly. Arnica. Very great soreness, as if from a bruise. The motions of the foetus cause a bruised and sore feeling in the abdomen, and the woman feels as if her child were lying crosswise, Avhich position hurts her constantly. Belladonna. If the pains appear suddenly, and after a time as sud- denly cease. The bed feels very hard to her. She cannot bear the slightest jar of bed or chair. The back feels as if it Avould break. Bryonia. The sufferings are rendered more severe by motion; even the slightest motion aggravates, taking a full inspiration, for instance; she desires therefore to keep quiet and to rest in a recumbent position. Stitching pains. PAINS. 363 Calcarea C. Cramps in the toes or soles of the feet. The feet feel cold and damp. Feels badly on ascending an eminence or going up stairs. Sensation of crackling or crepitation in the joints, as though they were dry. She is a long time in getting to sleep at night. Camphor. Cramps, Avith inability to remain covered. The surface becomes cold at night—as cold as marble—and yet covering is in- tolerable. Chamomilla. Abdominal pains, with frequent emission of pale, color- less urine in large quantities. Feels disagreeable and unhappy. Spite- ful irritability. Whatever pains she may have she feels very keenly, and regards them as unbearable. Sleeplessness. Chelidonium. A great deal of pain under the inner inferior angle of the right scapula, sometimes extending into the chest; this pain is frequently accompanied Avith gastric or hepatic disturbances. Cimicifuga. Cramps in the extremities, and even intermitting spasms. Especially suitable for Avomen who have a tendency to hysterical attacks. Cocculus. A paralyzed feeling in the limbs, which are very Aveak. Nausea, Avith vertigo and tendency to faint. Spasms, which occur frequently at midnight. Coffea. Often indicated when there is much excitement and sleep- lessness. The pains she experiences are continuous and very distress- ing, so that she feels as if she would " go distracted." Colocynth. Frequent attacks of colic, which draw the patient nearly double. The pains she has cause great restlessness, so that she Avrithes and twists herself in every direction, yet without obtaining relief. Cuprum. When there are cramps in the fingers and toes or in the pit of the stomach; violent cramps. Coppery taste. Restlessness. Gelseminum. Pains in the abdomen, which run directly upward or backAvard and upAvard, which are very severe and resemble the pains of commencing labor. Feeling as if the muscular power was weakened, which arises from a weakness of the will-poAver, which is unable to command muscular movements as in health. Ipecacuanha. Sharp, colicky, coiling pains around the umbilicus, with nausea; clutching and squeezing in the abdomen. Lycopodium. Cutting pains running from right to left across the abdomen. A great deal of commotion and borborygmus in the ab- domen. The foetus is unusually active. Red sand in the urine. Nux v. Sufferings from high living or from a sedentary life; con- stipation of large, difficult stools as an accompaniment. Aggravation in the morning at four o'clock; she is obliged to get out of bed at 364 DISORDERS INCIDENTAL TO PREGNANCY. that time, on account of a pain in the back, and she finds relief from rising and walking about. She cannot turn over in bed on account of the pain in the back. Plumbum. A sensation in the abdomen at night in bed, which causes the patient to stretch violently for hours together; sometimes she must stretch in every possible direction, or she feels that she must do so, and this inclination is almost uncontrollable. Feeling as if there Avas not room enough in the abdomen, or as if the abdomen and back were too close together. Sensation as if the abdominal walls were pulled inward. Pulsatilla. She cannot sit long at a time; she must walk about to relieve her pain. A close or warm room is very oppressive, and she feels as if she must be in the open air, which is extremely grateful to her. Rhus tox. Cramps in the legs, causing her to rise and walk. Cramps in the legs every night, causing her to jump out of bed. She is very restless at night, and can find ease but for a short time in any position. Secale c. Frequent and prolonged forcing pain in the abdomen, particularly in thin and ill-conditioned Avornen. Sepia. Frequent bearing-down pain in the back and abdomen. Sense of weight in the anus as an accompaniment. Painful sen- sation of emptiness in the pit of the stomach, which makes her feel miserable. Sulphur. Cramps in the loAver extremities, with hot flushes and weak, faint spells. Burning in the soles of the feet; she must put them outside the bed-covers or into a cool place. Feels hungry and faint at about eleven A. m. ; she cannot wait for her dinner. Cannot walk or sit erect. Always feels worse before a storm. Pains are mostly on the left side. Veratrum a. Cramps in the extremities, with cold perspiration. Very great feeling of distress in the pit of the stomach after eat- ing, lasting for an hour or two. She feels very weak, so much so that she is obliged to lie down. Violent retching, with cold sweat breaking out. Disorders of the Apparatus' of Locomotion. inflammation of the pelvic articulations. This not very common form of inflammation is sometimes seen during pregnancy, but less rarely after parturition. The affection ap- pears spontaneously, Avith severe, acute and sometimes lancinating RELAXATION OF THE ARTICULATIONS OF THE PELVIS. 365 pains in one or several of the pelvic articulations. These pains are necessarily aggravated by pressure, by standing and by attempts at walking, AAdiich the inflammation may render impossible. In some cases, probably those Avhich were strongly predisposed to suppuration, the inflammation has taken this course, the articular surfaces becom- ing denuded of cartilage. In two instances referred to by M. Cazeaux this affection terminated fatally. Perfect quiet must of course be observed in such inflammation of parts which are not only immediately engaged in locomotion, but which have to sustain also all the superincumbent Aveight of the body. The character of the pains themselves, together Avith their conditions of aggravation as to time and circumstances, will readily suggest to the homoeopathic practitioner the remedy applicable to each particu- lar case, by the timely exhibition of Avhich much suffering will be saved to the unfortunate patient. Relaxation of the Articulations of the Pelvis. In certain constitutions there appears during pregnancy a consider- able amount of relaxation of the ligaments which unite the bones of the pelvis, and a consequent mobility of the pelvic articulations. This change occurs in different degrees in different persons, being scarcely perceptible in some and rendering walking impossible in others. The precise cause of this affection it may not be easy to designate although those who suffer in this manner usually appear to possess what is termed a scrofulous constitution. And indeed this tempo- rary relaxation and displacement is in no small degree analogous to the chronic scrofulous disease which goes by the name of rachitis. The immediate cause of the relaxation is found to consist in a soften- ing of the ligaments by which the pelvic articulations are usually so firmly bound together. And in this respect this affection differs from the rachitic softening of the bones Avhich so often produces distortion during the period of childhood, and also from the corresponding soft- ening of the bones in adult years, malacosteon, which occasions so many varieties of pelvic deformity. A certain enlargement of the synovial bursa?, and corresponding hypersecretion of the synovial fluid, have been noticed in the more aggravated cases of pelvic re- laxation. This spontaneous relaxation and dislocation from the very first occasions such an amount of instability in standing and insecurity in attempting to Avalk as to indicate at once the nature of the difficulty. The pains which accompany the affection, being felt principally from 366 disorders incidental to pregnancy. motion or pressure, such as standing or Avalking, might be incapable of being distinguished from those of inflammation of the articulations, but for this remarkable sense of instability Avhich appears in the in- cipient stages, and Avhich is subsequently aggravated to exceeding difficulty of standing and impossibility of walking. In such cases the sensation experienced on attempting to stand is that Avhich so strongly characterizes belladonna, as if her whole body would sink down betAveen her thighs. This relaxation of the pelvic articulations may, when not too much developed, render delivery less easy and speedy by destroying the firmness and stability of the point dJappui which the abdominal mus- cles derive from the bones of the pelvis. But when farther advanced this relaxation, by enlarging the pelvic cavities, may facilitate the ex- pulsion of the child's head, thereby rendering spontaneous a delivery Avhich Avould otherwise have been very difficult on account of the dis- proportion between the size of the head and the dimensions of the pelvis. After delivery the relaxation has been known to continue for several months, or even for years or the whole lifetime. In all cases of relaxation of the pelvic articulations in pregnancy the most perfect quiet, and even absolute rest, should be enjoined, in order to prevent the increase of the difficulty which must result from moving about, and in order to obviate the danger of inflammation arising from undue irritation of tissues already morbidly affected. A careful study should be made of all the indications and symptoms, in order to reach the constitutional dyscrasia which lies at the bottom of the difficulty, and thus at the same time arrest the progress of the present mischief, prevent future trouble, and radically and perma- nently improve the patient's health. A disposition to fall sometimes greatly troubles the pregnant woman. That which arises from sudden attacks of syncope is not referred to here, but rather that Avant of firm balance in walking, that danger of stumbling and that general sense of instability Avhich often prove a constant source of annoyance. The equilibrium of the body in mo- tion in the natural state is only preserved by the incessant although entirely unconscious effort of the muscular apparatus, Avhich as in- stinctively regulates the movement and position of the body in accord- ance Avith the la\y of gravity as the muscles of the eye adapt the size of the pupil to the various degrees of light. In persons afflicted with hereditary muscular Aveakness, Avhich is but the particular manifestation of some general and constitutional dyscrasia, the constant task of main- taining the proper centre of gravity, aggravated by the aAvkward dispro- RELAXATION OF THE ARTICULATIONS OF THE PELVIS. 367 portion in size and large addition of weight in front which characterize the advanced stages of pregnancy, is entirely beyond their strength. Hence the severe myalgic and neuralgic pains already described as affecting the abdomen, breasts, back and lower limbs; hence, too the difficulty of Avalking, the unsteadiness of gait and the danger of fall- ing with which such persons are afflicted. A careful collection of all the symptoms of such cases, and an equally careful comparison of them with those belonging to the fol- lowing remedies, and to others Avhich may be indicated in the rarer forms of lesion of the locomotory apparatus in pregnancy, will enable the homoeopathic physician to prescribe for these various difficulties with confident hope of affording to these sufferers both present and permanent relief. Jlsculus h. Where the sacro-iliac symphysis is the point of the trouble. She cannot walk because that part of her back gives out, and it fatigues her so that she must sit down, and she feels better still when lying. Aloes. Where a sense of weight and pressure into the pelvis seems to cause the lameness. Arnica. Where a sensation of soreness as of a bruise prevails. She can hardly move about at all from the soreness in the symphysis pubis or in the sacro-iliac symphyses. Calc. carb. Will be indicated in leucophlegmatic constitutions; great fatigue on Avalking even but a short distance, from a general feeling of lameness in the pelvis. Cold, damp feet. Vertigo on ascending. Does not sleep after three A. m. She is clumsy. She stumbles and falls very easily. Calc. phosph. She is very much worse after taking a little cold. She is liable to rheumatic pains in all her joints after taking cold. ^ Gelseminum. This remedy will be found useful in cases where the difficulty of walking or the inability to stand appears to be due to an inability to control muscular movements. Kali carb. The back aches so badly while she is walking that she wishes to lie down at once, and says "she feels as if she could lie down in the street" at such times, to obtain immediate rest and relief. Manganum. The limbs are affected, and are very tender and sen- sitive to the touch. The point or part affected, and to which the lameness is ascribed, is sensitive on pressure. Pulsatilla. She cannot walk so well toward evening. She feels 368 DISORDERS INCIDENTAL TO PREGNANCY. worse Avhen warm in bed. She can hardly find an easy jiosition through the night, owing to the pain in the pelvic articulations. Rhus tox. A sense of stiffness in the pelvic articulations on first attempting to walk; better after getting Avarm in Avalking. At night she must change her position frequently, feeling quite easy for a Avhile after every change, but she must shortly change again. Silicia. In cases where ulcerations take place Avith fistulous open- ings, which are very tender to the touch. If pimples make their appearance around the ulcerations, hepar may be indicated. Sulphur. With her pelvic sufferings she has flushes of heat and weak, fainty spells. She is weak and faint from about eleven o'clock till noon. Coldness of the feet. Thuya. The sufferings are greater in the left sacro-iliac articulation, the pains running into the left groin. The pain from walking is so insupportable that she must lie down. Derangements and Affections of the Nervous System. The sympathetic nervous disorders Avhich affect young girls in dif- ficult menstruation are but the prototypes of those affections which occur during pregnancy in women of corresponding unhealthy consti- tutions. Hence, in addition to the more strongly-marked disorders of pregnancy just described, we find disturbances of the nerves of special and of general sense, abnormal conditions of the intellectual faculties, and various depravations of the moral and emotional sphere. The more important of these various disturbances will now be briefly considered. Loss of Hearing. Davis mentions having seen two cases of entire deafness which came on during gestation. In the one case the abolition of the sense of hearing came on suddenly during one of the earlier months, and very gradually returned after delivery; whilst in the other it came on by imperceptible degrees in the seventh and eighth months of gestation, and returned suddenly and with painful acuteness on the sixth day after delivery, when the lochia entirely ceased to flow. From Paul- lini the same author quotes the case of the wife of a citizen avIio was subject to be seized Avith an entire loss of hearing about four or five days before being taken with labor-pains, the deafness going off after delivery. Indeed, such cases are by no means uncommon, particu- larly where the deafness is not complete, but is merely an impairment of the sense of hearing in a greater or less degree. And there may be accompanying the deafness, or occurring with but little or no deaf- affections of the eyes. 369 ness whatever, various and most distressing noises in the ears, tinni- tus aurium, etc. Where these sounds are heard, however, the practi- tioner before prescribing any medicament should ascertain whether they are not due to impacted cerumen making pressure upon the membrana tympani. The following remedies should be consulted, as well as others not here enumerated: Capsicum. The petrous portion of the ear is much swollen, red and painful. Carbo. an. She is able to hear, although faintly, but cannot tell ac- curately from whence the sounds proceed. Causticum. Keverberation of all sounds, even of the patient's own voice, in the ears. Graphites. Great dryness in the ears. The deafness is better when riding in a carriage. Lachesis. The cerumen is too hard, too pale and insufficient. Mercurius. Sensation of coldness in the ears continually. Nitric acid. Much swelling of the internal ear; it is nearly closed, and sometimes there is much pain Avithin it. Phosphorus. Difficulty in distinguishing the human voice. Pulsatilla. Sensation as if the ears Avere stopped up. Silicia. Partial relief is obtained by blowing the nose. Sulphur. Aggravation for a while after eating or blowing the nose. Compare, also, Calcarea c, Petroleum, Hepar, Staphysagria, etc. Affections of the Eyes. The eyes sometimes become the seat of a still more painful affection in pregnancy. Dr. Bezard * relates the case of a lady who, in the fifth month of her ninth pregnancy, was suddenly and without any known cause seized with a deep-seated pain in her right eye. There was no external sign of disease, except that there was no secretion of tears; there was, however, a sensation of strong pulsation at the bot- tom of the orbit, accompanied by acute and frequently repeated lanci- nating pains, by appearances of rapidly-darting specks before the eyes and by errors of the vision. Pain of the forehead and at the root of the nose, together with a sense of weight and oppression about those parts, aggravated the patient's distress. In a short time the rays of hght ceased to irritate the retina, the eye became insensible to the con- tact of the finger, and the patient could intently stare at the sun with- * Journ. de Med., par Leroux, xxxiii., p. 72. 24 370 DISORDERS INCIDENTAL TO PREGNANCY. out producing any painful excitement. Inability to sleep accompanied this local affection for several weeks. The delivery Avas happily ac- complished, and in the course of some days subsequently the lady found that she could perceive light with the eye which she considered as lost to her, and after some days she could clearly distinguish objects Avith it. She gradually improved in this respect for eighteen months, when she became enceinte for the tenth time. At about the fifth month, at the same time as in the former pregnancy, she Avas seized with similar but much more intensely severe pains in the same eye. In this pregnancy the difficulty extended to the left eye also, Avhich after delivery in great measure recovered its functions, but the right eye remained permanently insensible to light. According to Beer,* amblyopia or amaurosis, accompanied with nausea or Avith vomiting which cannot be quieted, sometimes occurs early in pregnancy and ceases after parturition. He saAV a young JeAvess, Avho in her first three pregnancies, which followed in quick succession, began to grow blind in the early period, and became quite amaurotic in the third or fourth month. On the first two occasions she continued blind until after parturition, and the third time her sight never returned. Desmarres also mentions pregnancy among the indirect causes of amaurosis.f Exactly opposite to this is the case quoted by Cazeaux, of a young woman whose imperfect vision had compelled her to use spectacles from childhood, but whose sight had so much improved immediately after the beginning of her pregnancy that she had no longer need of magnifying-glasses. In affections of the eyes study the following remedies: Aurum. Objects appear as if divided horizontally. Belladonna. Dim appearance of objects; they appear inverted or double. Calc. c. All objects appear as if seen through a mist. Causticum. Sudden and frequent loss of sight, with sensation of a film before the eyes. The dimness of vision is greater after every headache. Paralysis of the upper eyelids, so that they hang down. China. She can only distinguish the outlines of distant objects. When reading, the letters appear pale and surrounded with a white border. She sees better after sleeping. Cicuta V. The letters seem to move about when she is reading. Cina. She can see more clearly for a while after rubbing the eyes. * Lawrence on the Eye, p. 612. f Maladies des Yeux, Paris, 1847, p. 715. HEADACHE AND NEURALGIA. 371 Hyoscyamus. Frequent spasms of the eyelids. Strabismus. All objects appear of a red color, or larger than they are. Natrum mur. Frequent spasmodic closing of the eyelids. Nux V. Heaviness and contraction of the lids. Phosphorus. All objects appear to be covered with a gray veil. Pulsatilla. Sensation as if the eyes were covered with a mist, or as if the dimness could be removed by rubbing something off from the eyes. Sulphur. Dimness of vision 'and the gas- or lamp-lights appear to be surrounded by a halo. Compare, also, Cyclamen e., Drosera, Glonoine, Mercurius, Ruta, Senega, Sepia, Veratrum, etc. Headache. This forms one of the most common and most painful affections of pregnancy. It may arise in part from sedentary habits, especially in the more advanced stages of pregnancy, and for similar reasons it may be both complicated with and aggravated by constipation. In persons who are usually subject to headache the condition of preg- nancy may serve to increase the difficulty. The cephalalgia of preg- nancy may attack those of an anaemic habit and nervous temperament, or it may appear in connection with a plethoric condition, indicated by flushing of the face and giddiness aggravated by stooping. Or, again, the headache may accompany nausea and other gastric disturb- ances, with paleness of the face and general debility. The treatment will usually be very simple, since the indications can hardly fail to be plain. When the disorder appears in connection with constipation, increasing in severity upon each occasion till the bowels are moved, and seems also to result in some measure from the sedentary mode of life to which so many women addict themselves even when not enceinte, exercise in the open air should be strongly advised, to be taken in the manner best suited to the circumstances of the patient. Neuralgia. Facial neuralgia in pregnancy differs but little from headache in its causes and requisite mode of treatment, except that while like headache it may arise in connection with constipation, it is otherAvise more apt to occur in persons of a pale, anaemic or nervous tempera- ment than in those of a ruddy, plethoric habit of body. According to Tyler Smith, "facial neuralgia from uterine irritation is a very common affection of pregnancy. It generally affects the dental nerves, 372 DISORDERS INCIDENTAL TO PREGNANCY. particularly those of the upper jaw. In many subjects acute caries of the teeth occurs; in some child-bearing Avomen a tooth or two is lost in each pregnancy." In neuralgia of the face in pregnant Avomen, without disease of the teeth, the same author says a generous diet is called for, and he ad\dses also wine and porter.* The latter articles we think can hardly ever be needed in this country, unless perhaps temporarily in cases of great privation from suitable nourishing food; in such instances a^little Avine may aid in restoring the system from its enfeebled condition, and thus enable it the more readily to avail itself of a wholesome and nutritious diet. Great care must be taken in cases of severe neuralgia in pregnancy—cases which may constitute a true spinal neuralgia—lest from loss of sleep, inability to assimilate suitable food and the depressing influence of long-continued suffering, the system may become so much reduced as to induce abortion, and even fatal marasmus. In selecting a remedy for the cure of the headaches and neuralgias of pregnancy the practitioner should bear in mind the importance of the concomitant symptoms, as well as of those especially of the disorder itself. The following medicines may be studied among others for these painful and distressing affections: Aconite. In headache or neuralgia, accompanied by vertigo on rising up in bed. Crampy sensation in the root of the nose. Sensation as if the whole brain would press out at the forehead. She fears to be in a place of excitement or confusion. Belladonna. Flushed face and injected eyeballs. Cannot bear noise or bright light. She seems to be in a stunned or stupid condition. Bryonia. A splitting headache; she wishes to keep very still. Dry- ness of the lips and mouth. Nausea on rising in bed. Calc. c. Headache, with an unusual accumulation of dandruff on the scalp. Headache is aggravated by ascending, as in going up stairs; the blood seems to be forced into the head, causing a burning sensation. Vertigo on ascending. Coccuius. Her head feels worse after eating or drinking. Head- ache, as if the eyes would be torn out, particularly on motion, with vertigo. Cimicifuga. Lancinating pain over either eye or in the eyeball, which is Avorse every other day. Heat, sense of fullness and throbbing in the head.^ The pain is relieved in the open air, and aggravated by the heat of the stove. Throbbing in the head when ascending. * Braithwaite's Retrospect, xxxiii., p. 252. HEADACHE AND NEURALGIA. 373 Coffea. Intense pain, the head feeling contracted or as if too small. Nervous excitement, with sleeplessness; or droAvsiness, yet with in- ability to go to sleep. Gelseminum. Sharp shooting pains through the face, eyes and head, which feel like rheumatic pains; the face is congested and of a dark or dusky hue. The headache commences in the neck quite suddenly, and spreads from thence over the head, or vice versa; dimness of vision; heaviness of the head; vertigo; stupor; dull expression of the countenance. Glonoine. Whirling in the head, with giddiness; sensation as of expansion of the brain, the head feeling as though it would burst. Confused feeling in the head; perceptible throbbing of the carotid and temporal arteries. The headache or the neuralgia has been brought on by exposure to the rays of the sun, or is aggravated by such exposure. Ignatia. Headache confined to one side of the head; clavus; un- bearable pain, as of something sharp being forced into the brain; weak feeling in the stomach; suitable for women of melancholy disposition who are given to sighing, or to hysterical women. Magnesia c. The pains are aggravated by talking or by mental ex- ertion. She feels sad and disconsolate. Nux V. This medicine is especially suitable for headaches or neu- ralgias of pregnant women who are addicted to high living, the use of wine and spirits or coffee, and to keeping late hours, or who lead a too sedentary life. Constipation of the boAvels or hemorrhoids habitual. The head feels as if it would split, and the scalp is sore to the touch; pressure with the hands on the head relieves the pain. Nausea; accumulation of gas in the stomach after a meal, and other symptoms of dyspepsia. Pulsatilla. Hemicrania, occurring in women of mild and gentle disposition, given to weeping. The suffering, whether from headache or neuralgia, is much worse in a Avarm or close room, and is relieved by going into the fresh, open air. Sepia. Headache, with aversion to all kinds of food, a feeling of emptiness or goneness in the pit of the stomach, which is very dis- tressing. Headache occurring every morning, with nausea, vertigo, epistaxis. In Avomen who have "moth-patches" on their foreheads, who are of sallow complexion, or who have a yellow streak across the Midge of the nose and under the eyes. Spigelia. Facial neuralgia, generally of the left side of the face, and vei7 severe type. The parts supplied by the fifth pair of nerves 374 DISORDERS INCIDENTAL TO PREGNANCY. are especially affected. The pain invol\res the eyeball and orbit, and sometimes the eye of the affected side is very much congested. The pains are lancinating or lacerating, and are someAvhat relieATed by firm pressure. Verbasc'im thapsus, on the contrary, is indicated when even the slightest pressure greatly aggravates the suffering. Sulphur. Heat on the vertex, habitually; frequent flushes of heat all over; cold feet; spells of faintness. Veratrum a. Headache causing delirium, dementia, and cold sweat on the forehead. Toothache. Toothache is a common and very distressing accompaniment of pregnancy, being in fact only a particular form of neuralgia. Leadam strongly advises against extracting the teeth in such cases, since abor- tion has been known to follow the operation. Tyler Smith states that they ought only to be extracted with caution under such circumstances. But those having in their hands the homoeopathic remedies, and blest with even a moderate amount of skill in administering them, will nevTer be tempted to resort to a practice at once barbarous and danger- ous. Still, it must be borne in mind that neither local applications nor remedies selected with reference to the teeth alone will suffice, in many cases, to remove an affection which is at once painful, sympa- thetic and constitutional—that is, connected with some individual idiosyncrasy. Here, as in all other cases of disease, the remedy should be selected in accordance with the totality of symptoms. One or the other of the following remedies Avill usually be found useful: Alumina. Drawing toothache, extending to other parts, as down the larynx, neck or shoulders, etc. Arsenicum. Periodical toothache, occurring most frequently at night, however; it is then unbearable and drives the patient almost to frenzy. She is unable to remain in bed, and must get up. Belladonna. Pains as if caused by ulceration, Avorse after lying down at night or when in the cold air. Pains mostly on the right side of the face, extending to the eye and its orbit. The pain causes moan- ing and Aveeping. Calcarea c. The pain is aggravated by the slightest change, as from a current of air, whether warm or cold, drinking anything warm or cold, noise, mental excitement, etc. Chamomilla. The pains are perfectly unbearable, and give rise to TOOTHACHE—chorea. 375 much irritability of temper and impatience; redness of one cheek Avhile the other is normal or pale; jerkings in the teeth. Gelseminum. General nervous excitement or weak and trembling. The pains come in paroxysms, are decidedly neuralgic, and dart through the jaAvs and face. Congestion of the head and face. Hyoscyamus. Violent tearing and pulsating pain, causing spasmodic jerks of the fingers, hands, arms, facial muscles. Spasms in the throat, etc. Magnesia C. Insupportable pain during repose; she must get up and walk about. Mercurius sol. The teeth feel sore to the touch—so much so that pressing them together, as in eating, increases the suffering. The teeth feel elongated and as if loose". Mezereum. Pains extending to the bones of the face and temples, particularly Avhen they run along the left malar bone to the temple. Nux m. Pains in the front teeth on inhaling cool air or taking warm drinks; feeling as if the teeth Avere grasped to be pulled out. Nux v. Toothache occurring in Avomen of irritable disposition, or who are high livers and are troubled with constipation or haemor- rhoids. Phosphorus. The pain is of a jerking or twitching character. The periosteum of the tooth is inflamed and tender of pressure. Pulsatilla. The pain is better Avhen taking cold food or drink or upon exposure to cold air, and is worse from Avarm food or drink and in a warm room. Rhus tox. Rheumatic toothache, or toothache occurring from get- ting wet. The pain is relieved by applying warmth to the face. Staphysagria. The teeth grow black, become carious and brittle. She is very sensitive to either mental or physical impressions. Chorea. Where this affection occurs in connection Avith pregnancy the spinal system of nerves is affected secondarily through the ganglionic. The symptoms of this disorder are too strongly marked and too Avell understood to need to be repeated here. The folloAving conclusions, arrived at by Dr. Lever twenty years ago, fully represent the present state of our knowledge in respect to most of the points mentioned. " In conclusion," says this Avriter, " I venture to submit the follow- >ng propositions: 1. That pregnancy is occasionally associated Avith cho- rea or convulsive movements; with paralysis of various parts of the body, of the extremities and of the nerves of special sense; and with 376 DISORDERS INCIDENTAL TO PREGNANCY. mania. 2. That the varying symptoms of such complications may be produced at any period of pregnancy, but when produced, although modified by treatment, are rarely removed during the existence of gravidity. 3. That the patients in whom these complications exist are Avomen of a highly nervous temperament, of great irritability, or Avhose constitutional poAvers have been reduced by some long-con- tinued but serious cause of exhaustion. Lastly: That although in most instances the symptoms will continue so long as pregnancy exists, yet in a majority of cases we are not justified, in inducing a prema- ture evacuation of the uterine contents." To these views of an old-school author let us add what our own school teaches in one most important respect. In those cases in which chorea or epilepsy appears for the first time during pregnancy, Ave must regard this latter state as having sufficed to develop a certain morbid element of the constitution which had hitherto remained latent; and Ave should seize upon the opportunity thus afforded to endeavor, by the exhibition of the appropriate remedies, to radically cure this morbid taint, and thus, at the same time, prevent the con- tinuance of the convulsive disorder after delivery, and provide against its return in a succeeding pregnancy. In those cases in Avhich wo- men become pregnant who have been subject to either of these ner- vous affections, the pregnancy may either render the convulsive attacks less frequent, cause them during the continuance of this state to cease entirely, or even render them of much more frequent occurrence than before. But Avhile it is believed that no instances are recorded of epileptic patients having been permanently benefited by pregnancy, M. Malgaigne * cites a singular case in Avhich the first attack of epilepsy Avas developed during pregnancy in an unfortunate young woman, who retained this fearful malady through all her sub- sequent life. Similar is the case quoted from a German author by Dr. Davis,f of a lady twenty-six years of age, of a bilious constitu- tion, and the mother of three children, who aa^s attacked Avith a periodical epilepsy whenever she conceived, and Avho sustained a paroxysm of this malady once a fortnight during the whole of her gestation. But as soon as she was delivered the disease left her. Its occurrence, therefore, was always a sign to her that she had become pregnant. Chorea, whether occurring during pregnancy or at any other period, is amenable to homoeopathic treatment. The subjoined reme- dies are presented as those most likely to be required, while the * Traite Theoretique et Pratique, etc., p. 368. f Obstetrics, ii., p. 900. CHOREA—HYSTERIA. 377 remedies and their indications given under the article on Chorea in the portion of this work devoted to the consideration of diseases of children may be studied with advantage : Belladonna. When the tongue is partially paralyzed. Difficulty of articulation. Right side more particularly affected. Red eyes. Much debility. Rather stupid. Calc. c. Chorea from a fright. In leucophlegmatic temperaments. Causticum. If the upper eyelids are particularly affected, so that they hang down—can't keep them up. She is worse in the open air and in the evening. Cocculus. She is always worse for a while after drinking, eating, sleeping or talking. Crocus. She is worse every evening, with alternations of excessive happy, affectionate tenderness and rage. Cuprum. When the spasms come on in paroxysms, grouped with other symptoms Avhich always appear grouped with these paroxysms. Or Avhen the paroxysm commences in one part—the finger or limb, for instance—and gradually extends till the whole frame is involved. Hyoscyamus. Twitching and jerking of all the muscles, including those of the eyes, eyelids and face. Ignatia. When there is much deep sighing and sobbing, or when the disorder is the result of a long-suppressed grief.. Nux v. Very fond of high living; troubled with constipation. Chorea is worse in the morning or in the early part of the day. Stramonium. Full of strange, inconsistent fancies. The attacks are brought on by fright or care, and are very violent, especially at night; excessive jactitation of the muscles. Study also Apis mel., Asafoetida, Arsenic, China, Cicuta, Cimicif., Coffea, Dulcamara, Opium, Pulsatilla, Sabina, Sepia, Silicia, Zinc, Vera- trum v. Hysteria. This affection is a frequent accompaniment of pregnancy. But in this place we need do little more than refer the reader to the very full discussion of the subject of hysteria in the succeeding portion of the work, similar indications being present and similar remedies called for in the pregnant as in the non-pregnant condition. Still, in cases of pregnant Avomen the remedies should be selected, if possible, with still greater care, since, for obvious reasons, much greater importance must be attached to the hysterical condition in the pregnant state. 378 disorders incidental to pregnancy. Dr. BurroAVs states that he has seen two cases in Avhich hysterical symptoms attended during pregnancy, and the patients in each case became insane almost immediately after delivery. Romberg instances among the debilitating influences which are the most fertile sources of hysteria, " repeated miscarriages and a rapid succession of preg- nancies and lactations." In most cases of women subject to hysteria, or any other form of general disorder of the nervous centres, the occurrence of pregnancy serves rather to aggravate than to ameliorate the pre-existing morbid condition. Disturbances of the Intellectual Faculties. Pregnancy is sometimes accompanied Avith a partial mental derangement, Avhich may become complete insanity. Esquirol men- tions the case of a young woman of a sensitive habit who had an attack of madness in two successive pregnancies, commencing imme- diately after conception and lasting fifteen days. Montgomery states that he knew a lady Avho was attacked with insanity in eight suc- cessive pregnancies; and another who was similarly affected three times soon after conception, and remained so until Avithin a short time after labor, when she became sane and continued so until the next pregnancy. It should be obsen7ed that insanity in pregnancy, Avhether arising in connection with the hysterical condition or not, has two distinct sources; in the one, the disturbance of the intellectual faculties appears to result rather from the physical condition, and to be dependent upon pregnancy physically considered; in the other, the mental powers manifestly gh7e way and the reason loses its balance under the depressing influence of the melancholy and settled gloom Avhich belong entirely to the moral sphere. And at the same time it should be remembered that a certain constitutional dyscrasia may be the real cause of the physical condition Avhich leads up to insanity on the one hand, and even of the profound moral and spiritual dejection which leads down to it on the other. There are, hoAvever, numerous unfortunate cases, especially of young AAromen who become pregnant while yet unmarried, in Avhom the agony of disappointed hopes, of affections misplaced and cruelly abused and betrayed, the present scorn of society, and the apprehension of a still increasing shame, suffice to hurl reason from its throne, to destroy the better judgment, and induce such madness as finds its necessary crisis in suicide. These are cases in which the grief of irreparable afflic- tion, the mental anguish and moral suffering, can scarcely fail to disorders op the affections, emotions and feelings. 379 derange the soundest mind in the soundest body, and destroy both together. But Avhile time alone can effectually mitigate the more poignant forms of affliction, the homoeopathic remedies are yet remarkably efficacious in " ministering to a mind diseased," whether the mental derangement result from physical dyscrasia, from moral suffering, or from both combined. The physician should most carefully explore all the symptoms, circumstances and conditions in respect to the physical system, to the sensorial, the intellectual, and the affectional faculties, in order to discover in the Materia Medica the exact simile of his patient's case. The serious responsibility which rests upon the physician to do all that human science can accomplish in such cases is not limited to the present condition or future well-being of the mother; regard must also be had to the unborn child, to preArent the predisposition to insanity from being perpetuated in the infant, and in a still greater degree developed in succeeding generations. To give indications for remedies for the various and varying dis- turbances of the intellectual faculties Avould be a task of great magni- tude, and, Ave might add, a work of supererogation, inasmuch as all the remedies comprising the Materia Medica would haA7e to be recorded. Reference may be made with advantage, hoAvever, to those especially recommended for Disorders of the Affections, Emotions and Feelings. In addition to the disturbances of the intellectual faculties already mentioned as incidental to the condition of pregnancy, there are fre- quently seen certain anomalous variations of the spirits, temper and affections, for which the physician will be called upon to prescribe, either in connection with physical symptoms or in their absence. The special adaptability of the homoeopathic Materia Medica to abnormal conditions of the sensational, intellectual, emotional and affectional faculties gives the homoeopathic physician an immense advantage in this class of cases. The settled gloom, the profound melancholy to which allusion has already been made as occasionally productive of insanity is some- times seen to appear Avithout any other assignable cause than the general one of pregnancy. When this depression of spirits assumes some particular phase—as, for example, that of a disposition to commit suicide—the appropriate remedy is at once suggested. The limits of the present Avork restrain us from doing more in this connection than merely to mention some of the most prominent forms of mental and 380 disorders incidental to pregnancy. moral derangement, and to indicate the principles upon Avhich thev should all be treated. For a fuller exposition of the various mental and moral diseases, and a more detailed statement of the numerous homoeopathic remedies applicable to them, the reader is referred to Dr. Franz Hartmann's very excellent work on Mental Diseases.* Remarkable changes of temper also appear, and in a still more nu- merous class of pregnant women. " FeAV Avomen are quite as self- possessed or in as even spirits during pregnancy as at other times; little things annoy them, trifles depress them. Sometimes the most sweet-tempered women become irritable, cross and quarrelsome. The husband of a patient of mine, Avhose wife was remarkably good-tem- pered and attached to him, told me that the earliest symptom of pregnancy in her case was a disposition to quarrel Avith him espe- cially. Dr. Montgomery mentions the case of a lady Avho, for the first two or three months of her pregnancy, was so irritable that, to use her OAvn words, ' she was a perfect nuisance in the house.' "— Churchill. Sometimes women whose ordinary dispositions have been soured by the trials of life, or who are characterized by a habit of fault- finding and complaining, experience a very happy change of temper on becoming pregnant. But more often those usually of a cheerful, lively disposition become sad, depressed and even morose, refuse all comfort or encouragement, and persist in the fixed belief of a fatal termination of their labor. Except in a very few and remarkable cases, such gloomy anticipations of impending evil are happily dis- appointed by a successful delivery, which is therefore succeeded by the restoration of the accustomed cheerfulness. And in those few instances in Avhich the foreboding of a fatal termination of the labor proved prophetic, it is believed that some deep-seated dyscrasia of the physical system gave rise to this instinctive fore-consciousness, such as is sometimes seen in a similar fulfillment of such predictions in cases of ordinary illness. The feelings and affections in many instances undergo a distressing transformation in pregnancy. It is related of one young woman that she was seized at about the fifth month Avith an unconquerable aver- sion to her apartment; so that, after much effort of reasoning and persuasion had been tried in vain, it became necessary to leave her in the country during the remainder of her pregnancy. Another * Special Therapeutics, according to Homoeopathic Principles, by Dr. Franz Hart- mann. Third volume, Mental Diseases. Edited by Dr. G. H. G. Jahr. Translated by J. M. Galloway, M. D. Manchester: Henry Turner, 1857. disorders of the affections, emotions and feelings. 381 case is recorded of a young lady, for the first time pregnant, Avhose former love for her husband was replaced by an almost invincible antipathy to him. Similar to this is the moral state of those Avho from imagining, in their hypersensitive, nervous condition, that they do not receive proper and necessary attention from their husbands and their friends, turn against them and conceive for them a strong dislike. In most cases all such morbid changes of the affectional sphere disappear Avith the termination of the pregnancy under the in- fluence of Avhich they Avere developed. But it becomes no less im- portant for the physician to do all in his power to relieve such moral disorders, not only on account of the present suffering and distress to all concerned, but also because in some instances, at least, these dis- orders may become permanent, and even ultimate themselves in dis- turbances of the intellectual faculties, in subsequent puerperal mania, and finally in some dangerous forms of physical disease. These dis- orders of the feelings, emotions and affections may be connected with an hereditary predisposition to insanity, or with some deeply-seated and even malignant dyscrasia, which, if not remedied at its incipient appearance, may develop the most serious mischief in the present and in future generations. Happily, these disorders are usually amenable to careful medical and hygienic management. In selectirfg a remedy for any of the above-described conditions, even the most trifling symp- toms, as Avell as those of apparently more grave import, should be taken into the account which makes up the totality of the individual case. And while individualizing is the touchstone of successful treat- ment in all cases, it is through it only that success can be attained in treating any of the varied affections of the mind. A few of the medicines most frequently called for in these cases are herewith sub- joined : Aconite. Fear and presentiment of approaching death; she fixes the time of her death. Aurum. She has no confidence in herself, and thinks others have none in her; this makes her unhappy. She looks on the dark side of everything; Aveeps and prays ; thinks she is not fit to live, and has a strong inclination to suicide—to jump out of the window or from a height. Sleepless at night. Anacardium. Estrangement from individuals and society, with fear of the future. Strange temper; she laughs at serious matters; is grave over laughable occurrences. Swears; thinks herself a demon. Loss of memory, dullness of the mind and inability to think. Dyspepsia. 382 disorders incidental to pregnancy. Arsenic. Periodical attacks of anguish, inquietude, tossing and in- ability to lie in bed; fear of death; excessive dread of death; she is sure she will die. Easily exhausted; looks pale and haggard. Puffed and waxy appearance of the face. Arnica. Thoughtless gayety; great frivolity and mischievousness. Belladonna. Great distress with inquietude. Frightful visions; she Avishes to hide herself. She has a Avild look, a stunned appearance. She wishes to strike, bite and quarrel. Difficult deglutition. Calc. C. Excessive mischievousness, with obstinacy. She thinks and talks about murder, incendiarism, rats and mice. She imagines people think she is insane. China. She thinks she is very unfortunate and constantly harassed by enemies. The symptoms appear to be paroxysmal and are worse every other day. Hyoscyamus. She fears she will be poisoned or betrayed or in- jured; she Avishes to run away. Ignatia. She wishes for solitude; sighs and sobs; she will not be comforted. She is full of grief. Lachesis. Excessive loquacity, with rapid change of subject, talks of one thing, then of another, etc. Jealous, proud, suspicious. Lycopodium. Very reproachful and overbearing. Restless at night, and complains of not sleeping well. Moschus. She complains much, but of nothing in particular. Natrum c. Estrangement from individuals and society, even from her husband and family. See also Anacardium, Conium and Natrum m, Nux v. Loss of mental power; can't read or calculate, because she loses the connection of ideas; she thinks she will lose her reason. Worse in the morning or early part of the day. Opium. Thinks she is not at her home; this is continually in her mind. Phosphorus. Great sadness with tears, alternating with gayety and laughter. Suitable especially for tall and slender Avomen; thin, hard and dry stools, which are evacuated with difficulty. Platina. Past events trouble her. Contempt for other persons. She thinks all persons are demons. Pulsatilla. Much Aveeping, even at answering a question. Most suitable for mild and gentle women, who are easily controlled. Sepia. She is very uneasy about the state of her health; constantly worrying, fretting and crying about her real or imagined illness. Silicia. She is occupied with pins—counts them, hunts for them, etc. She is always worse during the increase of the moon. DISORDERS OF THE AFFI CTIONS, EMOTIONS AND FEELINGS. 383 Staphysagria is very similar in some respects to Sepia. The pa- tient is very sensitive to either mental or physical impressions. Stramonium. She is worse in the dark or in solitude. Full of strange, ridiculous ideas. Talks or prays earnestly and constantly. Sulphur. She is very happy, and imagines she is in possession of beautiful things. Awakens at night singing, she is so happy; she dreams very happy dreams, etc. Veratrum. A desire to Avander about the house. Erroneous and haughty notions. Disposed to be very taciturn. Asafoetida, Gelseminum, Cimicifuga, Cocculus, Cypripedium, Moschus, Nux moschata, Phosphoric acid and Zincum may likewise be consulted. The patient should receive the best advice from her physician in regard to the necessity of self-exertion in assisting to overcome the tendency to a disordered mental state. She should be urged to bear up bravely, and to resist, to the full strength of her ability, those feelings which are unnatural and are harmful. And those who sur- round her should likeAvise be instructed, if necessary, to treat her with the utmost kindness and consideration. If these conditions are not fulfilled, it is possible for the homceopathically selected medicine to effect a cure; but there can be no doubt that its effects will be poAver- fully aided by a proper attention to mental discipline and hygiene on the part of the patient, and a proper degree of kindness, yet withal firmness, on the part of her friends. In concluding the general subject of disorders incident to preg- nancy, it may be proper to remark— I. "While pregnancy serves in many cases to develop in some form —physical, mental or emotional—whatever latent tendency to disease had existed in the system, it does not render the body more liable to be attacked by external diseases; and in some instances, as is often seen in the phthisis of those enceinte, it actually retards the develop- ment and prevents the fatal termination of pre-existing disorders until after delivery. II. The disorders of the mental and moral or emotional and affec- tional spheres Avhich so often accompany pregnancy will ahvays speedily disappear with the successful delivery of the child, unless based upon and representative of some profound constitutional dys- crasia. In this latter case such affections not only tend to perpetuate themselves after parturition, but to become developed in puerperal mama, and even ultimated in some malignant form of bodily disease. 384 THERAPEUTICS OF LABOR. CHAPTER XVIII. THERAPEUTICS OF LABOR. The Pains of Labor. PAINS ceasing.—1. Bell., Kali c, Op., Puis., Sec. corn. 2. Cham., Natr. m., Nux v., Ruta, Sep. 3. Arn., Bor., Camph., Carb. veg., Chin., Coca, Graph., Ignat., Lye, Magn. m., Nux v., Plat., Sulph., Thuy. ------ distressing.—1. Cham., Gelsem., Kali c., Sep. 2. Aur., Bell., Coffi, Con., Lye, Nux v., Sec. corn. ------spasmodic.—1. Cham., Gelsem., Hyos., Puis. 2. Bell., Coca, Cupr. m., Ipec, Nux v., Sep. ------too weak.—1. Bell., Cann., Cauloph., Cimicif., Gelsem., Kali c, Op., Puis., Sec. corn. 2. Cham., Natr. m., Nux v., Ruta, Sep. 3. Arn., Bor., Camph., Carbo veg., Chin., Cocc, Graph., Ignat., Lye, Magn. m., Nux m., Plat., Sulph., Thuy. ------too strong.—Bell., Cham., Coff., Con., Nux v., Puis., Sec. corn. Aconitum. Great distress, moaning and restlessness during every pain. She fears that she will not be delivered, that she will die, or that something will certainly go wrong. The vulva, vagina and os are dry, tender and undilatable. Arnica. With each pain there is great flushing of the face and heat of the head, Avhile the rest of the body may be cool. The pains are so violent as to drive her almost distracted, yet little good is accom- plished. Frequent desire to change position. She feels unaccount- ably sore and bruised in any position. The pains are very feeble, Avith a desire to change the position frequently. Aurum. The pains make her desperate, so that she would like to jump out of the window or dash herself doAvn; with congestion to the head and chest and palpitation of the heart. Belladonna. The pains come on suddenly, and disappear after a time as suddenly as they came. Spasmodic contractions of the os, which is hot, dry and tender. Very red face and injected eyeballs, with pain ; labor slow and tedious. Throbbing headache, Avith great sen- sibility to light and noise. The os uteri does not dilate readily in proportion to the pains. Borax. The pains are accompanied by violent and frequent eructa- THE PAINS OF LABOR. 385 tions. She fears a doAvmvard motion. She is very sensitive to the slightest noise, as the rumpling of paper, fall of the door-latch, etc. Chamomilla. Her pains are spasmodic and distressing. She can hardly bear them; she Avishes to get away from them. She is very fretful, peevish and cross; can't return a civil answer. Tearing pains down the legs. She is spiteful, or shrieks out sharply. Camphor. Her pains have ceased, and her skin is cold, dry and shrunken; she does not like to be covered, and is restless. Cam- phor200, or higher, will Avarm the patient, restore the pains, and, other things being equal, produce spontaneous delivery. Caulophyllum. Extraordinary rigidity of the os uteri. Spasmodic and severe pains, without progress being made. The pains become very weak and flagging from exhaustion, on account of the long con- tinuance of the labor. Thirst and feverishness. False pains. Causticum. She complains mostly in her back of a sore, distressing pain. ^ Her suffering is principally in the back. When the unnatural condition of the pains is attributable to debility from night-Avatching, grief, or other depressing influence. Carbo veg. The pains are too weak, or cease from great debility. Particularly indicated Avhere there is a varicose condition of the vulva, or when there has been a great loss of animal fluids, or the woman is laboring under the debilitating effects of previous or existing disease. China. Where much blood has been lost or there have been fainting fits, convulsions, etc. Cessation of pains from the loss of blood, a pro- tracted diarrhoea, etc.; her skin may even be cold and blue. She can't bear to be touched during the pains, not even on her hands. Cimicifuga. The Avoman complains that the pains do not seem to be located properly to effect expulsion, but they are of a tearing and distressing character. Suitable to women of a rheumatic tend- ency. The pains are very violent and spasmodic, and there is great nervous excitement. Cocculus. Her pains are of a spasmodic, irregular and paralytic character. She will have one hard one, and then, after a longer in- terval, several light ones, etc. Much headache. Numb or paralyzed feeling of the loAver limbs. Coffea. Labor-pains insupportable to her feelings; she feels them intensely, weeps and laments fearfully. Although the pains are severe they are not efficacious. Comum. If there are scirrhosities in either the breasts or uterus and abor does not progress normally—pains spasmodic; vertigo, particu- larly on turning in bed; rigidity of os uteri. 386 THERAPEUTICS OF LABOR. Cuprum. Violent spasmodic pains appearing at irregular intervals, often Avith violent cramps in the lower extremities, or the cramps may be confined to the fingers and toes. Great restlessness between the pains. Gelseminum. Cutting pains in the abdomen from before backward and upAvard, rendering the labor-pains useless; these come on with every pain. These pains are very distressing, and may be felt throughout the abdomen. Gossypium. In cases of lingering almost painless labors, Avhere the uterine contractions are entirely inefficient. The case presents nega- tive rather than positive symptoms. Graphites. In large and corpulent women of venous constitution, Avho are subject to tettery eruptions, which itch and emit a glutinous fluid. The pains are weak or have ceased entirely. Hyoscyamus. There is delirium, startings and jerks in various parts of the body, in the face, eyelids, and sometimes all over. Ignatia. Deep sighs and sadness; she must take a deep breath in order to breathe at all. The labor does not progress. Ipecacuanha. One constant sense of nausea, not a moment's relief. The pains are distressing by reason of a sharp cutting about the um- bilicus, which darts off toward the uterus; this distress hinders the proper action of the uterus. Kali C The pains begin in the back, and instead of coming round in front like a regular pain, pass off down the buttocks or the glutsei muscles; or they are sharp and cutting across the lumbar region, arresting contractions. She is sometimes greatly disturbed by sharp stitching pains. Lycopodium. During the paroxysms of her pain she is obliged to keep in constant motion, Avith weeping and lamenting; there may be even spasmodic contraction of the os, Avith the above symptoms. She finds relief by placing one foot against a support and pressing and relaxing alternately, so as to agitate her Avhole body. Magnesia m. The labor-pains are interrupted by hysterical spasms. (See Hysteria, same remedy.) Natrum c. Anguish, tremor and perspiration with every pain, during which she desires to be gently rubbed; this rubbing affords relief. Natrum m. Very, very sad and foreboding—so much so that labor goes on very slowly, from feeble pains. Nux m. She is very drowsy, sleepy and disposed to fainting spells, the pains being correspondingly slow and feeble, or quite suppressed. THE PAINS OF LABOR. 387 Nux v. Every pain causes an inclination to go to stool or to urinate. Every pain causes fainting, and thereby interrupts the progress of the labor. Retarded and painful labor in women accustomed to a seden- tary life, and to those accustomed to high living and an inactive, in- dolent life. Opium. The pains have been suppressed by fear or fright. She is in a soporous condition, with red face, injected eyes and stertorous breathing, and there is twitching and jerking of the muscles. Phosphorus. Tall and slender Avomen of phthisical diathesis, the pains being distressing and of but little use. Very weak and empty feeling in the abdomen, sometimes with cutting pains. Platina. The contractions are interrupted OAving to the very painful sensitiveness of the vagina and external genitals. Very painful though ineffectual, spasmodic labor-pains. Pulsatilla. Suitable to mild, tearful Avomen, who are in an appar- ently healthy condition, yet the uterus seems almost inactive. The pains excite palpitation, suffocating and fainting spells, unless the doors and windows are Avide open; she feels that she must have them open, as she wishes for cool, fresh air. Absence of thirst, Labor progresses very slowly. Ruta. General lameness and soreness all over, with weak, feeble contractions. Secale c. Particularly in weak, cachectic women, or in women de- bilitated from venous haemorrhages. In such cases it is particularly efficacious for weak, suppressed or distressing pains. By far the best is the m, or higher. Fainting fits in such cases, small or suppressed pulse. Sepia. Shuddering attends the pains, and she rather wants to be covered up more, because she can bear the pains easier. Indura- tions are felt upon the neck of the uterus. Shooting pains in the neck, extending upward. Spasmodic contractions of the os in these cases. Stannum. The pains seem to exhaust her very much, and make her speech difficult from weakness in the chest. She cannot answer ques- tions; she is all out of breath ; the labor does not progress. Sulphur. She has flushes of heat, frequent weak and fainty spells wants more air. Cold feet, heat on top of head. Thuya. In some cases of complication Avith syphilis, Avhich hin- ders the proper contractility, this remedy will do much good imme- diately. Veratrum. The pains are accompanied Avith cold sweat, particularly 388 THERAPEUTICS OF LABOR. on.the forehead, fainting on the least motion, the pains exhaust her much, and she feels completely done over after every pain. Rigidity of the Os Uteri. Where rigidity of the os uteri in labor depends on organic lesions of the cervical tissues the treatment to be resorted to is laid down on page 236. But Avhere, as is commonly the case, the rigidity or spas- modic contraction is due to mere functional disturbance, one of the following remedies Avill be found to be sufficient to produce a gradual relaxation and dilatation. Bigidity of the vaginal walls, dependent on a similar cause, may likewise be removed by the same remedies. Aconite. When there is great dryness of the vagina; much moan- ing, restlessness, feeling of discouragement; fears she will not do well; the parts feel contracted, rigid and undilatable. Aconite, in Avater, every half hour till better. Belladonna. There is heat of the parts,, with great tenderness; moan- ing; flushed face; injected sclerotica; throbbing of the carotids; all her motions are quick; pains come suddenly and disappear suddenly. Caulophyllum. The pain is spasmodic; it appears in various parts of the abdomen; patient seems much exhausted and the pains very inefficient. Chamomilla. Where there is great irritability of a spiteful nature; she seems scarcely able to bear the pains; she moans, laments, calls for assistance, sometimes screams outr and the pains appear as if too severe to be endured. Cimicifuga. The pains seem intensely severe, but spasmodic and in- effective. The patient is of a rheumatic diathesis and subject to rheu- matic pains. Gelseminum. The pain extends, in the abdomen, from before back- ward and upward; this pain is a false pain, and is so severe as to in- terrupt the true labor-pain. The Za&or-pain seems utterly inefficient. The pain is sometimes cramping in various parts of the abdomen. The os is rounded and hard, and feels as though it Avould not dilate. Lobelia inflata. When the respiratory organs sympathize in the trouble, as in violent dyspnoea, with every uterine contraction, Avhich seems to neutralize the pain. Any remedy in the Materia Medica may be useful in these cases, as the rigidity or contraction is but the result of some morbific influence working upon the system; therefore see remedies for difficult labor. HOUR-GLASS CONTRACTIONS. 389 Hour-Glass Contractions. (See page 202.) The medicines most suitable for this condition are: Belladonna Chamomilla, Kali carb., Platina, Secale cornutum and Sepia. Next best: Cocculus indicus, Conium, Cuprum ars., Hyoscyamus Nux vomica, Pulsatilla, Rhus tox, Sulphur. Belladonna. Almost constant moaning, which seems to afford relief; injected eyeballs; flushed face; can't bear light or noise; pulse full and bounding; very hot skin. Chamomilla. Distress Avhich it seems she can hardly endure; a spite- ful irritability; thirst; desires fresh air; restless; more or less dis- charge of dark blood from the vagina. Cocculus indicus. Terrible pain in the small of the back; lower limbs feel paralyzed; frequent vomiting. Conium. Great vertigo Avhen turning the head; very sensitive across the abdomen. Cuprum. Violent and distressing cramps in the uterine region; cramps in the extremities, hands and feet. Hyoscyamus. Delirium; jerking and twitching of muscles; bluish color of the face. Kali carb. Distressing pain in the back, running down into the glutsei muscles; stitching pain in the abdomen; abdomen bloated with wind; restlessness and thirst. Nux vomica. Sore aching pain in the region of the uterus; a very frequent inclination to stool; great mental depression and nervous irritability. Platina. Very great sensitiveness of the organs; severe cramping pains in the region of the uterus; constant oozing of dark, grumous blood from the vagina. Pulsatilla. In very mild, tearful women; desires fresh air; very rest- less ; absence of thirst. Rhus tox. Occasional paroxysms of pains extending doAvn the pos- terior surface of the limbs; restless, with relief after every change of position; must change frequently. Secale cornutum. A sensation of a constant tonic pressure in the uterine region; this causes great distress; wishes fresh air; don't like to be covered much. Sepia. Numerous little darting pains, shooting upAvard from the neck of the uterus; flushes of heat; cold feet. Sulphur. Frequent weak and fainty spells; Avishes to be fanned; flushes of heat and cold feet. 390 therapeutics of labor. In the preceding cases the remedy should be repeated every fifteen minutes or half an hour till improvement sets in. Fainting, Swooning, Syncope. These are synonymous terms, but perhaps syncope represents the complete stage of SAVOoning. In treating this abnormal manifestation much will depend upon the correct observation of the practitioner, and much care is needed that a proper prescription be made. If the patient is not already lying doAvn, she should be placed in that position, and an abundant quantity of fresh air should be allowed to enter the room. All applications are usually injurious, excepting perhaps a little cold water applied to the face by sprinkling or gentle bathing. The homoeopathic remedy is the safest dependence. The remedies herewith mentioned are suitable for attacks of syncope occurring before, during or after parturition: Aconite. When there is violent palpitation of the heart; congestion of blood to the head; buzzing in the ears; pale face on assuming an erect position from the recumbent; after a fright. Arnica. From injuries of any kind; from fatigue; from stitches about the heart; when the head is very hot and the body cool. Arsenicum. Result of debility or prostration, when the least effort causes fainting; thirst for frequent sips of cold water; wishes to be wrapped up warmly; pale bloating of the face. Carbo vegetabilis. Fainting from weakness caused by loss of animal fluids; after sleeping; after rising in the morning; much belching of wind or eructations. Chamomilla. Where there is great irritability of a spiteful kind; she is very sensitive to the pains, which cause fainting, with vertigo, dimness of vision, dullness of hearing and nausea; must have fresh air and fresh water. China. After loss of blood particularly or other animal fluids, with ringing in the ears, coldness of the skin, loss of pulse, and cold perspiration. Coffea. In highly sensitive persons after a fright, if aconite fails. Digitalis. Where the pulse is very slow and irregular; cold sweat; deathlike appearance of the countenance. Nux vomica. As the result of over-indulgence, as from over-eating, etc.; after vomiting; after every labor-pain; after stool; with con- gestion of the blood to head or chest, with trembling. weakness, debility, exhaustion. 391 Ignatia. When the fainting seems to result from grief; much trembling; sighing and sobbing. Sepia. Feet and hands cold as ice; flushes of heat; a distressed empty feeling in pit of stomach. Stramonium. Fainting spells occurring every day or several times a day; the person suddenly falls, with pale face and almost insensible breathing; sometimes face is bloated red; the fainting may continue a long time. Veratrum album. Fainting from the slightest exertion, turning in bed, straining at stool, retching as if to vomit, etc.; cold SAveat upon the forehead. Bryonia. When the fainting fits occur from the least motion, even Avhen no effort is required; sighing respiration; thirst for cold water. Camphor. Where there is a marble coldness of the surface of the whole body; very weak pulse. Cocculus indicus. Paralyzed feeling in all the limbs, with trembling; paralytic weakness, particularly in the lower extremities; spasmodic pains in the uterus, Avith nausea and vomiting. Lachesis. Fainting fits, Avith great and almost unconquerable sadness and gloom; dreads society and company; great and persistent consti- pation, Avith a sensation as though the anus Avere closed. In all these cases during the attack it is better to administer the remedies every five or ten minutes till consciousness is restored, and then wait for the next attack. Weakness, Debility, Exhaustion. Arsenicum. From any cause Avhen there is sense of great exhaustion after every effort, however small; chilly, wants to be Avrapped Avarmly; cold water disagrees; waxy paleness of skin; may be bloated; going up stairs is very exhausting; great restlessness, particularly after tAvelve o'clock at night. Calcarea carbonica. In leuco-phlegmatic temperaments; much per- spiration about head and upper part of body; every exertion is fatig- uing; ascending causes vertigo; cold, damp, clammy feet; the least cold air is almost unendurable. China. Particularly Avhen haemorrhages or loss of animal fluids are the cause; ringing in the ears like bells; vertigo; cold perspiration; feeble pulse; almost insensibility. Ferrum. Frequent attacks of tremor, alternating with a sensation of weaknesses if very weary; trembling of the whole body; feeling 392 THERAPEUTICS of labor. very weak; feels very Aveak even from talking; Avishes to lie do#n; face and lips very pale, or the cheeks may be fiery red. Iodine. Pulsation in all the arteries at every muscular effort; great prostration of strength, so that even talking causes perspiration; the sensibility of the nervous system is greatly increased. Kali carb. When one feels the pulsation of all the arteries even doAvn to the tips of the toes; feeling of emptiness in the Avhole body, as if the body Avere hollow; the whole body feels heavy and broken doAvn, so that it is only Avith the greatest effort that one can make any exertion. Lycopodium. When lying in bed she feels as if she would die from weakness; the loAver jaAv drops, not being able to keep the mouth shut; the breathing is slow and through the mouth; the eyes half open; Avhen walking she is obliged to let her hands hang down, and the bones of her lower extremities are painful; sudden weakness com- ing on even Avhen sitting; red sand in the urine; flatulency. Muriatic acid. Great debility, with hsemorrhoids so sensitive they can hardly be touched, and they often bleed; so weak cannot lie up on the pilloAV, but constantly slides doAvn into the bed. Nux vomica. Debility from abuse of coffee, wine, spirituous liquors or narcotic substances, from the abuse of highly seasoned food; night-Avatching; cannot walk on account of giving out of lower ex- tremities; knees knock together; wishes to lie doAvn all the time; cannot sleep Avell after three o'clock in the morning; great sensitive- ness to external impressions, noise, talking, strong scents and odors, or bright light; trifling ailments affect her almost beyond measure; blue margin around the eyes; nose looks sharper and more pointed than usual; the face shrunken. Rhus tox. Restlessness characterizes the use of this medicine; she is very restless, and is ahvays relieved for a short time by a change of position, Avhen she must move again; loss of appetite; cold Avater disagrees. Sepia. Sepia debility is usually characterized by a painful sensation of emptiness at the pit of the stomach; icy coldness of feet and hands; urine deposits a very hard, crusty sediment; flushes of heat; loss of appetite. Stannum. Characterized by great sense of weakness in the larynx and chest, thence all over the body, from talking or reading aloud. Sulphur. Weak, fainting spells coming frequently during the day; feels very faint and Aveak from eleven to tAvelve every morning; flushes of heat; cold feet; heat on top of the head. HAEMORRHAGE. 393 Veratrum. Excessive Aveakness; is obliged to move very slowly; so weak she can hardly raise her hand, and every motion seems to in- crease the debility; even a movement of the boAvels causes great de- bility ; very Aveak, almost imperceptible pulse; cold SAveat, particularly on the forehead; thirst for icy cold water. The above treatment, it need hardly be remarked, is suited not only to the Aveakness which sometimes manifests itself during the progress of labor, especially of tedious labor, but as well when occurring either during pregnancy or after parturition, or, in fact, at any other period of the woman's life. CHAPTER XIX. HEMORRHAGE. rjIHE haemorrhage that may occur in non-pregnant women will -L hereafter be considered under the head of Metrorrhagia, Avhile that which arises during the earlier months of pregnancy will be dis- cussed in connection with Abortion, in which it tends to result. Puerperal haemorrhage, our present theme, includes the flooding which occurs during the latter months of pregnancy, just previous to parturi- tion, during its progress or subsequent to the delivery of the child. No complication of labor is more justly dreaded by the practitioner, since there is none capable of proving more rapidly fatal unless promptly arrested. Nor indeed can this indispensable result be pro- duced unless the physician so completely retains his presence of mind in the most trying moments as to be able to ascertain the cause of the mischief, institute the requisite procedure where direct interference is needed, and select the proper medicaments Avhen operative interfer- ence is not called for. Fortunately, uterine haemorrhage is not a fre- quent complication of pregnancy and parturition. According to Churchill, out of 170,221 cases, haemorrhage occurred 1370 times, or nearly 1 in 124. The mortality of mothers and children is in frightful proportion, however, to the number of cases, for, according to the same author, out of 782 cases, 126 mothers died, or about 1 in 6; while of 944 cases, 288 children perished, or about 1 in 3. These results occurred in cases treated by practitioners who knew nothing of the efficacy of medicines applied homceopathically for controlling 394 HAEMORRHAGE. haemorrhage. The extent of the modifying effect homoeopathic treatment has upon the mortality of mothers and children in these cases is truly Avonderful and diminishes fatal cases almost to none at all. It may be laid doAvn as a general proposition that nearly all forms of hsemorrhage connected with child-bearing are due to a partial separation of the placenta, by which the utero-placental vessels are torn and their uterine orifices left patulous through the non-contraction of the uterine muscular fibres. (Post-partum haemorrhage, either before or after the expulsion of the placenta, may depend upon a variety of causes other than that just stated.) When hsemorrhage occurs before or during deli\rery it is due either to an accidental separation of the placenta, which may be properly im- planted at the fundus of the uterus, or to an unavoidable separation, in consequence of its being unnaturally located at the cervical extremity of the uterus and implanted more or less centrally over the os, so that the placenta beyond a certain point cannot grow nor the uterus ex- pand, nor can delivery be effected Avithout a more or less extensive separation of the placenta. From these circumstances haemorrhages occurring before or during labor ha\re been termed Accidental and Unavoidable. Accidental Haemorrhage. This form of hsemorrhage occurs when from any cause the placenta becomes partially detached from the uterine Avail; and generally the danger is proportionate to the extent of the detachment, though this is not always the case, for a fatal result may follow a slight separa- tion. The flow of blood may show itself externally if there be room for it to descend betAveen the uterus and the epichorion, and generally this is the case; or, on the other hand, it may be concealed, going on insidiously even to a fatal extent, and can only be known by its effects upon the system. The usual causes of this separation of the placenta are—shocks or bloAvs or violence of any kind, fatigue, over-exertion, straining from lifting or reaching, jolting in a carriage or on a rail- road, etc. It may likewise be produced by mental emotions, which, by exciting uterine action, may produce a separation of the placenta. In some constitutions, plethoric or susceptible, the slightest influences suffice to bring on the detachment and hsemorrhage, and in certain cases it seems to arise, as it were, spontaneously and without traceable cause during the course of labor. And again, there appears in some ACCIDENTAL HAEMORRHAGE. 395 cases to be an acquired tendency to accidental hsemorrhage, which the history of the case reveals to the practitioner. When the Aoav of blood is external the case is plain enough, and even Avhen the hsemorrhage is concealed its effects are so pronounced that a diagnosis is easily made. The most marked and characteristic symptoms are—acute pain, which occurs at the seat of injury, gener- ally the fundus; collapse ; great distension of the fundus of the uterus. In addition to these there may be rigors, tension and sensation of weight and fullness in the abdomen, and fainting. The pulse will be quick and feeble, and if the loss t of blood be considerable there will be pallor of countenance, great agitation, partial or total blindness, noises in the ears or complete deafness. In an article on " Concealed Accidental Haemorrhage " in the Amer- ican Journal of Obstetrics, August, 1869, Dr. William Goodell of Philadelphia gives the histories of one hundred and six cases. From this article Ave quote a portion of his summing up of the most marked indications of the occurrence of this unfortunate complication : " An analysis of the foregoing one hundred and six tabulated cases shows that by far the most frequent symptom is an alarming state of collapse, carrying dismay into the heart of the bystander. Every de- tailed example, without exception, presents most of its characteristics, such as coldness of the surface, excessive pallor, feebleness of the pulse, yaAvns, sighs, dyspnoea, restlessness and retching. "Pain holds the second rank in frequency. Out of these cases, sixty-four exhibit every grade of suffering, from the ' queerish feeling' to the 'greatest torture' and 'agonizing shrieks.' ... In the great majority the pain Avas referred to the site of the placenta, and Avas of a bursting character. . . . "The third most constant symptom is the absence or extreme feeble- ness of the pains of labor. Of the former, twenty-eight examples are tabulated, of the latter, fifty-six; but of these the majority presented no labor-pains until the membranes Avere ruptured, either naturally or artificially. In only twelve were the pains normal from the outset. "Next folloAvs a marked distension of the uterus, which produces those painful sensations of ' bursting,' that burden of every cry of the sufferer. Out of the one hundred and six examples, forty-tAvo presented this symptom, although not ahvays recognized during the life of the patient. . . . " V ery often, before the lapse of many hours, a show of blood, rang- ing from an ooze to a gush, will clear up all obscurity; but this trust- worthy symptom does not usually occur at the outset of the attack, 396 HAEMORRHAGE. but at a time Avhen it may be too late to interfere. A diagnosis should not, therefore, depend upon its presence, but simply be affirmed by it." The occurrence of such grave symptoms as these during the course of a labor should always excite strong suspicion of internal haemor- rhage ; and if there be a history of a fall, a bloAV, or any other me- chanical injury having been inflicted, the diagnosis is strongly con- firmed. Should accidental hsemorrhage occur during the progress of labor, and the pains are not arrested thereby, it will be noticed that during a pain the flow nearly or entirely ceases, in consequence of the closure of the mouths of the bleeding vessels by that natural hsemostatic uterine contraction. The opposite of this is the case in unavoidable hsemorrhage (placenta prsevia), where the floAV occurs during a pain and nearly or entirely ceases during the intervals. The diagnosis of accidental from unavoidable hemorrhage is essential to its proper treatment, and it may be determined by means of the following distinctions: I. Accidental hsemorrhage before labor or during its progress usually results from some definite and ascertainable cause, such as mechanical injury, while in placenta prsevia there is no such history, and the Aoav of blood commences, as it were, spontaneously, perhaps while the Avoman is at perfect rest or asleep in bed. II. In accidental hsemorrhage the discharge takes place freely in the intervals between the pains, and is arrested during the continuance of the pains ; Avhile in unavoidable hsemorrhage from placenta prse- via the conditions are exactly opposite, the flow occurring during the pain, Avhich expands the os uteri. III. In accidental hsemorrhage the os uteri is free, and closed by the membranes only, which may be tense or flaccid, and the presenting part of the fcetus may be made out by the finger; while in placenta prsevia the placenta, as a soft, spongy mass, may be detected Avithm the os, and in all probability the presenting part of the fcetus cannot be touched or made out. IV. In cases in Avhich accidental hsemorrhage occurs the lips of the os Avill not have more than their usual thickness; Avhile in placenta prsevia they will be thick, and active pulsation will be strongly marked. V. " In accidental hsemorrhage the blood, before being discharged, having to find its way some distance to the os, deposits its fibrin, so that coagulation does not occur in the vagina, which is free from clots; whereas the blood in placenta prsevia comes directly from the uterine ACCIDENTAL HAEMORRHAGE. 397 or placental vessels, or both, into the vagina, and is there discharged as blood, leaving coagulations behind in the vagina." * The treatment of cases of accidental hsemorrhage must be directed entirely by the circumstances of each case. If the woman has not advanced to full term and the hsemorrhage is slight, Avhich may be known by its effects upon the system, there is reason for believing that placental detachment has not taken place to any great extent. In such a case, by perfect rest in the recumbent posture, the allaying of all excitement or anxiety, cool drinks, and the administration of the appropriate and homoeopathic medicaments, the hsemorrhage may be arrested, and the Avoman delivered at term without any further untoward circumstances arising. At the close of this chapter the medicines appropriate in all cases of uterine haemorrhage are given, with their indications in detail; and to these remedies the reader is referred. The nicest discrimination is needed in effecting a proper selection of the remedy, and when the truly homoeopathic remedy has been selected in accordance with the totality of symptoms, subjective and objective, the practitioner will often be surprised by the happiest results in A^ery gloomy cases. The use of plugs of any kind, or the resort to other mechanical measures in such cases, will almost cer- tainly bring on labor. Even in the Avorst cases of accidental hsemorrhage a fair trial should be given to the homceopathically indicated medicament before proceeding to operate interference; this being Avarranted by the well-ascertained hsemostatic power of such specific medication, and by the success which has attended such efforts. In cases, hoAvever, where the flooding is very great, the danger is imminent, the woman is at her full term and the hamiorrhage is accom- panied with pains; or, again, in the above-described milder cases, where the measures recommended have failed, and labor has come on sponta- neously or in consequence of the irritation produced by plugging the vagina, the object of treatment must be to bring on labor, to induce uterine contractions, and to secure the expulsion of the child. These indications will be best fulfilled by rupturing the membranes, by which means the bulk of the uterus is diminished by the evacuation of the hquor amnii, its walls more effectually contract upon the placenta, at least temporarily arresting the Aoav from the uterine sinuses, and at the same time facilitating the expulsion of the foetus. This being done, a period of rest should be allowed to the patient, giving her time to rally, and at the same time giving opportunity to the natural * Dr. Calthrop, in Braithwaite's Retrospect. 398 HAEMORRHAGE. forces to complete the labor; and if dilatation of the os uteri pro- gresses and expulsive pains come on and increase, the case should be left Avithout further interference. Should the os be dilating naturally though slowly, and the flow be great, the vagina may be plugged if medicine fails to arrest the hsemorrhage Avhile the dilatation is com- pleted. Should the pains be feeble and the os not dilating, remedies suited to the existing condition in these respects must be selected- remedies Avhich will render available such desultory and inefficient pains as may be present. If, however, the case is such as to demand prompt delivery to secure safety for the mother, and the os fails to dilate, Barnes' dilators must be used for the purpose of effecting dilatation; and when that has been sufficiently accomplished labor may be completed by the long forceps, by podalic version or the bimanual mode of turning, according to circumstances. After the delivery of the fcetus, which is generally born dead in consequence of the collapse of the mother, the placenta usually comes aAvay as in ordinary cases; if it does not, the course of treatment to be pursued will be similar to that laid down for retained placenta under other circumstances. The after-treatment of the woman must be conducted with the utmost care, in order to secure a reaction of the vital forces. The remedy homoeopathic to her deplorable condition should be chosen, and such a remedy may be found in China or some other medicament mentioned hereafter. Unavoidable Haemorrhage—Placenta Previa. Placenta prsevia occurs when the ovule has descended after concep- tion, and has become fixed to some spot in the loAver part or cervical region of the uterus, so that the placenta becomes developed very near the internal os, overlaps a portion of it, or covers it completely, centre for centre. Such malposition of the placenta is by no means of fre- quent occurrence, happening about once out of every five hundred cases. In cases where the placenta is thus, misplaced, it is obvious that, as the uterus develops from above downward to the internal os, the dis- proportion betAveen the rapidly developing placenta and the slowly developing cervical region must become greater and greater, and about the sixth month it is very considerable: hence a rupture or de- tachment usually takes place at this period of pregnancy, and haemor- rhage—unavoidable hsemorrhage—occurs, more or less abundantly, and is repeated from time to time. UNAVOIDABLE HAEMORRHAGE—PLACENTA PRAEVIA. 399 In explanation of the phenomena Avhich occur in cases of pramal implantation of the placenta, Dr. Robert Barnes writes thus lucidly: " The inner surface of the uterus may be divided into three zones or regions by two latitudinal circles. The upper circle may be called the upper polar circle. Above this is the fundus of the uterus. This is the seat of fundal placenta, the most natural position. It is the zone or region of safe attachment. The lower circle is the lower polar circle. It divides the cervical zone or region from the merid- ional zone. The meridional space comprised between the two circles is the region of lateral placenta. This placenta is not liable to pre- vious detachments. Attachment here may, however, cause obliquity of the uterus, oblique position of the child, lingering labor, and dis- pose to retention of the placenta and post-partum hsemorrhage. " Below the lower circle is the cervical zone, the region of danger- ous placental attachment. All placenta fixed here, whether it consist in a flap encroaching downward from the meridional zone, or whether it be the entire placenta, is liable to previous detachment. The mouth of the womb must open to give passage to the child. This open- ing, which implies retraction or shortening of the cervical zone, is incompatible with the preservation of the adhesion of the placenta within its scope. In every other part of the womb there is an easy relation betAveen the contractile limits of the muscular structure and that of the cohering placenta. Within the cervical region this relation is lost. The diminution in surface of the uterine tissue is in excess. " The lower polar circle is, then, the physiological line of demarca- tion between prsevial and lateral placenta. It is the boundary-line below which you have spontaneous placental detachment and hsemor- rhage; above which, spontaneous placental detachment and hsemor- rhage cease." Haemorrhage seldom occurs until after the sixth month, and then comes on suddenly, Avithout admonition or apparent provoking cause. The flow may commence while the woman is sleeping, sitting at her sewing, at the piano, or elsewhere, and will as suddenly cease. The first hsemorrhage is not apt to be so profuse as subsequent attacks, and as a general rule the nearer the Avoman is to full term the greater will be the discharge. " The suddenness of the attack, the profuse- ness of the discharge, and its coming on without any evident cause, are peculiarly suspicious." In a longer or shorter period after the nrst attack the hsemorrhage is repeated, and is liable to become more and more profuse at every attack; for the disproportion between the 400 . HAEMORRHAGE. placenta and the de\relopment of the loAver segment of the uterus be- comes greater and greater as the time for delivery approaches. When these haemorrhages occur prior to the eighth month, and sub- side spontaneously Avithout bringing on labor or doing serious damage to the system of the mother, the best treatment is to keep the patient as quiet as possible and to prescribe such medicines as seem to be in- dicated by her symptoms. This course may be pursued from time to time till the arrest of the hsemorrhage or the prevention of labor seems no longer possible. Indeed, if from the first the hsemorrhage is great, and the mother is reduced to so miserable a condition that it would seem unadvisable and almost impossible for her to go to full term, labor may be induced as the best procedure. " It may be laid down as a rule of general application, and one which ought to be rigidly observed, that, no matter Avhat the period of gestation, any large loss of blood demands the termination of preg- nancy; for to leave a patient to be subjected to another attack, coming on, as it Avould do, without any warning, is in truth to place her life in imminent danger. The only justifiable ground for a temporizing policy is the concurrence of the folloAving conditions—that the dis- charge is slight, the period of pregnancy short of six months, the absence of pain, and an undilated os. If, on the contrary, the dis- charge is excessive, that alone justifies interference; and if at the same time there is pain, the result of uterine contraction, and the os is beginning to dilate, so much the better, as the chance of a speedy delivery is greater; but if the two latter conditions are not present, the chief object of our treatment will be to secure them."—Meadows. On making an examination per vaginam, the finger passed into the open os will detect the presence of a thick, soft, spongy mass, having the feel of a clot of blood, but with more firmness and consistence, quite unlike the smooth surface of the membranes, and blocking up the entrance to the uterus. It may be judged that the placenta in such a case is centrally implanted over the os uteri. If the placenta but partially cover the os uteri, then only one lip or side Avill be thickened ; and the condition will be shoAvn by the inability to carry the finger up within the uterus on that side, and by the ability to carry it up on the other side, and to feel there the smooth membranes or the presenting part of the child. If labor has set in, and there are pains, the haemorrhage will ahvays be Avorse during the pains, and will lessen or cease when they subside. The cause of this circumstance is as fol- lows : The object of the pain, or contraction of the uterus, is to dilate the os, so as to complete the first stage of labor; and of course the UNAVOIDABLE HAEMORRHAGE—PLACENTA PRAEVIA. 401 more the os dilates the more its adhesions with the placenta will be broken up; and as it cannot expel a bag of membrane full of water so the greater the pains the greater the hsemorrhage during their continuance. By far the best method of treating such cases—of lessening the haemorrhage and causing it to cease, of securing uterine contractions, and of bringing about dilatation of the os uteri—consists, in my opin- ion, in puncturing the membranes through the placenta and evacuating the liquor amnii. By this means the bulk of the uterus is lessened ; it contracts upon itself, and the haemorrhage is controlled. As the con- tractions take place, the os is dilated Avithout tearing up the adhesions of the placenta. And as dilatation is effected the placenta separates between its cotyledons, and the presenting portion of the child is per- mitted to pass through it. The placenta itself is finally delivered after the birth of the child, as in ordinary cases. The method of operating is as folloAA's: The finger must explore a sulcus between the cotyledons of the placenta, and with the same hand a female catheter, previously concealed in the palm, must be forced through the placenta and the membranes during a pain. The liquor amnii now passes off freely through the catheter; the bulk of the uterus begins at once to shrink and the hsemorrhage ceases. The finger may be used instead of a catheter, but much care is needed in this event, in order that the Avaters do not discharge themselves too rapidly, and thus produce atony from too sudden relief, for then the haemorrhage would not cease. The liquor amnii must drain off slowly; and as surely as it thus Aoavs, so surely will the hsemorrhage cease. After the waters have pretty much escaped, the finger may take the place of the catheter and aid in tearing the orifice larger, so that the presenting part can descend. Should the presenting part be the head, which is not always the case, its engagement in the os acts as a plug against any possible flow of blood, and gives further security if any is needed. If the shoulder is found presenting, or there be any other malpresentation, the case must then be treated in accordance with the directions laid down for such cases occurring under other circumstances. I have not heard of a single case of loss of the mother Avhere this method of procedure has been followed, and the child is almost in- variably saved. It must be remembered to evacuate the liquor amnii very slowly. Every accoucheur knows what bad effects follow the emptying of the uterus rapidly under such circumstances ; the atony thereby produced is more to be dreaded than the former state. When 26 402 HAEMORRHAGE. the placenta is only partially over the os, even if it be but the edg< of it, the same principle and practice hold good. Almost invariably after placenta prsevia has been thus treated the os uteri dilates in a natural manner, until it is sufficiently enlarged to admit of the passage of the child. Sli mid, however, a case occur in Avhich dilatation does not take place, Barnes' dilators may be used to effect dilatation, provided the homoeopathic remedy carefully chosen fails of its purpose. Some obstetricians have recommended, in cases of placenta praevia, that the hand be insinuated between the placenta and the uterus, the membranes reached and penetrated, and the child delivered by turn- ing. This is especially taught in cases where the placenta is placed centrally over the os. The suffering entailed upon the woman by this method, and the very great mortality of both mothers and children following its practice, sufficiently condemn it. Another plan of treatment has been recommended, especially by Sir James Simpson—namely, that of separating the placenta from the uterus entirely, and then trusting the case to nature. This procedure doubtless was suggested by the fact that in cases of placenta praevia, Avhere the placenta was spontaneously cast off and expelled previous to the expulsion of the child, the rate of mortality of mothers and children was less than under the ordinary methods resorted to by accoucheurs. In regard to this method Dr. Robert Barnes very justly remarks as follows: " But it is contended that clinical ob- servations prove that hsemorrhage has stopped on the total detach- ment of the placenta. These observations are partly true, partly fal- lacious. The true observations are those in Avhich the placenta has been spontaneously cast off and expelled before the birth of the child. These cases are not numerous. They do not justify the conclusion draAvn, that the artificial total detachment of the placenta will be equally followed by arrest of hsemorrhage. There is a fundamental physiological distinction between the two cases. When the placenta is cast off spontaneously, it is because the uterus contracts poAverfully. This contraction stops the bleeding. When the placenta is detached artificially, there may be, and probably is, defective uterine contrac- tion. The bleeding will be likely to continue. There is no inde- pendent virtue in the mere detachment of the placenta, as post-partum haemorrhage abundantly proves." Dr. Barnes offers a modification of Simpson's plan, which consists in separating from the uterus as much of the placenta as adheres within the orificial or cervical zone, and no more. He directs that one POST-PARTUM HAEMORRHAGE. 403 or two fingers be passed Avithin the os uteri and swept round in a cir- cle, so as to separate the placenta from the uterus as far as the finger can reach. " Commonly," he says, " some amount of retraction of the cervix takes place after this operation, and often the haemorrhage ceases. You have gained time. You have given the patient the precious op- portunity of rallying from the shock of previous loss, and of gather- iug up strength for further proceedings." Notwithstanding, however, the dictum of so eminent an authority, I am still fully persuaded that the puncture of the membranes and the gradual eA^acuation of the liquor amnii, as directed, is altogether the best method of treatment for cases of placenta prsevia. Post-Partum Haemorrhage. Haemorrhage following the delivery of the child may occur either before or after the delivery of the placenta. In the natural course of labor the child is delivered, while the placenta still retains more or less perfectly its connection with the uterus. In such cases little or no haemorrhage takes place up to this time. But with the first pains which occur after the expulsion of the child from the uterus the placenta begins to separate from its adhesion to the uterine parietes; and from this moment until the uterus has considerably contracted upon itself after the discharge of the placental mass there is some- times considerable loss of blood, sometimes almost none at all. Where all goes well, and the placenta is delivered, as it usually is, within fifteen or twenty minutes after the birth of the child, the hsemorrhage that does take place proves beneficial rather than injurious to the mother, by relieving the engorgement of the uterus and enabling the system in general more readily to adapt itself to the new condition. But just in proportion as this haemorrhage becomes prolonged, it be- comes more and more dangerous, whether it arise from causes Avhich hinder the progress of the labor in the first instance, or prevent the subsequent contraction of the uterine parietes. Hence, in order to be able intelligently to employ the requisite means, it is absolutely essen- tial to learn what are the efficient causes of the flooding in each indi- vidual case. This knowledge is to be obtained from the history of the case, from the conditions and symptoms obviously present, and from digital examination. If the haemorrhage be due to retention of the placenta, and the re- tention of the placenta be due to a want of tonicity of the uterus, in consequence of which it fails to contract, to close the mouths of the ute- rine sinuses and to expel its contents, the remedy appropriate to the con- 404 HAEMORRHAGE. dition should be chosen and administered; and if the placenta is de- tached and lying Avithin the uterus, it should be removed, as directed on page 201 of this Avork. From the list of remedies mentioned at the conclusion of this chapter the appropriate medicament may be selected. If, hoAvever, the placenta is adherent, and does not come away after a reasonable lapse of time and the administration of such remedies as Pulsatilla, Caulophyllum or Secale, Avhich have a tend- ency to excite uterine contractions, or if hsemorrhage should occur in consequence of the adherence of more or less of the placental mass, the hand must be introduced Avithin the uterus, and the placenta must be carefully and guardedly peeled from its attachments, in the manner directed on page 202, care being taken that neither too much nor too little is done, that the uterus is not injured by the fingers of the ac- coucheur, and on the other hand that no portions of the placenta are left behind, to occasion subsequent hsemorrhage or oozing of blood, septicaemia or other troubles. When the attempt is made to detach an adherent placenta in this manner, while the right hand of the ac- coucheur is engaged Avithin the uterus the left hand should be placed over the fundus uteri, to steady that organ in its place; and as the right hand and the placenta are AvithdraAvn, firm compression should be made with the left, following down the retreating uterus, to secure its complete and tonic contraction. If this is skillfully done the haemorrhage will cease. " You may suspect morbid adhesion if there have been unusual difficulty in removing the placenta in previous labors ; if, during the third stage, the uterus contract at intervals firmly, each contraction being accompanied by blood, and yet, on folloAving up the cord, you feel the placenta still in utero; if, on pulling on the cord, two fingers being pressed into the placenta at the root, you feel the placenta and uterus descend in one mass, a sense of dragging pain being elicited; if, during a pain, the uterine tumor do not present a globular form, but be more prominent than usual at the place of placental attach- ment." The other form of post-partum hsemorrhage, occurring after the de- livery of the placenta, is frequently very alarming, and may even be followed by a fatal termination. It is due to atony and relaxation of the uterus, whereby the mouths of the utero-placental sinuses remain open and pour forth a flood of blood, Avhich continues until firm ute- rine contraction is secured. Sometimes this comes on immediately after the delivery of the placenta, and continues Avithout cessation until arrested by appropriate treatment. At other times it comes on POST-PARTUM HAEMORRHAGE. 405 more insidiously; the uterus contracts apparently well after the deliv- ery of the placenta, and is found as a hard ball above the pubes, when suddenly the attention of the accoucheur is attracted by the woman declaring that she is flooding, or he sees by her countenance that her life-blood is wasting. The hand placed on the abdomen discovers the uterus distended and relaxed, high up in the abdomen and tender of pressure; and an examination per vaginam discovers a more or less copious Aoav of liquid blood, and perhaps the vagina, and even the uterus, filled with clots. It is evident that prompt and efficient measures are necessary in a case like this, not only with the view of saving life, but with the view also of saving blood, for " a pint of blood saved, and a pint of blood lost to the patient, may make all the difference between a rapid and a tedious convalescence—may make all the difference between a successful and a fatal issue." The most prompt and most efficient measure in such cases, according to my experience and that of a very large number of able homoeopathic practitioners, is, to apply that remedy which is homoeopathic to the totality of the case. This can be done as quickly as can any other procedure, and will be found efficient even in those cases where the blood flows pleno rivo and threatens almost immediate dissolution. The remedies appropriate for such occasions will be found laid down, with their indications, at the end of this chapter; and let me here remark that every practi- tioner should be as familiar with these indications as with the alpha- bet, and being so he will stand prepared in such emergencies with an armamentarium equal to the vanquishing of the most dangerous and desperate cases. It has been recommended to give brandy in unsparing doses, but this I regard as unnecessary. The pillow should be removed from beneath the woman's head, and the foot of the bedstead may be elevated a few inches higher than the upper part. Vomiting is not an unfavor- able indication, as it may excite uterine contraction; but if it occurs the woman's head should not be raised, but merely turned to one side' *irm pressure or grasping with the hand upon the Avomb is com- mended as a method of inducing contraction, and no doubt it is a measure of very great efficacy; but since the haemorrhage can be arrested by the administration of homoeopathic medicines alone it may be regarded as unnecessary to thus compress the tender womb effects6 thereby giVG n'Se t0 Seri°US and GVen dangerous after~ The use of cold or hot Avater injections, pieces of ice within the 406 HAEMORRHAGE. vagina and uterus, pouring cold or hot Avater from a height upon the abdomen, colpeurysis, and other similar measures for arresting the haemorrhage, all of Avhich are recommended by old-school authorities, are doubtless of more or less efficiency; and the homoeopathic prac- titioner Avould be justified in their use if the similar remedies failed to produce a prompt and satisfactory arrest of the flooding; but these do not fail when intelligently selected and applied, and a resort to them is avoided and a reliance on them condemned, a priori, by those only who have more faith in the above-mentioned appliances, or rather whose faith in the law of cure becomes faint when they are in the presence of a bad case of post-partum haemorrhage. Remedies for Uterine Haemorrhage. The medicines here mentioned are those most commonly indicated in cases of uterine hsemorrhage, whether occurring before, during or after parturition, or during the non-pregnant period. Special indica- tions, however, are given for the remedies useful in cases of threatened Abortion under the article on that subject, as well as for cases of ex- cessive menstruation under the article on Menorrhagia. The practi- tioner will do well to refer to these indications in connection with those given below. It is recommended that the indications for the remedies appropriate to all these forms of flooding be very carefully studied, that they may be indelibly impressed upon the memory and ready for instant use at the bedside. 1. Bell., Calc. c, Cauloph., Chin., Ferr., Ipec, Nux v., Sabin. 2. Bry., Cham., Croc, Erig., Hamam., Hyos., Lye, Merc, sol, Nitr. ac, Phos., Puis., Sec corn., Sep., Stram., Sulph., Trill. 3. Aeon., Ant. cr., Amm. c, Apocyn. c, Ars., Canth., Carb. veg., Coff, Iod., Nux m., Plat., Sang., Sil., Sulph. ac Aconite. In active haemorrhage, with fear of death and much ex- citability. She cannot sit up even in her bed. She seems so giddy she falls over. Particularly suitable to women of full, plethoric habit. Antimonium crud. Uterine haemorrhage, with a distinct pressure in the womb as if something would come out. Somewhat rheumatic. White tongue. Nausea and vomiting. Apis. Profuse uterine haemorrhage, Avith heaviness in the abdomen; faintness. Great uneasiness and yaAvning. Red spots like bee-stings REMEDIES FOR UTERINE HAEMORRHAGE. 407 upon the skin, and sensation as if stung by bees in the abdomen and in different parts of the body. Apocynum cann. There is great irritability of the stomach and vomiting; the blood is expelled in large clots, sometimes, however, in a fluid state; the vital powers are much depressed, and there is a disposition to faint. Argentum nit. Uterine haemorrhage, Avith much trouble in the head. Confusion, dullness and much pain, greatly aggrav