"\ M«J j<- \ l^j s % . . . . 302 ARTICLE VI. Lesions of innervation, ....... 303 Lesions of the sensorial, affective, and intellectual faculties—Vertigo, giddi- ness, syncope, ........ 303 Pruritus of the vulva—Itching of the skin, ..... 305 ARTICLE VII. Abdominal, lumbar, and inguinal pains, ..... 306 Uterine pains, ........ . 307 CHAPTER II. DISPLACEMENTS OF THE UTERUS. ARTICLE I. Prolapsus uteri, 309 CONTENTS. ARTICLE II. Faulty directions of the uterus, ..... Retroversion, ....... Anteversion, ........ ARTICLE III. Uterine obliquity, ...... Lateral obliquity, ....... CHAPTER III. OF ABORTION. ARTICLE I. Causes, ...... . . ARTICLE II. Symptoms, ........ ARTICLE III. Diagnosis, ....... ARTICLE IV. Prognosis, ........ ARTICLE V. Delivery of the after-birth, ..... ARTICLE VI. Treatment, ........ CHAPTER IV. OF DISEASES OCCURRING DURING PREGNANCY. Epidemic diseases, ...... Sporadic diseases, ....... Chronic diseases, ...... Surgical affections, ....... Ulceration of the neck of the uterus, .... PART III. OF LABOR IN GENERAL, BOOK I. Of premature labor, ..... Of retarded labor, ..... XX CONTENTS. BOOK II. OF NATURAL LABOR AT TERM, . • .360 CHAPTER I. CAUSES OF LABOR, . . . .366 CHAPTER II. PHYSIOLOGICAL PHENOMENA OF LABOR. Precursory signs, ..... First stage of labor, .... Second stage, ..... The pain, or contraction, Dilatation of the os uteri, .... Of the glairy discharges, Bag of waters, ..... Of the duration of labor, Effect of labor upon the mother and child, . CHAPTER III. OF THE MECHANICAL PHENOMENA OF LABOR. ARTICLE I. Of the presentations and positions, ...... 391 Table of presentations and positions, ..... 393 Classification of Naegele, Stoltz, and P. Dubois, .... 398 ARTICLE II. Of the vertex presentation, ....... 401 Causes—Diagnosis—Mechanism—Prognosis, ..... 402 ARTICLE III. Face presentation, ........ 420 Causes—Diagnosis—Mechanism—Prognosis, .... 421 ARTICLE IV. Presentations of the pelvic extremity, .... 432 Causes—Diagnosis—Mechanism—Prognosis, .... 433 ARTICLE V. Presentations of the trunk, ...... 444 Causes—Diagnosis — Mechanism—Spontaneous version— Spontaneous evolu- tion—rPrognosis, ....... 445 374 375 376 378 381 382 383 385 388 CONTENTS. XXI CHAPTER IV. OF THE NECESSARY ATTENTIONS TO THE WOMAN DURING AND AFTER LABOR. ARTICLE I. Of the attentions to the woman during labor, . . • • .454 ARTICLE II. Of the attentions to the child during labor, .... 464 ARTICLE III. Regimen of women in labor, . . . • • • ' ARTICLE IV. Of the attentions immediately after labor, ..... 470 ARTICLE V. 472 Phenomena of the lying-in state, ...••• ^'* Changes undergone by the generative organs after labor, ... 473 O o ./ o 4yy Of after-pains, ...•••••' Lochia, ...••••• Milk-fever, ....•■•• 483 486 ARTICLE VI. Attentions to the lying-in woman, ...••• CHAPTER V. OF THE ATTENTIONS TO THE CHILD IMMEDIATELY AFTER ITS. BIRTH. Debility or disease of the child—Apparent death of the child—Debility of new- born children, ..••••• PART IV. OF DYSTOCIA, ... 502 FIRST DIVISION. CAUSES OF DXSTOCIA, . . .502 BOOK I. OF LABORS RENDERED DIFFICULT, IMPOSSIBLE, OR DANGEROUS, BY DEFICIENT OR EXCESSIVE ACTION OF THE UTERINE FORCES. CHAPTER I. 503 Extreme slowness of the labor, . . Slowness or feebleness of the contractions, . XXU CONTENTS. • 507 Relaxation or suspension of the pains, . . • ^qq Irregularity of the pains, . 5^0 Of ergot, ...••• CHAPTER II. 514 OF TOO RAPID LABORS, . BOOK II. OF LABORS RENDERED DIFFICULT, IMPOSSIBLE, OR DANGEROUS, BY OBSTACLES OPPOSING THE READY EXPULSION OF THE FCETUS. CHAPTER I. DEFORMITIES OF THE PELVIS. 518 Of the pelvis deformed by excess of amplitude, . Of the pelvis deformed by excess of contraction, . ARTICLE I. Pathological anatomy, ..•••• ARTICLE II. Causes, ...•■>• ARTICLE III. Effect of contractions of the pelvis upon pregnancy and parturition, . . 540 ARTICLE IV. tv • .... 547 Diagnosis, ..•••• ARTICLE V. Indications presented by deformities of the pelvis, . . . .565 CHAPTER II. MALFORMATIONS OF THE VULVA AND VAGINA. Adhesions of the external and internal labia, . . . . 571 Persistence of the hymen, • 571 Smallness and rigidity of the vulva, '.....571 Resistance of the perineum, ....... 573 Malformations of the vagina, ...... 574 Inversion of the vagina, ....... 577 520 530 CONTENTS. XX111 CHAPTER III. TUMORS IN THE EXCAVATION. ARTICLE I. Tumors developed in the bony walls, . . . 578 Exostosis, ....••••• 578 Osteo-sarcoma, .....•••• 57» Deformed callus, ....•••• ^79 ARTICLE II. Tumors appertaining to the soft parts, ...... 580 CEdema of the labia externa, ...... 580 Sanguineous tumors, or thrombus of the vulva and vagina, . . • 580 Thrombus of the lips of the cervix uteri, ..... 588 Various other tumors, ....•••• 589 Tumors appertaining to the neck or body of the uterus, . . . 589 ARTICLE III. Tumors in the adjacent parts, ....... 593 Tumors of the ovary, ...•••• ^94 Tumors of the Fallopian tube, ....••• 596 Tumors of the rectum, ....... oyo Tumors of the bladder, ....•••• 5y' Tumors developed in the cellular tissues of the pelvis, . ... 598 Hernial tumors, ....••••• 5" CHAPTER IV. OBSTACLES DEPENDENT ON THE NECK OR BODY OF THE WOMB. ARTICLE I. Rigidity of the cervix, Spasmodic contraction of the cervix, Obliquity of the cervix, Agglutination of the external orifice, Tumefaction and elongation of the anterior lip, Abscess in the lips of the cervix, Induration with hypertrophy of the cervix, Cancer of the neck, Complete obliteration of the neck, . 602 603 605 607 608 609 609 609 611 ARTICLE II. Obstacles dependent on the body of the womb, . . • .611 Anterior obliquity, ...••■•• "** Posterior obliquity, ....••• Lateral obliquity, ...••••■ 613 616 XXIV CONTENTS. Hernia of the womb, ......■• Prolapsus uteri, ......-• CHAPTER V. OBSTACLES DEPENDENT ON THE F03TUS OR ITS APPENDAGES. ARTICLE I. Diseases of the foetus—Hydrocephalus, Hydrothorax and ascites, ...... Deformities of the foetus—Emphysematous condition of the foetus, Tumors of the foetus, ...... Anchylosis of the foetal articulations, .... ARTICLE II. Excess of volume of the foetus, ...... 627 Monstrosities, ......... 627 Multiple and adherent foetuses, ...... 628 Multiple and independent foetuses, ...... 629 ARTICLE III. Prolapsus or falling of the cord, ...... 634 ARTICLE IV. Shortness of the cord, ........ 639 ARTICLE V. Malpositions of the child, Inclined vertex positions, Anomalies in the mechanism of natural labor, Inclined breech positions, Face positions, .... Trunk positions, .... Complicated positions, BOOK III. OF THE DISEASES OR ACCIDENTS THAT MAY COMPLICATE LABOR, AND REQUIRE THE INTERVENTION OF ART. CHAPTER I. OF PUERPERAL HEMORRHAGE. ARTICLE I. Of the causes of uterine hemorrhage—Predisposing causes, Determining causes, ...... Special causes, ....... Insertion of the placenta upon the lower segment of the uterus, Rupture of the cord or of one of its vessels, 624 625 625 626 643 644 645 647 647 651 652 657 662 663 661 CONTENTS. xxv Shortness of the cord, ........ 670 Rapid contraction of the uterus, ...... 672 ARTICLE II. Symptoms of uterine hemorrhage, ...... 072 External discharge, ......... 673 Internal discharge, . . . . ' . . . . 673 ARTICLE III. Diagnosis, ......... 674 ARTICLE IV. Prognosis, ......... 678 ARTICLE V. Treatment, ......... 683 A synoptical table of the treatment, ...... 693 CHAPTER II. OF PUERPERAL CONVULSIONS Causes, ....... Symptoms, ...... Terminations, ...... Diagnosis, ...... Prognosis, ....... Pathological anatomy, ..... Nature of eclampsia, ..... Treatment, ...... CHAPTER III. OF RUPTURES OF THE UTERUS Causes, ....... Symptoms, ...... Prognosis and termination, ..... Pathological anatomy, ..... Treatment, ....... Ruptures of the vagina, ..... CHAPTER IV. OF RHEUMATISM OF THE UTERUS, . 743 CHAPTER V. OF CERTAIN DISEASES THAT MAY COMPLICATE LABOR, . 747 SECOND DIVISION. OBSTETRICAL OPERATIONS, . . 750 097 702 707 709 711 714 715 718 729 734 735 737 739 741 XXVI CONTENTS. Cephalic version, CHAPTER I. OF VERSION. ARTICLE I. ARTICLE II. Pelvic version, Precautions to be observed, Necessary conditions, General rules of the operation, . Difficulties that may be met with in its performance, Appreciation of version, Version in vertex presentations, Version in face presentations, Version in breech presentations Version in trunk presentations, . Trunk presentations with escape of the arm, CHAPTER II. OF THE FORCEPS. ARTICLE I. Preliminary precautions, ...... ARTICLE II. General rules for the application of forceps, .... ARTICLE III. Special rules for the application of forceps, .... Application in vertex presentations, ..... Application in face presentations, ..... Application of the forceps on the retained head, after delivery of the body, General considerations on its employment, ..... 751 757 757 759 760 765 772 773 774 774 775 776 782 783 789 789 797 800 802 CHAPTER III. OF THE LEVER OR VECTIS, 811 CHAPTER IV. OF PREMATURE ARTIFICIAL DELIVERY. ARTICLE I. Cases requiring premature artificial delivery, ARTICLE II. Operative procedures, 814 819 CONTENTS. XXV11 CHAPTER V. OF THE PRODUCTION OF ABORTION, . . 827 CHAPTER VI. OF THE EFFECT OF BLEEDING AND A DEBILITATING REGIMEN UPON THE DEVELOPMENT OF THE CHILD, . 831 CHAPTER VII. OF SYMPHYSEOTOMY, . . .834 CHAPTER VIII. OF THE CESAREAN OPERATION, . . 839 CHAPTER IX. OF EMBRYOTOMY, . . . .848 PART V. OF THE DELIVERY OF THE AFTER-BIRTH. ARTICLE I. Of the natural delivery, ARTICLE II. Of the artificial delivery, Inertia of the womb, Excessive volume of the placenta, Weakness of the cord, Irregular or spasmodic contractions of the uterus, Abnormal adhesions of the placenta, Of partial or complete retention of the placenta, Of putrid absorption of the placenta, Tardy expulsion of the placenta, Complete absorption of the placenta, ARTICLE III. Of hemorrhage before, during, or after the delivery of the placenta, Causes of hemorrhage—Inertia, ..... Symptoms, . . . • • • • Diagnosis, ....•••• Prognosis, ....... Preventive treatment, ...... 865 866 867 867 872 875 876 877 878 880 880 881 883 883 884 xxvm CONTENTS. Curative treatment, . Use of the tampon, ..... Compression of the uterus, .... Compression of the aorta—Discussion, Ergot, ....... Transfusion, ...... Inertia and secondary hemorrhage, Active and passive hemorrhage, but without inertia of the walls, Hemorrhage from the umbilical cord, . Inversion of the womb, . Rupture of the uterus, . 885 . 887 SS7 . 890 890 . 893 ills, 894 . 896 896 . 900 PART VI. OF THE HYGIENE OF CHILDREN, 902 BOOK I. OF THE ALIMENTATION OF CHILDREN, 902 CHAPTER I. OF LACTATION, 903 CHAPTER II. OF NURSING. ARTICLE I. Of nursing by the mother, ...... Precautions ^o be observed by women who intend nursing, Rules to be observed whilst nursing, ..... ARTICLE II. Of weaning, ....••■• ARTICLE III. Of the regimen of mothers, whilst nursing, .... ARTICLE IV. Of obstacles to nursing, ...... Of erosions and excoriations, of chaps, fissures, and cracks of the nipple Accidents which may obstruct nursing by the mother, Variations in the quantity of milk—Agalactia—Galactorrhoea, Health of the mother, . .... Alterations in the quality of the milk, ..... 909 910 911 920 922 923 924 92K 929 930 930 CONTENTS. XXIX ARTICLE V. Of mixed nursing, . . ...... 932 ARTICLE VI. Of wet nursing, ........ 935 Of the choice of a nurse, ....... 935 How to regulate nursing by wet nurses, ..... 939 Of the regimen of wet nurses, ....... 941 ARTICLE VII. Of nursing by a female animal, ...... 942 ARTICLE VIII. Of artificial nursing, ........ 942 CHAPTER III. GENERAL CONSIDERATIONS RESPECTING CERTAIN POINTS RELATING TO THE HYGIENE OF CHILDREN. Clothing, ......... 944 Washing—Bathing—Attention to cleanliness, . . . . . 944 Aeration—Promenades, ....... 945 Sleep,..........946 APPENDIX. On the use of anaesthetics in obstetrical practice, . INTRODUCTION. Labor is that function which consists in the natural or artificial expulsion of a viable foetus through the natural parts of generation. The term expulsion, evidently comprises three secondary ideas : namely, that of a body which expels, that of a body which is expelled, and that of an opening or canal through which this expulsion takes place. Fence, we may foresee to what an extent the structure, the position, the dimensions, and the relations of these different parts, must influence the degree of facility with which this func- tion is accomplished; as also, how greatly a knowledge of this structure, and these relations, must facilitate a comprehension of the forces brought into play by nature for the accomplishment of her work, and of the mechanism whereby the expulsion is effected. Consequently, the first part of this book will be devoted to a description of the generative organs of the female; in which, we shall first study the pelvis, and, after having described each of its constituent parts, shall consider it as a whole; carefully pointing out the peculiarities that its form, direction, or dimensions may offer; and then passing immediately to an anatomical description of the ex- ternal and internal organs of generation. Most of the leading authors, after describing all these parts in their normal condition, study their vices of confor- mation, position, &c.; but as this method appears objectionable, we defer the consideration of all those anomalies, that are justly viewed as causes of dystocia, to the division in which we treat of difficult labors. For, by thus bringing to- gether the causes and the effects they produce, we hope to avoid unnecessary repetition, to aid the memories of students, and at the same time to demonstrate more fully the importance of a knowledge of these anomalies. The physiology of the organs of generation is so intimately connected with their anatomical arrangement, as to make it impossible to describe them fully without treating at the same time of their functions. The phenomena which they present at certain periods are, besides, very properly considered as the pre- ludes of generation, rendering a previous study of them indispensable to all who would understand the modifications which these organs undergo during the puer- peral state. After having studied the organs of the female in the non-gravid condition, we shall examine the numerous and important modifications they undergo during gestation; and from this examination we shall deduce the signs of pregnancy, XXX11 INTRODUCTION. and the therapeutical measures that may be employed for the particular symp- toms to which they give rise. The second part will be concluded by studying the primary cause of all these modifications; that is, the foetus and its appen- dages, which will be severally considered at the different stages of their develop- ment. These preliminary points having been acquired, we shall then be prepared to describe the parturition, in which two orders of phenomena will be distinguished : the one, being purely physiological, is an expression of the vital actions brought into play for the expulsion of the foetus; while the other is entirely mechanical, and constitutes the mechanism whereby this expulsion is effected. We have devoted much space to the description, and more particularly to an explanation of the mechanism of natural labor; and we hope to have succeeded in explain- ing certain facts connected therewith, that have hitherto only been pointed out. In the fourth part, which is devoted to the management of difficult labors, we shall enumerate in detail the causes of dystocia, the mode of action of each, the signs by which their existence may be recognized, the indications for treatment they present, and the means of remedying them. In the fifth part, we shall study the delivery of the after-birth. Like the parturition, this is usually simple and natural, but it may be complicated by numerous difficulties and accidents that require the intervention of our art; and hence, in order to fill up properly the design we have traced out, it will be neces- sary to treat in detail of the natural, the artificial, and the complicated delivery of the after-birth. Finally, in the sixth and last part, we have endeavored to give, in as condensed a form as possible, such principles of hygiene as are applicable to the physical education of children from birth to the time of weaning. A TREATISE ON MIDWIFERY, PART I. OF THE FEMALE ORGANS OF GENERATION. The female organs subservient to generation are: the ovaries, the principal function of which is the secretion of the ovule or female germ; the Fallopian tubes, designed to receive the ovule, and conduct it into the cavity of the uterus; the uterus, a kind of receptacle, whose office it is to contain the fecundated germ during its period of development, and to expel it immediately afterward; finally, the vagina, a membranous canal extending from the neck of the uterus to the external genital parts. Most of these organs are situated within a large cavity, the walls of which are composed of bones and soft parts; the cavity is termed the cavity of the pelvis, or pelvic cavity. On account of the importance of the pelvis as an organ both of protection and transmission, we shall, with it, begin the study of the organs of generation. CHAPTER I. OF THE PELVIS. The basin, in Latin, pelvis, is a large, irregular, bony cavity, a sort of curved canal, which terminates the trunk inferiorly, and sustains it by its posterior part. It is placed directly upon the lower extremities, which afford it points of support, and to which, in the erect posture, it transmits the weight of the upper portions of the body. Its position in an adult of ordinary stature is, in general, about the central part of the whole trunk. In the infant at term, and more especially during the intra-uterine life, it is much below this point; and at a certain period of foetal existence, when the lower extremities resemble as yet but little nipples, it even occupies the inferior portion of the body. Especially should the accoucheur study the pelvis in its totality and in its relations with 2 18 FEMALE ORGANS OF GENERATION. the great function which it subserves. Now as the best way of understanding a whole is to decompose it, and study separately its constituent parts, we shall proceed at once to consider individually the bones which enter into the compo- sition of the pelvis. ARTICLE I. The bones which together constitute the pelvis are: the sacrum, and the coccyx, both placed behind and on the median line, and the ossa innominata or coxal bones. These last are in pairs, being situated at the sides and articula- ting with each other in front. § 1. Of the Sacrum. This is a symmetrical, triangular bone, which is curved forward at its lower part, and is placed at the posterior part of the pelvis, where it appears like a wedge, forced in between the two ossa innominata, immediately below the verte- bral column, and directly above the coccyx. It is traversed longitudinally by the sacral canal (a continuation of the vertebral canal), and, relatively to the axis of the body, it is directed from above downwards, and from before backwards; hence the column represented by it forms an obtuse angle with the lumbar vertebrae, being salient in front, and receding behind. This point is called the promontory, or the sacro-vertebral angle. Besides this direction, the sacrum is curved upon itself from behind forwards, so as to present an anterior concavity, the hollow of the sacrum: this curvature is generally much more marked in the female than in the male. Anatomists describe the bone as having two faces, two borders, a base, and an apex. 1. The spinal, or posterior face, is convex, rough, and very irregular, pre- senting on the median line three, four, or five prominences, the longest of which are above, and continuous with the ridge formed by the series of spinous pro- cesses of the vertebras; lower down, the sacral canal is terminated as a triangular gutter, being bounded laterally by two tubercles, called the cornua of the sacrum; upon each side of, and close to the median line, a large furrow exists, at the bottom of which the four posterior sacral foramina are seen, communicating with the vertebral canal, and serving to transmit the nerves of the same name. Outside of these foramina we find a series of elevations, apparently analogous to the transverse processes of the vertebrae; and above them two irregular fossae, into which the posterior sacro-iliac ligaments are inserted. 2. The pelvic, or anterior face, is smooth and concave, and is traversed by four prominent transverse lines, the remnants of the sutures between the different pieces that composed the bone in early infancy, and which served to separate some superficial, transverse, and quadrilateral grooves found there, from each other. Sometimes the first of these prominent lines is so well marked as to be mistaken, when practising the touch, for the sacro-vertebral angle. The anterior sacral foramina, four in number, are found nearer the lateral mar- gins ; they communicate with the sacral canal, and transmit the anterior branches of the nerves of the same name. Beyond the foramina is an unequal surface for the attachment of the pyramidal muscles. OF THE PELVIS. 19 3. The borders of the sacrum may be divided into two portions. 1. The superior, being very thick, presents, on its anterior half, a semilunar articular facet for joining with the coxal bone, and on its posterior part an excavation, and some rough projections for the attachment of the sacro-iliac ligaments. The other, or inferior portion, is quite thin, and is occupied by the insertion of the sacro-sciatic ligaments. 4. The base is directed upwardly and a little in front, and has its greatest dia- meter transversely. An oval facet, more or less inclined backwards, surmounts it at the middle, whereby the bone is articulated with the last lumbar vertebra. Upon each side is seen a smooth surface, which is concave transversely, and con- vex from before backwards. These surfaces incline forwards and are continuous with the iliac fossae, being covered, in the recent subject, by the anterior sacro- iliac ligaments. They are separated from the anterior face of the sacrum by a rounded border, which forms, as we shall hereafter learn, the posterior part of the superior strait. The two surfaces constitute the wings of the sacrum. Be- hind, are found the upper orifice of the sacral canal, and the two articular pro- cesses of the first piece of the sacrum. 5. The apex of the sacrum is directed downwards, and a little backwards; presenting an oval facet for the articulation of the coccyx. 6. The sacral canal, hollowed out in the thickness of the bone, is the termi- nation of the vertebral canal; being triangular and broad superiorly, it becomes narrow and flattened at its inferior part, where it degenerates into a gutter, that is converted into a canal by the ligaments. This lodges the sacral nerves, and communicates both with the anterior and the posterior sacral foramina. The sacrum, although quite thick, is a very light and spongy bone. Besides, it is pierced by a great number of foramina, and traversed by a central cavity, which serve to diminish its weight still more. It is formed of five principal pieces (false sacral vertebrae), sometimes of six, and in one case, seven were observed (Pauw). In Soemmerring's cabinet are three specimens which present but four pieces. The development of the sacrum is analogous to that of the vertebras, and takes place from thirty-four or thirty-five points of ossification, arranged in the follow- ing manner:— 1. Five of them, placed one over the other, occupy the anterior and middle parts. 2. In each of the interspaces which separate these, two small osseous laminae are developed some time after birth, which seem to form their articular surfaces. 3. Ten are situated in front and upon each side of the latter, that is, one for each lateral portion of the four or five primitive bones. 4. And behind them six others are developed, between which : 5. There appear three or four that correspond with the spinous processes, or their laminae; and 6. Lastly, there is one upon each side above the iliac surface, for the articular facet. § 2. The Coccyx. This name is given to an assemblage of three or four, occasionally five little bones, united with each other on the median line of the body, and apparently suspended at the point of the sacrum, of which, indeed, they appear to be only a movable appendage, continuing its line of curvature forwards. 20 FEMALE ORGANS OF GENERATION. M. Cruveilhier declares that he has known it, in some cases, to form a right angle or even an acute one with the sacrum. As a whole, the coccyx represents a triangular and symmetrical bone. 1. Its spinal, or posterior face, is convex and irregular, and is only separated from the skin by the posterior sacro-coccygeal ligament. 2. Its pelvic, or anterior face, is smooth and slightly concave, and lies in con- tact with the termination of the rectum, which rests upon it. Like the pre- ceding bone, it is marked by certain transverse grooves, corresponding with the intervals which had, for a long period, separated its different pieces. 3. Its two lateral borders are quite irregular, and are occupied by the attach- ments of the anterior sacro-sciatic ligaments, and the ischio-coccygeal muscles. 4. Its slightly concave base presents, above, an oval surface, which articulates with the apex of the sacrum, and behind, two little tubercles called the cornua of the coccyx. 5. The apex is rounded, irregular, and sometimes bifurcated, affording attach- ment to the levator ani muscle. The coccyx is developed from four or five centres of ossification, that is, one for each of its parts. § 3. The Coxal Bone, Haunch Bone, or Os Innominatum. This is a non-symmetrical, quadrilateral bone, curved upon itself, as if twisted in two different directions, contracted in its middle, and of a very irregular figure. The pair occupy the lateral and anterior parts of the pelvis. It presents an in- ternal and external face, and four borders, for our consideration. 1. The external, or femoral surface, is turned outwards, backwards, and down- wards, at its superior part, whilst inferiorly, it looks forwards. At its superior and posterior portion is seen an unequal, narrow, and convex surface, affording origin to the gluteus maximus muscle, and terminated below by a slightly elevated circular ridge, called the superior curved line. Beneath this, there is a larger surface, which is concave behind, narrowed in front for the insertion of the gluteus medius muscle, and bounded by a slight ridge below, called the inferior curved line; still lower, there is a third extensive and convex surface, serving for the attachment of the gluteus minimus muscle. All that portion of the femoral face just described forms a large fossa, alternately concave and convex, bearing the name of the external iliac fossa. Towards the front, the external face presents the cotyloid cavity or the aceta- bulum, at its superior part; and a little more in advance and below the sub- pubic, or obturator foramen. This opening is triangular, with rounded angles • its long diameter is inclined downwards and outwards, and its circumference is sharp and irregular, presenting above a groove, directed obliquely from behind forwards and from without inwards, through which the obturator vessels and nerves pass out. A fibrous membrane that subtends the foramen is attached to its periphery, except in the immediate vicinity of the groove. Upon the inner side of the obturator foramen, between it and the median line there is a concave or nearly plane surface for the origin of several muscles. 2 The abdominal, or internal face, is directed forwards at its upper part and backwards at the lower. It may be divided into two portions; the superior of OF THE PELVIS. 21 which is characterized by a large excavation, called the internal iliac fossa, by a semilunar articular surface found just behind this fossa, and called the auricular facet, and still more posteriorly, by some rugosities, analogous to those found on the articular faces of the sacrum. The superior portion is terminated below by a large, rounded, and concave line, which separates it from the other moiety. The latter, or inferior portion, presents behind a nearly triangular plane surface, which corresponds to the coty- loid cavity and to the body of the ischium; near its middle, we find the obtu- rator foramen, and in front, the internal face of the pubis and of the ischio-pubic ramus. 3. Borders. These are four in number. The posterior one has a very irregular shape, being oblique from above downwards, and from without inwards. The posterior superior spinous process is found at its junction with the superior border. This prominent, well-marked eminence is separated by a rough margin from an- other though less voluminous one, called the posterior inferior spinous process. Below this last apophysis, the student will observe a very deep notch, which contributes to the formation of the great sciatic foramen, and is terminated below by a triangular, pointed projection, bearing the title of the spine of the ischium. This process is more or less prominent in different individuals, and is sometimes directed inwards. A groove is seen just beneath it, in which the tendon of the obturator internus muscle plays; this groove is a part of the lesser sciatic notch; and lastly, this border terminates at the tuberosity of the ischium. The anterior border is concave, oblique above, and nearly horizontal in front. The anterior superior spinous process is formed by its union with the superior border. A considerable depression exists under this apophysis, which separates it from another one, called the anterior inferior spinous process. Then we find a groove just under this elevation, for the gliding of the conjoint tendon of the psoas magnus and the iliacus internus muscles; which groove is bounded, in front and below, by the ilio-pectineal eminence. And lastly, the border is termi- nated by a triangular horizontal surface, which is directed downwards and for- wards, and is broader externally than internally, and by the spine and angle of the pubis. The superior border or crest of the ilium is thick, convex, and inclined out- wards, excepting at its posterior part, where it looks slightly inward—being twisted, in its course, somewhat like an italic/. Anatomists have subdivided it into the external and internal lips, and the intervening space. The anterior superior spinous process bounds it in front, and the posterior superior one behind. The inferior border is shorter than either of the others; it presents, however, three parts for study. There is an oval surface above, for articulating with its fellow of the opposite side, forming the symphysis; below, it is terminated by the tuberosity of the ischium, and in the middle, we find the ischio-pubic ramus; this is a sharp ridge, formed superiorly by the descending branch of the pubis, and inferiorly by the ascending portion of the ischium. The coxal bone is developed from three principal centres of ossification, which appear at the same time in the iliac fossa, the tuberosity of the ischium, and in the pubis. Owing to this mode of growth, it has been customary to divide the os innominatum into three portions : the superior one, styled the ilium, forms, in oo FEMALE ORGANS OF GENERATION. a great measure, the contour and prominence of the hip; the pubis, being ante- rior, supports the genital organs; and the inferior one, which sustains the body when seated, is named the ischium. Several years after birth, an osseous lamina resting upon the superior border of the bone, is developed to form the iliac crest, whilst a similar layer embraces the tuberosity of the ischium, and extends to its ramus; at the same time, a third centre of ossification appears for the anterior inferior spinous process of the ilium, and a fourth forms the angle of the pubis. ARTICLE II. ARTICULATION'S OF THE PELVIS. These are five in number; namely, one in front for the pubes, two behind for the iliac bones and sacrum, that of the coccyx with the sacrum, and of the latter with the spine. Three of these articulations have also received the name of symphyses; for instance, the term symphysis pubis has been applied to the articulation between the two bones of the pubis, and that of sacro-iliac symphyses, to those of the sacrum with the ilium. They have been classed with the amphiarthroses. The researches of 31. Le- noir, however, have proved the correctness of those anatomists who regarded them as arthrodia. He has shown, by an examination of the bodies of twenty- two females, between the ages of eighteen and thirty-five years, that the four pelvic articulations are formed by the contact of surfaces covered in great part with cartilage, and lined with synovial membranes. § 1. Symphysis of the Pubis. This articulation is formed by the approximation of the oval surfaces occupy- ing the upper part of the lower border of the coxal bones. These surfaces are slightly convex and unequal, and are covered with a cartilaginous lamina which fills up the inequalities. The convex shape and the direction of their faces are such, that they only come into contact for an inconsiderable extent at their inter- nal or posterior part, and hence they leave above, in front, and below, an open space, which is the more considerable, in proportion to the distance from the centre of the joint. The articulating surface of the two cartilages is a little facet, about six to eight lines in its vertical diameter, by two to three in its transverse one. This facet is smooth, and furnished with a synovial membrane, which is the more lubricated with synovia as the female approaches the period of labor. A considerable thickness of the interpubic ligament fills up the interval which exists between the other points of these articular surfaces. This interpubic ligament is formed of a very dense fibrous substance. It has the form of a wedge, with the point forced down between the bones and the sides adhering to the rough surfaces fronting the articulation. Two planes of fibres are discoverable in it; the deeper ones, which pass from one iliac bone to the other, and are shorter in proportion to their depth, are crossed, and disposed in several layers. They constitute the interpubic ligament properly so called. The OF THE PELVIS. AO others, which are more superficial, are parallel, and pass obliquely from within outwards and from above downwards. Beginning at the upper part of the arti- culation they spread in descending, until they are finally divided* into two bundles, which become lost in front of the branches of the pubic arch by min- gling with the periosteum of the bones and the tendons of the muscles inserted in the vicinity. These form the anterior pubic ligament. The uppermost portion of the anterior pubic ligament seems to take its origin in the fibrous cord which is inserted on the spine of the pubis, and which cushions, so to speak, the upper edge of that bone, in such a way as to efface its inequalities. It constitutes the superior pubic ligament. Lastly, at its lowest part, the anterior pubic ligament assumes the form of a thick triangular bundle occupying the summit of the pubic arch, and fixed by its lateral edges to the upper and internal part of the two branches thereof. This ligament, called the triangular, or sub-pubic ligament, presents a rounded base, which completes the arch of the pubes by giving it a regular curve calculated to facilitate the exit of the foetus. Thus, we have three anterior pubic ligaments, a superior pubic and a sub- pubic ligament, all of them representing a spreading out of the interosseous liga- ment. Behind the symphysis, the fibro-cartilaginous substance forms a sort of projecting pad, which occupies the middle part only, and disappears from above downwards. Finally, the ligamentous arrangement of the articulation is completed by the posterior pubic ligament, composed of fibres extending transversely from one pubis to the other, above the projection just noticed. This ligament, which is very thin, and of moderate strength, forms the posterior lining of the synovial membrane. § 2. Sacro-iliac Symphysis. This articulation is formed by the junction of the semilunar facets, which were pointed out in describing the border of the sacrum and the internal face of the ossa ilia. Both these facets are covered with a diarthrodial cartilage, which is closely adapted to the inequalities they present; that, however, which pertains to the sacrum, being always much thicker than the layer which belongs to the iliac bones. The latter is so thin, that its existence has been denied. These carti- lages are covered with a synovial membrane, which secretes quite abundantly a viscid and transparent synovia. But, when the female has passed the prime of life, this fluid often concretes, and becomes disposed in isolated flakes upon the articular surfaces,—a fact which has caused its true nature to be misunderstood. A very limited sliding motion is all of which this articulation is susceptible. The bones are held together by the following ligaments: 1. The posterior, or great sacro-sciatic ligament, is found at the posterior in- ferior part of the pelvis. It is triangular, thin, flattened, and narrower in the middle than at the extremities. It arises by a large base from the posterior infe- rior spinous process of the ilium, the sacro-spinous ligament, the last of the pos- terior tubercles of the sacrum, and from the inferior part of the margin of this bone and border of the coccyx, and running outwards, downwards, and a little 24 FEMALE ORGANS OF GENERATION. forwards, is inserted into the tuberosity of the ischium. Its fibres are arranged in such a way, that the internal ones cross the external about their middle. 2. The lesser sacro-sciatic ligament is smaller than the preceding, though nearly of the same form, and situated more in front. Within, it is broad, being partially confounded with the other, but arising a little more anteriorly upon the sides of the sacrum and coccyx; thence, it passes forwards and outwards to be inserted into the spine of the ischium. The sacro-sciatic ligaments convert the two sciatic notches into foramina. They not only serve to unite the sacrum to the ilium, but also contribute to the formation of the parietes of the pelvis. 3. The posterior sacro-iliac ligament is a collection of yellow, elastic, fibrous bundles, intermixed with fatty pellets, which fill up the rough excavation ob- served behind the cartilaginous surfaces; very short, numerous, and interlacing in every direction, they become almost intimately blended with the sacrum and coxal bones. On account of their strength, they greatly consolidate this arti- culation. 4. The anterior sacro-iliac ligament is a simple fibrous lamina, extended transversely from the sacrum to the os innominatum. It is rather an expansion of the periosteum of the pelvis than a true ligament. 5. The superior sacro-iliac ligament is a very thick fasciculus, passing trans- versely from the base of the sacrum to the coxal bone. 6. The inferior sacro-iliac ligament (vertical sacro-iliac of M. Cruveilhier) arises from the posterior superior spinous process of the ilium, and is inserted just below the third sacral foramen into the tubercle found at the termination of the border of the sacrum; and behind, into the great sacro-sciatic ligament. § 3. Sacro-coccygeal Symphysis. This articulation, which for a long time was supposed to resemble those be- tween the bodies of the vertebrae, differs from them materially in being a true arthrodia. It is formed by the opposition of the oval surface of the point of the sacrum to that of the base of the coccyx; the middle of the former is projecting, and corresponds to a depression in the centre of the latter. The long diameter of the articular face of the coccyx is directed transversly. The cartilages cover- ing these surfaces are rather thinner at the centre than at the circumference. They are provided in the adult female with a synovial membrane, which is sup- posed by 31. Lenoir to be only developed by the movements of the coccyx upon the sacrum, since he has failed to meet with it in subjects under eighteen years of age. 1. The anterior sacro-coccygeal ligament consists of a few parallel fibres, which descend from the anterior part of the sacrum to the corresponding face of the coccyx. 2. The posterior sacro-coccygeal ligament is flat, triangular, broader above than below, and of a dark color. Arising from the margin of the inferior orifice of the sacral canal, it descends to, and is lost upon, the whole posterior surface of the coccyx. It also aids in completing the canal behind. In investigating upon the dead body the anatomical arrangement to which the motion of the coccyx on the sacrum is due, it was ascertained by 31. Lenoir that OF THE PELVIS. 25 the motion takes place almost as frequently in the sacro-coccygeal articulation, as in that of the second piece of the coccyx with the third. Sometimes it happens simultaneously in both, whilst in few cases only does it occur in the connection of the second piece with the third, or of the third with the fourth. These inter-coccygeal articulations are similarly constructed. In all cases, in fact, in which the points of motion of the coccyx were changed, M. Lenoir dis- covered a more or less complete anchylosis of the articulation between the sacrum and coccyx, and of those between the bones of the coccyx itself, at points above and below the one which preserved its mobility. Then, also, wherever situated, the movable articulation was constructed as follows: 1. Of articular surfaces irregular in form but corresponding exactly, which were incrusted with diarthro- dial cartilages and provided with a synovial membrane. 2. Of lax peripheral ligaments formed at the expense of the layers of fibrous substance covering the bones of the coccyx. 3. Lastly, motion was possible in every direction. It is to be observed that ossification is more frequent and rapid in the joint between the sacrum and coccyx than in that between the first piece of the coccyx and the second; the third and fourth become fused very early. It is therefore easy to understand how the great mobility of the sacro-coccygeal articulations renders luxation possible in labor, whilst in cases of anchylosis, either fracture or a sudden separation of the united bones might occur. During pregnancy, the ligaments of the pelvic articulations become so softened and swelled by imbibition of fluid, as to render the mobility of the articular surfaces very evident. This softening is very considerable in some cases, and may make walking, or even standing, impossible. § 4. Sacro-vertebral Articulation. This is produced by the junction of the sacrum with the fifth lumbar vertebra. It is a true amphiarthrosis, as are all the vertebral articulations. It takes place at three different points, viz., between the oval facet, seen at the middle of the base of the sacrum, and the inferior surface of the body of the last vertebra; and at the two articular surfaces found near the entrance of the sacral canal. The modes of connection are, a fibro-cartilage (which is much thicker in front than behind), the termination of the two anterior and posterior vertebral liga- ments, the interspinous ligament, and lastly, the sacro-vertebral ligament, a short, very strong, fibrous bundle, which descends obliquely from the anterior inferior part of the transverse process of the last vertebra, downwards and outwards, towards the base of the sacrum, where it is inserted. Further, a synovial membrane is found in the articulation between the oblique processes of the sacrum and those of the vertebrae. To these must also be added the ilio-lumbar ligament, which passes from the apex of the transverse process of the fifth lumbar vertebra to the thickest portion of the iliac crest; and the ilio-vertebral ligament, formed of two fibrous bands, the superior of which arises from the middle and lateral part of the body of the last lumbar vertebra, and the inferior, from the inter-sacro-vertebral space; both are then spread out on the coxal bone. The obturator membrane still claims a description, in order to finish the history of the ligamentous apparatus of the pelvis. This, as has been remarked 2(3 FEMALE ORGANS OF GENERATION. by M. Cruveilhier. like the sacro-sciatic ligaments already spoken of, is rather an aponeurosis serving to complete the pelvic walls, then a true ligament. These resisting membranes are probably intended to diminish, in the hour of labor, the compression of the mother's soft parts, included between the infant's head and the osseous parietes of the pelvis, as also to favor, by their elasticity, the passage of the head through the pelvic excavation. Obturator membrane.—This membrane subtends the foramen thyroideum, excepting at its superior part, where an opening exists, which converts the groove, intended for the passage of the obturator vessels and nerves, into a complete canal. Being inserted by its external semi-circumference into the corresponding part of the periphery of the obturator foramen, it is attached by its internal half to the posterior face of the ascending ramus of the ischium. Its surfaces afford origins for the two obturator muscles. This membrane is composed of aponeu- rotic fasciculi, which cross each other in every direction. (Cruveilhier.') ARTICLE III. OF the telvis in general. Studied in its general aspect, the pelvis represents a cone, slightly flattened from before backwards; the base of which, being above, is at the same time inclined forwards, whilst the apex is directed downwards and a little backwards. § 1. External Surface of the Pelvis. Anatomists have divided this surface into four regions: the anterior of which exhibits, on the median line, the front part of the symphysis pubis, which is directed from above downwards and from before backwards, at an angle with the perpendicular of some 15° to 20°; next (passing outwards) is a smooth surface, from which several muscles of the thigh arise, then the external obturator fossa, occupied in the recent subject by the muscle of the same name, and finally by the anterior half of the edge of the cotyloid cavity. The posterior, bounded by the hinder part of the iliac crest, presents, on the median line, the ridge of the sacral spinous processes, the inferior opening of the vertebral canal, the union of the sacrum with the coccyx, and the posterior face of this latter bone. The ten posterior sacral foramina, transmitting the nerves of the same name, are found in two deep gutters, on the sides. These grooves prolong the spinal gutters, and are occupied in the recent state by the commencement of the sacro- spinal muscles. The lateral regions may each be divided into two parts: one the superior, is the external iliac fossa; the other, or inferior, offers, behind, the posterior aspect of the sacro-sciatic ligaments, and the plane of the notches or foramina bearing the same name; and, in front, the cotyloid cavity and the ex- ternal face of the tuberosity of the ischium. § 2. Internal Surface. The internal surface or cavity of the pelvis has been aptly compared to the basin of the ancient barbers. ( Vesalius.) In fact, like those vessels, it has a OF THE PELVIS. 27 superior part, which spreads out freely, and is called the great, the superior, or the abdominal pelvis; and an inferior one, more contracted, bearing the title of the little pelvis, or pelvic excavation. 1. The great pelvis has a very irregular figure, and forms a species of pavilion to the entrance of the pelvis. Its walls are three in number: the anterior one is deficient in the dried skeleton, but in the living state it is supplied by the ante- rior abdominal muscles; its posterior parietes exhibit a notch in its middle, that is ordinarily filled up by the projection of the last lumbar vertebrae, which are usually left in connection with the pelvis, although in reality not forming any part of it. Two gutters are found on the sides of this eminence, occupied by the psoae muscles; further outwards, the anterior part of the sacro-iliac symphyses appear, which constitute the boundaries between the posterior and lateral regions: these latter are constituted by the internal iliac fossae, covered by the iliacus in- ternus muscles. 2. The lesser pelvis, or basin. This forms a curved canal, larger in the middle than at its extremities, and slightly bent forward. If all the parts described as appertaining to the great pelvis be removed by the saw, as recommended by Chaussier, a species of ring will remain, whose circumference, being narrow in front and much broader behind, will furnish a correct idea of the shape of the pelvis. Four regions are found in this cavity also: The anterior one is concave transversely, and is inclined upwards, having the posterior part of the pubic articulation near its middle: this is generally promi- nent, assuming the form of a longitudinal pad, which may in some cases project to the extent of from two to three-eighths of an inch. Towards the sides, a smooth surface appears, and then the internal obturator, or sub-pubic fossa, hav- ing, at its upper external part, the inner orifice of the sub-pubic canal, through which the external obturator vessels and nerves pass out from the pelvis. It is not at all uncommon for females to complain during labor of severe cramps in the muscles of the upper internal part of one thigh. These pains re- sult from the pressure made by the child's head upon those nerves, as it glides over this portion of the excavation. The posterior region—constituted by the front face of the sacrum and coccyx— is directed downwards, and is concave from above, downwards. It consequently exhibits those peculiarities already noticed when describing the sacrum. The lateral regions present two quite distinct portions: the anterior one is wholly osseous, corresponding to the back part of the cotyloid cavity, and to the body and tuberosity of the ischium. It is directed from above downwards, from behind forwards, and from without inwards. The posterior one is formed by the internal face of the greater and lesser sacro- sciatic ligaments, and by the internal aspect of the great and small sciatic notches, converted by them into foramina; it has an opposite direction to the former. One of these foramina is larger and situated higher up than the other, and is of an oval form. The other is triangular, smaller, and more inferior. The pyramidal muscle, the great sciatic nerve, gluteal artery, and the internal pudic vessels and nerves, escape from the pelvis through the great sciatic foramen. The small sciatic hole is filled up by the obturator internus muscle, and the internal pudic vessels and nerves, which re-enter the pelvis in order to supply the perineum. 28 FEMALE ORGANS OF GENERATION. If two vertical sections be made, the one extending on the median line through the sacrum and the pubis, dividing the pelvis into two lateral halves, and the other at right angles to the first,, dividing it into anterior and posterior halves, four equal parts or quarters of the pelvis will be thereby produced, which ac- coucheurs have designated as the anterior and posterior inclined planes. L>esor- meaux included only the lateral regions of the excavation, which he divided into two equal parts, in the composition of these planes: according to him, the ante- rior inclined planes are continuous with the anterior region; the posterior, with the front face of the sacrum; and the spine of the ischium is found at the point of union of these two. The direction of the inclined planes is always the same, whatever be the manner in which they are formed. That is, the anterior are directed from without inwards, from above downwards, and from behind forwards; the posterior, from without inwards, from above downwards, and from before backwards—in a word, in such a way as to resemble somewhat the four sides of a lozenge which is slightly curved in its length. By most authors, these inclined planes are supposed to play an important part in the mechanism of labor; for they imagine that their direction has an immediate influence upon the movements which the head of the foetus performs in the excavation. In anticipating that the description of the mechanism of labor hereafter given will invalidate this assertion, we shall simply observe that the movements of rota- tion executed by the head, take place more frequently whilst the latter is strongly bulging out the perineum, and is so far below the inclined planes as scarcely to feel the influence of their direction, and further, that these motions often occur in an opposite direction. The great and the lesser pelvis are separated from each other by a kind of horizontal circle, which has been designated by accoucheurs as the abdominal, or superior strait, the isthmus, or margin of the pelvis. Finally, the apex of the pelvis presents an opening that is limited by a circle, partly osseous, partly liga- mentous, to which the name of the inferior strait has been applied. Conse- quently, these two straits are the extreme limits of the pelvic excavation. § 3. Of the Superior Strait. The superior strait is formed, behind, by the sacro-vertebral angle, and the anterior border of the wings of the sacrum : outwardly, by the rounded margin that bounds the internal iliac fossa below; and in front, by the ilio-pectineal eminence and the horizontal ramus of the pubis, terminating at the symphysis of this bone. The abdominal strait has been variously compared to an ellipse, an oval, and to the heart of a playing card. We may assert, however, with Chaus- sier, that its shape is that of a curvilinear triangle, the angles of which have been rounded off, and having its base behind and the apex in front. It constitutes the entrance to the lesser pelvis, and is therefore the first part of the narrow canal which the foetus has to traverse. Hence, the pains taken by accoucheurs to study this osseous opening can readily be conceived. All the modern authors since the days of Deventer, have endeavored to fix precisely the degree of inclination of its plane and axis, to ascertain the direction OF THE PELVIS. 29 the foetus should follow in engaging in the pelvic canal, and to determine care- fully the dimensions of the latter, and their accordance with those of the body, which is to pass through it. The plane of the superior strait is inclined obliquely from above downwards, and from behind forwards ; but writers are far from being unanimous in regard to the degree of its inclination; that is, in determining the angle formed by the sacro-pubic line, at the point where it meets a horizontal one, drawn from the superior part of the symphysis pubis towards one of the points on the anterior face of the sacrum. Although originally placed at 45° by J. J. Muller (1745), this angle has successively been fixed at 35° by Levret; at 75° by Camper, and at 55° by Saxtorph; and still more recently, Professor Naegele, after a great number of researches, has concluded to consider it as an angle of 60° (1819). It is now generally admitted that the degree of inclination in the plane of the superior strait is from 55° to 60° in the erect position of the female. The direction of the plane being once understood, it is an easy matter to as- certain that of its axis; for the latter being a line which falls perpendicularly upon the centre of this plane, it must evidently form with the vertical the same angle that the plane itself does with the horizontal line, and consequently must have just the same degree of inclination. Being thus understood, the axis of the superior strait is a line (a b, Fig. 1) which, commencing near the umbilicus of the female, would pass directly through the centre of this strait, and fall upon the point of union of the upper two-thirds of the coccyx, with its inferior third. Hence, it will be directed from above downwards, and from before backwards. Further, the inclination of this plane varies according to the woman's posi- tion. Thus, it is almost nothing when recumbent, and sometimes in this posi- tion the plane of the superior strait in- stead of being directed forwards and upwards, even looks upwards and back- wards (Dubois); when the trunk is bent strongly forward, the inclination of the plane is diminished and becomes more nearly horizontal; towards the end of gestation, on the contrary, the inclina- tion increases, especially when, in order to restore equilibrium, the upper part of the body is carried much backward. As the figure which represents the circumference of the superior strait is not a perfect circle, its dimensions, taken at different points, are, of course, un- equal, and, accordingly, writers have admitted several diameters for it, thus : There are three principal ones (Fig. 2), namely, an antero-posterior or sacro- pubic diameter a a, which extends from the sacro-vertebral angle to the upper part of the symphysis pubis; it is from four and a quarter to four and a half Fig. 1. .—fr. c h. The plane of the superior strait prolonged beyond the pubis, c e. The plane of the inferior strait prolonged beyond the pubis, c d. Shows the departure of this plane from the horizontal line. a b. The axis of the superior strait, g f. The axis of the inferior strait. 30 FEMALE ORGANS OF GENERATION. inches in length. 2. A transverse one, Fig. 2. from the piddle of the a a. The antero-posterior, or sacro-pubic diameter, b b. The transverse diameter, c c. The two oblique diameters. a. c. The sacro-cotyloid interval. b b, passing rounded border that terminates the iliac fossa of one side, to the same point on the opposite side; this is five and a quarter inches long. 3. An oblique diameter, c c, extending from the anterior part of the sacro-iliac symphysis to the ilio-pectineal eminence of the opposite side; this is found on both sides, and is four and three- quarters inches long. Lastly, M. Velpeau admits a fourth diameter, called by him the sacro-cotyloidean; before de- scribed, however, by Burns, under the more exact name of the sacro- cotyloid interval a c, existing between the promontory and the posterior part of the cotyloid cavity. This interval, according to the examinations of the French surgeon is from four to four and one-eighth inches in extent; but from the results of Naegele and Stoltz's researches it is much less, being scarcely three and a half inches (the mean obtained from ninety pelves). The circumference of this strait varies from thirteen to seventeen inches; Levret taught, that it equalled one-fourth of the female's height; but to establish such an approxima- tion, the development of the pelvis should always be in direct proportion to the stature of the individual, which is certainly not the fact. § 4. Of the Inferior Strait. The inferior strait—the perineal strait—or apex of the pelvis (as it is vari- ously called), is more irregular in shape than the superior one. Its outline presents, in fact, three tuberosities or osseous projections, separated by as many deep notches. If, however, the advice of Chaussier be followed, and a sheet of paper be placed over this opening, so as to trace its outline with a crayon, it will be found to have an oval figure, the smaller extremity of which is in front, and the larger one, looking backwards, is broken in upon by the prominence of the coccyx. This point, disappearing at the moment of the head's passage, offers no obstacle to the delivery; and, therefore, the strait may be considered as nearly an oval. The periphery of the pelvis at its apex is formed by the inferior part of the symphysis pubis, the descending branch of this bone, the ascendino- branch and tuberosity of the ischium, the inferior margin of the great sacro-sciatic liga- ment, and by the border and point of the coccyx. Hence, three triangular pro- jections are found in it: the two ischia upon the sides, and the coccyx behind. The first two are immovable, but the last, on the contrary, is effaced at the period of delivery, as just mentioned; for the mobility of the sacro-coccygeal articulation allows the coccyx to be pushed downwards and backwards by the foetal head as it traverses the inferior strait. The two lateral prominences, made by the tube- OF THE PELVIS. 31 rosities of the ischia, are placed on a plane somewhat lower than the point of the coccyx; and consequently, in the sitting posture, the weight of the body rests solely on those tuberosities, and not at all upon the coccygeal extremity. This circumstance furnishes us a reason why transverse contractions of the pelvis are far more frequent at the inferior strait than the antero-posterior ones. The three notches also require a passing notice; thus, the two postero-lateral ones are very deep, but when the sciatic ligaments have been preserved, they are comparatively superficial; the third is found anteriorly; its apex corresponds to the inferior part of the symphysis pubis, its base to a line drawn between the anterior parts of the tuberosities of the ischia, and its sides are formed by the ischio-pubal rami. The term arch of the pubis has been applied to this notch. The columns of the arch are distorted outwardly, as if a rounded body had been forcibly expelled from the pelvis, whilst the bones were soft, and had pushed them before it; and this arrangement, which is more marked in the female than the male, favors the descent of the head. The arch is three and a half to three and three-quarter inches broad at the base; but only one and a quarter to one and a half inches at its apex; in height, it is about two, to two and a half inches. Hence the area of the inferior strait will not present a uniform plane (should it be desirable to ascertain the irregularities it exhibits), because all parts of its margin are not upon the same level. However, to obviate the difficulty met with, in determining the direction of this plane, Duges has divided the strait into two nearly equal portions, the one anterior, and the other posterior, meeting at the tuberosities of the ischium, and each presenting a distinct plane and axis; but as this method of proceeding uselessly complicates the question, we prefer considering the terminal plane of the pelvis, as represented by the coccy-pubal line, thus leaving out the lateral projections altogether. The question is then reduced to these terms: What is the direction of the line that extends from the point of the coccyx to the inferior part of the symphysis pubis? Writers, likewise, variously describe this; for instance, according to the majo- rity of the French accoucheurs, the plane of the inferior strait is slightly oblique, from below upwards, and from behind forwards, so that it would unite with that of the superior strait (if prolonged) in front of the symphysis pubis. On the other hand, M. Naegele concludes, from his numerous researches, that the incli- nation of the antero-posterior diameter of this strait is from 10° to 11° from the horizon, and that the point of the coccyx is found, as a mean, from a half to' three-quarters of an inch higher than the summit of the pubic arch; and, there- fore, the coccy-pubal line is a little oblique from above downwards, and from be- hind forwards. The lower extremity of the axis of this plane of the inferior strait would cut the coccy-pubic diameter at right angles, and terminate above at the sacro-vertebral angle. As a further result of his labors, he has found that, in five hundred well-formed persons, of different statures, four hundred and fifty- four have the point of the coccyx more elevated than the inferior portion of the symphysis; in twenty-six it was lower, and in twenty individuals both points were on the same level. M. Velpeau remarks, as we think with some reason, that, at the moment of delivery,—the only time, after all, when it is requisite to form an idea of the direction of this plane—the point of the coccyx, being pushed 32 FEMALE ORGANS OF GENERATION. fi...... e d. The horizontal line, ferior strait (during labor) ferior strait. downwards and backwards by the passage of the head, is at least on a level with, if not lower than the inferior part of the symphysis. The assertion of 31. Naegele, there- fore, although true as applied to the female not in labor, fails during partu- rition; and it must be admitted that the plane of the inferior strait is then ob- lique from below upwards, and from be- hind forwards. The axis of this strait is represented by a line (a b, Fig. 3) directed from above downwards, and from behind for- wards, which, starting from the first piece of the sacrum, falls at a right ee. The plane of the in- angle upon the middle of the bis-ischi- a b. The axis of the in- atic space. The remarks made upon the variations in the direction of the plane, apply with equal force to its axis. The latter crosses the axis of the superior strait in the excavation, forming with it an obtuse angle, the sine of which is in front. It is also very important to know the dimensions of the perineal strait, and hence obstetricians describe three principal diameters at that point, namely— 1. The antero-posterior or coccy-pubal Fl£- 4- diameter (a a, Fig. 4), running from the point of the coccyx to the summit of the pubic arch; it is usually four and a quarter inches long, but may increase to four and three-quarter inches during labor, by the retrocession of the coccyx. 2. The bis-ischiatic, or transverse dia- meter, 6 6, is four and a quarter inches in length, and goes from one tuberosity of the ischium to the other. 3. The oblique diameter, c c, commences at the middle of the great sacro-sciatic liga- ment, and crosses to the point of union of the ascending branch of the ischium, with the descending ramus of the pubis, and is four and a quarter inches long, but may become one quarter of an inch more during labor, from the elasticity of these ligaments. All the diameters of the inferior strait are, therefore, in the dried pelvis about four and a quarter inches in length, though their dimensions are susceptible of great variation during labor. a, a. The antero-posterior or coccy-pubal diame- ter, b b. The transverse or bis-ischiatic diameter. c c. The two oblique diameters. OF THE PELVIS. 33 § 5. Of the Excavation. The excavation is that space comprised between the superior and the inferior straits, and it is in this cavity that the foetal head executes its principal move- ments ; and it is somewhat surprising that, until quite recently, this canal was scarcely mentioned in the majority of the classic works, notwithstanding the importance of a knowledge of its dimensions, as also of the direction of its plane and axis. Its dimensions comprise both the height and width at the different points: thus the height in front, is one and a half inches; upon the sides, three and three-quarter inches; whilst it is four and a quarter inches behind, if a straight line be drawn from the sacro-vertebral angle to the point of the coccyx, and five inches and a quarter, following the curve of the sacrum. Three diameters are also described for this cavity (like the straits), so as to appreciate its extent in the different directions. All of them are taken at the centre of the excavation, and they consist of an antero-posterior one, of four and three-quarters to five and one-eighth inches in length, a transverse diameter four and three-quarter inches long, and an oblique one, of the same length; conse- quently, all the diameters of this cavity are very nearly four and three-quarter inches each. If the canal forming the excavation were a cylinder, it would only be neces- sary to divide it by a plane, perpendicular to its walls, in order to represent the opening of this cavity, but a simple division, thus made, would not give a just conception of the excavation, for two reasons. First, the canal is not cylindrical, because its sides are not parallel, and the anterior face of the sacrum presents a well-marked curvature; the pubic wall being nearly straight, and the Fi&- 5- lateral parietes very oblique from without inwards, and from above downwards. Consequently, to fur- nish an exact idea of the general arrangement of the pelvic exca- vation, it seems necessary to divide the canal (see Fig. 5) by a series of planes, all passing from the point c (the point of intersection of the planes of the superior and inferior straits) to any point whatever,^) q r s t, on the anterior face of the sacrum Each of these planes will show the open- ing of the pelvic cavity at the level where it is found. Now, to deter- mine, with certainty, the direction of the general axis of this excava- tion, it is requisite to raise a perpen- dicular line from the geometrical centre of each of these sections, and to draw a line g k through the base of each 3 a b. The plane of the superior strait, i d. The plane of the inferior strait, c. The point where these two planes would meet, if prolonged, m n. The horizontal line, e f. The axis of the superior strait, g k. The axis of the exca- vation, pqrst. Various points taken on the sacrum to show the plane of the excavation at each point. 34 FEMALE ORGANS OF GENERATION. This line g 7c (which, as the student will observe, is not straight) is called the general axis of the pelvis. It is now readily understood that this line is nearly parallel to the anterior face of the sacrum, and its extremities correspond with the axes of the superior and the inferior straits; hence, this curve exactly represents the whole axis of the pelvis, or, in other words, the line which the foetus must follow in traversing the pelvic excavation. We have considered the line, representing the entire axis of the excavation (perhaps incorrectly), as a simple curve; for 31. Naegele has well observed, that it cannot be composed of two straight lines, as often taught, nor is it a simple arc of a circle. In fact, the anterior face of the bodies of the first two bones of the sacrum forms a straight line; the sacral curve embracing only the last three bones. Consequently, the central line, which is evidently parallel to this, will consist of a straight and a curved portion—straight, for that part of the excava- tion corresponding to the two superior vertebrae, and curved in the space, which is bounded behind by the last three sacral vertebrae, and in front by the anterior pelvic walls. § 6. Base of the Pelvis. The base of the cone, represented by the pelvis, has its circumference directed upwards and in front; it exhibits, behind, a notch, into the bottom of which the base of the sacrum projects, and which is further filled up by the last lumbar vertebrae (generally left in situ to complete the posterior wall of the greater pelvis), by the ilio-lumbar ligaments, and by the quadratus lumborum muscles; 2, out- wardly, the anterior two-thirds of the iliac crest furnishing attachments to the external and the internal oblique and transversalis abdominis muscles; and 3, in front, the anterior superior and inferior spinous processes of the ilium, the groove for the passage of the conjoint muscles—the psoas magnus and iliacus internus, the ilio-pectineal eminence, the superior border of the horizontal branch of the pubis, the spine, and lastly, the upper margin of the symphysis of this bone. § 7. Differences of the Pelvis. 1. According to the sex. Considered as a whole, the pelvis in the male is smaller but deeper, the bones are thicker, and the muscular impressions more marked, than in the female. The superior strait being more retracted, resembles the figure of a heart on a playing card. The excavation is not so wide, though it is deeper, especially in front, owing to the greater length of the symphysis pubis; the arch of the pubis is straight, nearly triangular in its shape, and is not widened in front. The coccyx is early joined to the sacrum, and the articula- tions of the pelvis are much sooner anchylosed than in the female. In the latter we may add, that the iliac fossae are larger and more warped outwardly (whence the prominence of the haunch bones), and the iliac crest less twisted in the form of an italic /; the interval separating the angle of the pubis from the cotyloid cavity is more considerable, causing, in part, the projection of the great trochan- ters, and a wider separation of the femurs; the superior strait is larger and more elliptical; the curve of the sacrum deeper and more regular; the tuberosities of the ischium are farther apart; the pubic symphysis shorter; the foramen thyroi- OF THE PELVIS. 35 deum more triangular; the arch of the pubis broader, more rounded, and more curved, and the lateral borders, formed by the ischio-pubic ramus, more contorted outwardly. 2. According to the age. At birth, the pelvis is extremely narrow and elon- gated, and of such inconsiderable dimensions, that its cavity will not contain several of the organs afterwards found in it; from which circumstance, the pro- tuberance of the belly, observed in the foetus and in children at term, in great measure results; the excavation has the form of a cone, the abdominal strait being strongly inclined downwards; the sacrum is nearly flat, and so much ele- vated that a horizontal line drawn from the superior part of the pubis would pass beneath the coccyx; the coxal bones are narrow, elongated, and nearly straight at their superior part, and the cartilaginous iliac crests are not twisted. From this disposition it necessarily happens that the greatest.diameter of the pelvis extends from the sacrum to the pubis. Burns declares that this form changes by degrees as the little girl advances in age: thus, the— Antero-posterior diameter mea- At 9 years. At 10 years. At 13 years. At 14 years At 18 years. 2£ inches 2f " 3J inches 3 in. 5 lines 3J inches 3| " 3| inches 4 " 3$ inches § 8. Uses of the Pelvis. The pelvis constitutes the base of the trunk, and, according to Desormeaux, it forms a complete ring, that may be reduced to two arches; the posterior and superior of which receives the whole weight of the trunk, whilst the anterior and inferior one serves as a buttress to it. The two lower extremities are attached to the lateral parts of this circle, and support, in the erect posture, all the weight of the superior part of the body. This use of the pelvis satisfactorily explains to the accoucheur the vicious forms the cavity often assumes when ossification is retarded, or whenever any disease alters and softens the bones. Another function of the pelvis is to enclose and protect the bladder, rectum, and seminal vesicles of the male; the uterus, Fallopian tubes, and ovaries in the female. During gestation, it sustains and gives a proper direction to the womb; and in labor, it affords a passage to the child. ARTICLE IV. OF THE PELVIS, COVERED BY THE SOFT PARTS. It will not suffice to study the pelvis as found in the skeleton alone, for the changes produced in its form and dimensions in the living female, by the arrangement of the soft parts, also require our special attention. Being continuous above with the abdomen, the great pelvis encloses and supports the mass of the intestines, and affords points of attachment by its walls to two orders of muscles. The one destined to form the enclosure of the belly fills the large opening exhibited in front, and thus constitutes the anterior 36 FEMALE ORGANS OF GENERATION. abdominal wall; the extensibility of which, in comparison with the resistance of the posterior plane, accounts rea- dily for the tendency of the uterus to incline forward in the advanced stage of gestation. The others, two in number, are placed in the iliac fossse; they are the iliacus, internus, and the psoas magnus muscles, which, from being situ- ated on the lateral parts of the abdominal strait, change both its form and dimensions. The first of these has radiated fibres, and occupies the iliac fossae; the second descends from the sides of the lumbar vertebras, and after having been joined to the preced- ing; is inserted into the lesser trochanter of the thigh bone. These two muscles, surrounded and confined by an aponeurosis (fascia iliaca), may be regarded as a sort of cushion, forming a convenient support to the developed uterus, and destined to protect it by the elasticity of the soft parts against the shocks and concussions continually pro- duced by locomotion. Notwithstanding the presence of these muscles, the strait still resembles a curvilinear triangle in shape, the base, however, of the triangle being in front instead of behind, as it was in the dried pelvis; the transverse diameter is diminished half an inch by their presence; the antero-posterior one is, perhaps, a little abridged by the thickness of the vesical walls, uterus and soft parts that line the posterior face of the symphysis and anterior surface of the sacrum, the oblique diameters alone remaining unchanged; the location of the rectum, however, on the left, shortens slightly the corresponding diameter. The modification of the transverse diameter, produced by the psoas muscles, is always much less when these are in a state of relaxation from the flexure of the thighs. Finally, as Baudelocque has remarked, the bis-iliac diameter is diminished in length, in proportion to the thickness of these muscles, and the antero-posterior one being more contracted, the strait becomes more elliptic or rounded. Two muscles are also found on each side of the excavation, covering the obturator and ischiatic foramina; namely, the obturator internus, and the pyramidales. Flamand attributes the movements of rotation, executed by the head in the pelvis, to the action of these muscles; but the same reasons that caused us to reject the influence of the inclined planes on this process, equally deter us from entertaining the opinion of the Professor of Strasbourg. The pelvic cavity is still further diminished by the rectum, bladder, and cellular tissue; more especially when the latter is loaded with fat. Consequently, the foetal head descends with more difficulty in very corpulent women than in others. Fig. 6. Pelvis, with the soft parts seen from above. A. A section of the aorta, b. The vena cava inferior, c. The internal iliac artery, arising together with d, the exter- nal 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 appen- dages, k. The bladder, the fundus of which is depressed so as to bring the womb into view. OF THE PELVIS. 37 The perineal strait, although open in the dried skeleton, is here occupied by a sort of contractile concave partition, which sustains the viscera of the pelvic and abdominal cavities. This floor, so to speak, is composed of two muscular planes; the interior of which, formed by the levator ani and coccygeal muscles, is concave above; and the other, having its concavity below, is constituted by the sphincter ani, the transversus perinei, the ischio-cavernous, and the con- strictor vaginae muscles. The internal pudic Tjessels and nerves, a large amount of cellular tissue, the skin, the pelvic aponeurosis, and an inter-muscular apo- neurosis complete this floor, which, in the hour of labor, ought to become thin and distended, but which occasionally offers such an obstacle to the spontaneous delivery of the foetus as to require the intervention of art. The extent of the perineum, in its ordinary condition, is three inches, namely: from the point of the coccyx to the anus, there are one and three-quarter inches, and from the anus to the vulva, one and one-quarter inches; but at the instant of the passage of the head through the genital fissure it becomes so distended, that the interval separating the anterior commissure from the coccyx, is increased from four to four and three-quarter inches. It must now be evident that the terminal outlet of the pelvic canal, in the pelvis, covered with its soft parts, is not at the point of the coccyx, but rather at the anterior commissure of the perineum; in fact, the latter is so greatly dis- tended in the last moments of labor, that its anterior border goes beyond the in- ferior part of the symphysis pubis, thereby prolonging very considerably the posterior wall of the pelvic excavation, and, as a consequence, the canal to be traversed by the foetus. Wherefore, the direction in which the head is ulti- mately disengaged is not represented by the axis of the inferior strait, but by that of a plane which may be drawn from the lower part of the symphysis to the anterior commissure of the distended perineum. Hence, in order to form an exact idea of the line traversed by the foetus, from its entrance into the superior strait until its final exit from the vulva, it will be necessary to continue the operation already pursued upon the anterior face of the sacrum (see page 33) over the curve represented by the anterior face of the dis- tended perineum: that is, to make a series of planes from the point c (Fig 5) to the divers parts of the perineal curve; and, from the centre of each, raise a perpendicular, so as to form by their union a complete axis, the upper extremity of which is the axis of the superior strait; the middle part, a curved line, having its concavity anterior and its convexity parallel to the front face of the sacrum and perineum, and the inferior extremity directed from before backwards, and slightly from above downwards. It must not, however, be forgotten, that the direction just described belongs to the vertical posture, and that it becomes remarkably altered in the various at- titudes assumed by the female. Thus, whilst lying upon the back, as is usual in France during labor, the plane of the superior strait instead of looking upward and forward will be turned upward and backward, and its axis directed from above downward and from behind forward. At the same time, the plane of the inferior strait, which before looked backward and downward, will be turned almost directly forward, its axis also passing directly from before backward. Finally, the terminal'orifice formed by the contour of the vulva presents another plane, o>> FEMALE ORGANS OF GENERATION. which at the moment of delivery (the horizontal position being still maintained), is directed upward and forward. In short, the central line followed by the fatus Fig. 7. Position of 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. Peri- neum as distended at the moment of the passage of the head. r. Anal orifice, ev. Terminal plane of the pelvis. during its expulsion is a strongly-marked curve, whose concavity is turned almost directly upward (Fig. 7). CHAPTER II. OF THE ORGANS OF GENERATION. The genital apparatus of the female is much more complicated than that of the male, and is composed of organs situated in the interior of the pelvis, and of parts attached to its exterior. The former are the ovaries, Fallopian tubes, uterus, and vagina, and the latter, the mons veneris, vulva, and perineum. SECTION I. OF THE EXTERNAL PARTS OF GENERATION. These consist of the mons veneris, vulva, and perineum. Art. 1.—3Ioxs Veneris. The mons veneris is a rounded eminence, a species of relief, more or less pro- minent according to the embonpoint of the individual, situated in front of the pubis, and surmounting the vulva; this eminence is partly produced by the bones OF THE ORGANS OF GENERATION. 39 Fig. 8. and partly by the subcutaneous adipose tissue; the skin covering it is very thick and elastic, but being little extensible, it cannot aid in the enlargement of the vulva, as asserted by M. 31oreau, at the period of delivery. In the adult female, it is covered with hair, and contains a great number of sebaceous follicles. Art. II.—Vulva. The vulva is a longitudinal opening or fissure, situated on the median line at the base of the trunk; being bounded in front by the mons veneris, behind by the perineum, and laterally by the external labia. We shall comprise in its description, as properly appertaining thereto, all the parts included between the labia majora. 1. The labia majora, or labia externa, are two cutaneous folds, flattened transversely, and thicker in front than behind, which bound the opening of the vulva externally; com- mencing at the mons veneris, they gradually recede from each other, as they pass back- wards, nearly to their middle, where they again approach, so as to unite at the posterior extremity, and form there a bridle or commis- sure called the fourchette, which is generally lacerated during the first labor. The labia externa present an external or cutaneous surface, which is covered with hairs after puberty; and an internal one, moist, smooth, of a rose color, and formed by a mu- cous membrane that is provided with a consi- derable quantity of mucous follicles. In young girls, the external lips are some- what thicker above, and approach each other closely; but in females who have borne chil- dren they are separated, and have lost their regularity. They consist of a cutaneous and a mucous layer, between which is a fibrous partition, a continuation of the superficial fascia of the perineum. Between this aponeurosis and the internal surface of the integument, is found a very thick layer of cellulo-adipose tissue, filling up a peculiar pouch hitherto unknown to anatomists until discovered by 31. Broca. From a dissection of it very obligingly executed before me by the skillful prosector of the Faculty, the account of it is given. The interest which it possesses for the surgeon and the physiologist, in- duces me to describe it in detail in the note below.1 External genital parts. A. Mons veneris. B Labia majora. C. Clitoris. D. Labia minora. E. Orifice of urethra. F. Orifice of vagina. H. Poste- rior commissure of the vulva. I. Peri- neum. J. Anus. 1 Imagine a membranous pouch, with a long and narrow neck, to be inserted between the skin and the superficial aponeurosis, so that its bottom shall be towards the fourchette, and its orifice directed upward and outward, terminating at the external inguinal ring, and we shall have an exact idea of the double layer which I am about to describe. This layer commences at the bend of the groin, in front of the opening of the external inguinal ring, and derives its fibres in great part from the fascia superficialis of the thigh and abdomen; some of them, however, proceed directly from the spine of the pubis and 40 FEMALE ORGANS OF GENERATION. The external labia are provided with vessels, both arterial and venous, and nerves: the lymphatics proceed to the inguinal glands. 2. The nymphat, or labia interna, are brought into view, by separating the external lips, under the form of two mucous folds, resembling the comb of a from the external pillar of the ring. These fibres then descend obliquely from above down- ward, and from without inward, producing a conical cavity, the narrowest part of which is uppermost, and is large enough to receive the forefinger with ease. Enlarging in propor- tion as it descends, this membranous pouch becomes flattened from before backward, and lodged in the external labium, which it fills accurately; at the fourchette, its walls come in contact, and are united into a single membranous layer, which is continuous with the fascia superficialis of the parts by the side of the anus. The anterior surface of the pouch is devoid of adhesion; it is removed from the skin by a little adipose tissue, and a moderate traction effects its separation. It may also be readily isolated with the handle of the scalpel. The posterior surface of the pouch is likewise free from attachments in its upper half; but below this, that is to say, from the orifice of the urethra to the fourchette, it adheres to the superficial aponeurosis and can only be separated from it by dissection. At the point of insertion of the corpus cavernosum upon the iliac bone its detachment is well- nigh impossible, for there the fibres of the pouch are inserted directly upon the bone and blended with the superficial aponeurosis. The external border of the pouch is free in its upper half but from the place of at- tachment of the corpus cavernosum, it adheres to the ischio-pubic ramus. The result is, that the upper part of this border forms a species of arch, with the concavity turned out- ward, the lower extremity being implanted upon the ischio-pubic ramus, and the upper upon the external pillar of the inguinal ring. The internal border of the pouch is also free in its upper half; here, however, some of its fibres are lost in the suspensory ligament of the clitoris. The lower half of this border is adherent to the mucous membrane of the external labium, some of its fibres being even inserted directly upon the integument. The cavity of the pouch is filled with fat, which I have never known to be wanting even in the most emaciated subjects. What is most important to observe is, that the round ligament, after having contributed some of its fibres to the periosteum of the pubis, enters the neck of the pouch, traverses it throughout its length, dividing at the same time into several cords of a pearly whiteness, and descends, still remaining in the cavity of the pouch, to lose itself in the thickness of the external labium, where it can be followed no longer. Finally, the structure of the walls of the pouch is evidently fibrous, all the fibres' being parallel and inclined downward and inward; they are of a yellowish-white color, and manifestly elastic. The elasticity is greater in recently-delivered females, and the fibres are then reddish and form a thicker layer. The analogy between this pouch and the dartos of the male is complete; both have the form of a sack, they are in direct connection with the surrounding fascia superficialis, of which they are but a transformation, and both are connected with the femoral arch, the pubis, and the suspensory ligament. One is situated in the external labia, and the other in the scrotum, which is universally regarded as the analogue of the external labia. One surrounds the testicle and its dependencies, whilst the other receives the round ligament only: yet the analogy between this ligament and the gubernaculum testis cannot be mis- taken ; besides, if we refer to the period of intra-uterine life in which the testicle still remains in the abdomen, we find the resemblance between the dartos of the male and that of the female to be complete. The only difference results from the presence of the vulva in the female. The juxtaposition of the two pouches of the dartos in the male produces a partition which is often imperfect; whilst in the female the two sacks being separated by the genital fissure can have no immediate connection with each other. The dartos of the female plays an important part in the diseases of the external OF THE ORGANS OF GENERATION. 41 young cock. Contracted behind, where they are continuous with the internal face of the labia externa, they spread out in front as they converge towards each other. These lips scarcely descend to the middle of the external ones, but they mount up in front as high as the clitoris, where they bifurcate; the inferior branch of this bifurcation is lost in the clitoris; but the other surmounts it, joins its fellow of the opposite side, and forms above this body a little fold in the shape of a hood, called the prepuce of the clitoris. At birth, the nymphae project be- yond the external lips, but at puberty, they are concealed by the latter. Again, they become visible in child-bearing women; rather, however, by the separation of the labia majora than by their own prominence. Further, their dimensions are very variable in different individuals, and in various climates; thus, in certain countries of Africa, they are very long, and constitute the famous apron of the Hottentots. Besides, as Velpeau has re- marked, these parts are so extensible that, under the influence of continual trac- tions, they may become very much elongated. I have met with a young female, in my own practice, who was afflicted with an excessive itching at the vulva at the commencement of her pregnancy. To relieve this, she was in the habit of scratching continually, and in her impatience dragged on the right nympha, so that, in less than a fortnight, it had become twice as long as its fellow. The internal lips are furnished with a cryptous apparatus, visible to the naked eye, which is the seat of an abundant sebaceous secretion, that occasionally be- comes very irritating. 3. The Clitoris.—Under this name, a little erectile tubercle, resembling the corpus cavernosum of the male (except in volume), is described. Its free ex- tremity appears at the front part of the vulva, about half an inch behind the anterior commissure of the labia externa, and its body is attached by two crura to ischio-pubic rami; these roots ascend, converging and increasing in size, to the level of the symphysis, where they unite to form a single cavernous body, flattened on its sides, which, after a course of two or three lines in front of the symphysis, becomes detached and curved forward so as to present a convexity above and in front, at the same time growing more and more slender towards the free extremity, which is called the glans clitoridis. During the first months of the intra-uterine life it is difficult to make out the distinction of the sexes, because the clitoris is as long as the penis; even in the earlier years of existence its dimensions are quite considerable, but after this period it ceases to grow, and, in some females, apparently diminishes. Again, in certain rare cases, it acquires a great length; for instance, M. Cruveilhier has seen one whose free extremity measured two inches, and a case is on record labia. Inguinal hernia descends inevitably into its cavity. The tumors known as hy- droceles of the female, which are in reality cysts of the external labia increasing from below upward and entirely independent of the canal of Nuck: these tumors, I repeat, must be situated within the pouch of the dartos, for thus alone can the uniformity of their relations with surrounding parts, and the identity of their shape, which is ovoid, with the upper end directed outward, be explained. Lastly, the effusions of blood in the external labia as a result of contusions, and abscesses of the vulva, all give rise to swellings which remain circumscribed by the exact limits of the pouch of the dartos, and which I am therefore convinced must be contained in its cavity. 42 FEMALE ORGANS OF GENERATION. where it reached from four and a quarter to five inches. Most of the pretended hermaphrodites may be referred to anomalies of this kind. Henle gives a representation of a case so singular and rare as to deserve men- tion. It is a congenital division of the clitoris occurring in a girl of seventeen years of age, in which the body of that organ was completely divided through the middle so as to form two nipples, each invested with a prepuce. The halves of the prepuce thus divided, are prolonged respectively toward the corresponding nymph a, from which it is separated by a notch, and is lost, above, in the frenum clitoridis. The clitoris, like the penis, has a suspensory ligament, and an erector muscle; the canal of the urethra in the female passes between the two branches of the cavernous body, as it does in the male. In its intimate structure, the clitoris consists of erectile tissue; and hence, the blood determined there during coition, swells it up and causes an erection. Ac- cording to Cobelt, the glans-clitoridis is much more abundantly supplied with nerves than is the glans of the penis, and is asserted by all authors to be the principal seat of voluptuousness in the female. 4. The vestibule is a small triangular space placed at the upper part of the vulva. It is bounded above by the clitoris, below by the urethra, and laterally by the nymphae. 5. The Urethra.—The meatus urinarius is situated just below the vestibule, about an inch from the clitoris, and immediately above the prominent enlarge- ment of the anterior part of the vagina. The orifice is usually more contracted than the canal, but the tubercle, or enlargement just alluded to, enables us to sound females without uncovering them, for it is only necessary to recognize it by the finger in order to direct the instrument properly. In my estimation, the following is the most simple method of introducing the catheter without uncover- ing the patient: I first introduce my finger into the orifice of the vagina, and rest its palmar face against the anterior vaginal wall; I then slide the instru- ment along this palmar face until it is arrested by the fold already alluded to; then I depress the extremity so as to elevate the point of the instrument one or two lines, and, in the majority of cases, the canal is easily entered in this manner. The difficulties experienced in sounding pregnant women will be treated of hereafter (article Pregnancy). Some women who have borne children, have the tubercle which terminates the anterior column of the vagina in front so voluminous as almost completely to mask the orifice of the urethra. In such cases it becomes necessary to uncover the patient, separate the labia, and glide the catheter from above downward in the sort of groove between them. The urethra, a continuation of the meatus urinarius, just described, varies in the female from one to one and a half inches in length. It is large, conical, and slightly curved. Its inferior portion is confounded with, or at least intimately united to, the anterior vaginal wall, and its anterior parietes, separated in front from the pubis by some cellular tissue only, is located on a level with the sym- physis, under the junction of the two crura of the clitoris. The canal of the urethra is muscular and erectile, having a thick lamina of OF THE ORGANS OF GENERATION. 43 muscular fibres, which seem to be a continuation of those of the bladder; a simi- lar one of spongy tissue lies subjacent to the mucous membrane. Occasionally, this canal is enormously dilated. Flamand met with a case that permitted the introduction of the finger, and Meyer, with another, which eventu- ally admitted of coition ! 6. The Hymen.—The irregular opening of the vagina is found beneath the meatus urinarius; it is of variable dimensions after coition, and in females who have had children; but in virgins, it is provided with a membrane by which the orifice is diminished. This membrane is the hymen, a species of diaphragm, in- terposed between the internal organs and the external genital apparatus and the urinary passages. It resembles a crescent in shape, (Fig. 9,) the concavity being anterior; sometimes, the horns of the crescent are prolonged enough to join each other, thus forming a complete circle, perforated in the centre, (Fig. 10) ; its free margin is thin and concave; the convex one is continuous with the membrane of the vagina or vulva, and as this blocks up the posterior and lateral parts of the vagina, a notable difference will exist in the extent of the orifice, dependent upon the greater or less size of the hymen. Sometimes the hymen forms a complete imperforate membrane. Though often thin, transparent, and very fragile, it is occasionally found thick and resisting. Fig. 9. Fig. 10. Fig. 9. Hymen in the form of a crescent. a. Clitoris, b. Labia externa, c. Labia interna, d. Orifice of the urethra, e. Hymen, p. Orifice of the vagina, a. Posterior commissure of the vulva. Fig. 10. This figure exhibits the hymen in the form of a circle, b. The hymen, g. The central opening somewhat elongated. The two forms just mentioned are not the only ones which the hymen may assume; ether varieties have been described by M. Velpeau, as follows: 1. In the semicircular species, the hymen may form such a narrow and solid fold as to permit copulation without being ruptured. 2. In the crescentic variety (Fig. 9) the concave border approaches more or less towards the urethra, in such a way as to contract the vagina behind, and hence it almost always gives way in coition. 3. In the circular variety, the free border is much thinner than the other (Fio\ i 70 44 FEMALE ORGANS OF GENERATION. 10), often being fringed, as it were, and and leaving an opening which is some- times round, sometimes slightly elongated, though in general situated somewhat nearer to the anterior than the posterior wall of the vagina. 4. Again, we find a disk or complete diaphragm, that is ordinarily pierced by a number of small holes like those of a watering-pot, and at other times is without the least aper- ture. 5. In some instances a species of bridle, or a small cord attached under the urethra, or on the concave border of the hymen, supplants both the valve and the circle. 6. Lastly, a second hymen occasionally exists above the first. This membrane is regarded as the seal of virginity; and yet, as just shown, it is often found after a fecundation; and, on the other hand, numerous causes besides coition may destroy it. It is generally ruptured at the first sexual ap- proaches, and of its debris are formed two or three little tubercles, bearing the name of carunculoz myrtiformes. The hymen is composed of a fold of mucous membrane, containing between its laminse a few vessels and some areolar tissue. 7. The carunculoz myrtiformes are some little tubercles, two to five in num- ber, found in females only, which appear to be the debris of the ruptured hymen; the two most anterior ones, according to certain physiologists, appertain to the median columns of the vagina.1 8. Fossa Navicularis.—This is a little depression, of half an incb only in ex- tent, bounded behind by the fourchette, and in front by the convex border of the hymen. It, like the fourchette, formed, as before stated, by the junction of the inferior extremities of the labia majora, mostly disappears after delivery. Art. III.—Of the Secretory Apparatus of the External Organs op Generation. In an excellent work read at the Academy of Medicine, the manuscript of which has been obligingly delivered to me by M. Huguier, this learned surgeon divides the glandular organs of the vulva and vaginal orifice into two classes, viz: 1. Sebaceous and piliferous follicles. 2. Muciparous organs. Class first.—The sebaceous and piliferous follicles are exceedingly numerous, and are found only on the penil, the labia majora, and the genito-crural folds! Those of the lesser labia are exclusively sebaceous. The function of all of them consists in the production of an unctuous matter, adapted to the maintenance of the flexibility, moisture, and sensibility of the external genital organs, to the pre- vention of adhesions between them, and especially, to protect them from the irri- tating influence of the urine, of the uterine and vaginal secretions, and from the perspiration, which in some persons is acid and irritating. Class second.—The muciparous organs differ essentially from the follicles, both as regards their situation and the nature of the fluid which they secrete. Their 1 In consequence of oft-repeated friction, these caruncles may inflame, degenerate and even become the source of an abundant purulent discharge; and having been mistaken under such circumstances for syphilitic vegetations, the patient had been subjected to anti-vene- real treatment, which, at least, was useless. Personal cleanliness, and some of the ve^e- to-mineral lotions are usually sufficient to cause their disappearance. M. Velpeau has • resorted, however, in some cases, to excision. OF THE ORGANS OF GENERATION. 45 Fig. 11. mode of arrangement and the manner in which their secretions are discharged upon the entrance of the vagina, admit of their being noticed as two varieties. Those of the first variety are disseminated and placed beside each other upon certain points of the vaginal orifice, or else they are grouped and collected in patches. Already described by several authors, and of late by M. Robert, they are called by M. Huguier isolated or agminated muciparous follicles. Those of the second variety are united and heaped upon each other; they are enclosed in the same envelope, and discharge through a common excretory canal. Thus they form a true gland, which was noticed by Bartholin, but is better described by Huguier, as the follicular body of the vagina, or the vulvo-vaginal gland. A. Isolated or agminated muciparous follicles. These exist at three or four points of the circumference of the vaginal orifice. 1. Some six or eight which are found in the vestibule, are all minute, shallow, simple, and variously disposed. Their openings are very small, rounded, and placed so obliquely in the thickness of the mucous membrane as to appear covered by a kind of very thin valve, which may be raised upon the end of a stylet. These are called by M. Huguier vestibular follicles (Fig. 11, A.) 2. Others, termed urethral follicles on account of their situation, are stated by M. Huguier to be less readily discoverable than the preceding, on which account they were supposed by M. Robert to be less nume- rous. They are of considerable size, and are situ- ated at a depth of from three-eighths to four-eighths of an inch in the cellulo-vascular tissue of the ure- thra (Fig. 11, c). They are placed beneath the mucous membrane in a direction parallel to the canal, and discharge in close proximity to the ori- fice of the urethra upon the surface of the projection which forms the inferior boundary of that opening in such a way as to form a semicircle, or sometimes even an entire circle, around it. They are closer together than those which have been just described, and sometimes several of them open into the same excretory cavity, so as to produce the ramified ar- rangement which Graaf has figured and described. 3. Laterally, and at some distance from the ure- thral orifice, are several small and shallow ones, with a common opening at the bottom of a remark- able conical depression. M. Huguier states that these are often absent, and he proposes calling them the lateral urethral follicles (Fig. 11, B.) 4. Besides these, some two, three, or four large follicles are found in some females upon the lateral parts of the vaginal orifice, immediately below the hymen or the upper carunculae myrtiformes (Fig. 11, d); they are the lateral follicles of the orifice of the vagina. Their openings ordinarily correspond neither in number, situation, nor arrangement, with those of the opposite side; some are slightly projecting whilst others are not so, and some are readily visible whilst others are hidden beneath the myrtiform caruncles. B. Vulvo vaginal gland.—This gland has been completely lost sight of by 46 FEMALE ORGANS OF GENERATION. Fig. 12. modern anatomists, although described by Gaspar Bartholin; and attention has only recently been called to it by 31. Huguier. It belongs to the class of conglo- merate glands. There are two vulvo-vaginal glands, one on each side, where they form peculiar bodies whose position it is important to define with exactness. They are situated at the limits of the vulva and vagina, upon the lateral and pos- terior parts of the latter, about three-eighths of an inch above the upper surface of the hymen or of the myrtiform caruncles, in the triangular space formed on each side by the juxtaposition of the rectum and vagina, upon the latter of which they repose. They lie at a distance of from three-eighths to five-eighths of an inch from the internal surface of the ascending rami of the ischia, and from three- quarters of an inch, to one and a quarter inches from the external labia. The vulvo-vaginal gland has somewhat the shape of an apricot kernel, resem- bling in this respect the lachrymal gland; like the latter, its two surfaces are flattened, and it is besides slightly lobular and mamelonated. According to 31. Huguier, it is much flatter in women who have borne children, which he attri- butes to the species of separation which its granular elements must undergo from the enormous distension of the vulva during labor. The gland of the right side does not always resemble that of the left; it is indeed not uncommon to find one much more developed than the other. Its size varies much according to age, habits, and, adds 31. Huguier, according to the development of the ovaries, which appear to exercise a decided influence over it; for be has always found the largest gland upon the same side with the most voluminous ovary. It also appears larger in females who indulge immoderately in sexual pleasures. Its size is greatest, in general, between the ages of sixteen and thirty-five years. Its diameter at this period of life is, on an average, from four-eighths to five-eighths of an inch. It is very small at puberty, and becomes atrophied in old age. Excretory Duct.—Each of the granules of which the gland is composed, is fur- nished with a minute duct, which, by uniting with those of the neighboring granules, gives rise to three separate ducts. The latter soon join to form a single canal, which proceeds from the internal surface and vulvar extremity of the gland (Fig. 12, D), and opens in virgins, or in Stylet engaged in the orifice of the excretory females in whom the hvnien has bpon rmlv duct. D. Its glandular extremity. E. Its vul- ,-, , • , . ^ eU naS Deen only var extremity and orifice, f. Bnib of the va- Qllatea>in tQe internal angle which the great gina. g. Ascending ramus of the ischium. circumference of this membrane forms by its union with the contour of the vulvar opening, and, when the hymen has been ruptured, at the base of the lateral and &4- AA. Vulvo-vagiual Gland. Section of the labia majora and of the nymphse, showing the excretory duct and its orifice. B. The gland. C. Excretory duct. C. OF THE ORGANS OF GENERATION. 47 posterior myrtiform caruncles (Fig. 12, E). The orifice, which is smaller than the duct which it terminates, is in most women surrounded by a vascular area, which serves, by its lively red color, to distinguish it from the neighboring parts. If required, it will only be necessary to turn the caruncle inward in order to render it conspicuous: it should however be distinguished from three or four minute openings found in the same furrow, and which belong to the lateral fol- licles of the orifice of the vagina. The direction of the opening of the duct is perpendicular, but its oblique orifice is directed upwards and inwards. Its external semi-circumference is provided with a small falciform, valvular fold of mucous membrane, which increases the difficulty of its detection. In the normal condition the diameter of the orifice hardly exceeds the one-one-hundredth of an inch. The diameter of the duct varies from the one-twenty-fourth to the one-eighth of an inch, and its length, which lessens as the gland is more voluminous and approaches nearer the myrtiform caruncles, is, on an average, about five-eighths of an inch. Organization.—The tissue proper, or glandular tissue, is of a yellowish-white color, and, when examined by a magnifier, or even by the naked eye, appears composed of lobules, themselves formed of granulations having a rounded and hollow appearance. The entire mass is surrounded by a fibro-cellular envelope, the thickness and transparency of which varies in different individuals. From the internal surface of the envelope are sent off a great number of fibrous pro- longations, which serve both to connect and separate the granules of the organs. These glands are provided with arteries, veins, lymphatic vessels, and nerves. The arteries, two in number, are derived from the clitoric branch of the internal pudic; one of them is sometimes given off directly from the trunk of the latter. The veins, which form a sort of plexus upon the surface of the organ, empty partly into the pudic veins, and partly into the venous plexus of the vagina and the bulb. The lymphatic vessels proceed to the lymphatic ganglions found in the cellular triangle included between the lateral parts of the vagina and the rectum, and not into the inguinal glands. The nerves are derived from the deep branch of the perineo-vulvar branch of the internal pudic. 31. Huguier is inclined to believe, from the result of his injections, that the ultimate ramifications of the excretory canal have a direct communication with the ramuscules of the arteries and veins. When the glands are incised, they are found to contain a glutinous, thick, and unctuous fluid, which is generally colorless, transparent, or slightly turbid. In some cases it is brownish or of a deep chestnut color, which appearance is due to altered blood corpuscles. Uses and Functions.—The vulvo-vaginal gland, like the entire generative apparatus of which it forms a part, acquires its full development only at puberty. This concordance alone, independently of observation, would lead to the sup- position that the fluid which it secretes is destined to bear a part in the generative act. The amount of its secretion is, in fact, variable. It is especially increased 48 FEMALE ORGANS OF GENERATION. during sexual intercourse, illicit contacts, and under the influence of lascivious thoughts, desires, and dreams. When, during coition, the muscles of the peri- neum and vulva are excited to involuntary and convulsive contractions, it is expelled in an intermittent manner or by jets, as is the sperm in the ejaculation of the male. According to 31. Huguier, the use of this abundant secretion is to lubricate the external parts, and thus render the first approaches less painful, to maintain the humidity of the organs during the act, and thereby preserve their extreme sensibility. There is besides, a synergy of action between this gland and the muciparous follicles of the vaginal orifice, which is satisfactorily explained by the anatomical connection of the two parts, by means of nerves and vessels which are common to both. Therefore, the fluid which covers the entrance of the vulva and of the vagina during intercourse, is the joint product of the gland and of the follicles. Art. IV.—Perineum. 9. The perineum is a sort of bridge, scarcely an inch to an inch and a half long, which separates the vulva from the anus; its inferior plane is composed of the skin. But, for a more full description of the parts entering into its struc- ture, I must refer to the treatises on anatomy. (See art. Pelvis.) SECTION II. OF THE INTERNAL PARTS. The internal parts of generation are the vagina and the uterus, together with its appendages, the Fallopian tubes and ovaries. Art. I.—Or the Vagina. The vagina, or vulvo-uterine canal, is a cylindrical membranous tube, extend- ing from the vulva to the uterus; it is situated in the pelvic excavation between the bladder and rectum; extending from the vulva to the superior strait, it has of course the same direction as the general axis of the pelvis: that is, it forms a curve, the concavity of which is anterior; the walls are soft and yielding, flat- tened from before backwards, with their surfaces in contact. Its length varies from four and a quarter to five and a quarter inches, though, according to Pro- fessor Velpeau (Lecons Orales), it is much less than has been generally imagined, or than he himself has pointed out in his works, being hardly two and a quarter to two and three-quarter inches long. Although this remark may be true if the length be measured in the dead subject, where the soft flabby walls of the vagina easily yield under their own weight and that of the uterus, and in consequence, the vertical extent of this cavity does not exceed three or three and a half inches • yet, the elasticity of these walls will permit the introduction of a speculum five or six inches long, and when the uterus is raised completely above the superior strait, the estimate of the Professor of La Charite is certainly below the truth. The length of the vagina varies in different females; thus, for instance the negress has it longer and more spacious than the European, as a general rule. OF THE ORGANS OF GENERATION. 49 Professor Chomel informed me that he had frequently remarked this fact, and I have since had occasion to verify its truth; nor is the vagina uniform in its size, A vertical Section of the Pelvis, showing the Organs in situ. B. The bladder is seen in front, with its urethra passing out under the symphysis. Just behind it, the uterus u, and the vagina v, are observed to occupy the middle of the excavation ; the rectum r, is still more posteriorly, being separated from the vagina by the recto-vaginal septum, p. The perineum. By reference to the upper part of the figure, the peritoneum can be traced from the anterior abdominal walls to the fundus vesicae, then down between the bladder and womb, forming a pouch, next over the fundus uteri, and then between the womb and rectum, forming another pouch, and finally to the posterior abdominal wall. in all parts of its extent; for the inferior orifice is the most contracted, the supe- rior extremity is the largest, whilst the middle part, especially in women who have had many children, frequently exhibits a considerable extension. The walls apparently retract in aged females, and greatly diminish the area of its cavity, returning very nearly to the same dimensions as are found in young girls. This canal is sometimes very short, reduced even to one and a half or two inches; but this congenital brevity must not be confounded with the apparent shortening produced by the descent of the uterus.1 1 M. Cruveilhier says these cases are daily confounded in practice, though nothing, how- ever, is easier than to distinguish them from each other; for, in the former one, the uterus cannot be raised, whereas, in the case of descent, it yields without resistance to the pres- sure of the finger, and resumes its natural position. Congenital shortening is a frequent cause of sterilhy, as well as of sharp pains in coition, and is a fruitful source of the acute or chronic inflammatory engorgements of the uterus. I have met with a case of considerable shortening of the vagina, in which the os tinc^e had been sufficiently dilated by the membrum virile, to admit the index finger. In some instances the repeated coition produces a sort of artificial vagina, behind the os uteri, at the expense of the posterior vaginal wall, and if the finger be then carried under the neck of the womb, it will dip into a pocket, the anterior wall of which is placed against the posterior one of the uterus. This artificial vagina, produced by forcing up the posterior cul-de-sac, is sometimes longer than the natural canal.—Anatomie Descriptive. 4 50 FEMALE ORGANS OF GENERATION. The vagina is in relation by its external face: in front, with the bas-fond of the bladder, to which it is united by some condensed areolar tissue, and also with the canal of the urethra, which indeed appears to be channelled out in its sub- stance ; behind, it is connected with the rectum, superiorly by a double fold of peritoneum, and infcriorly by areolar tissue, which is less condensed than that existing in front. Hence, the rectum is seldom drawn upon in the displace- ments of the uterus, whilst the bladder always participates more or less in these accidents. The lateral borders afford attachment, above to the broad ligaments, and below to the pelvic areolar tissue and to some venous plexuses. The internal face of the vagina is covered by a mucous membrane, continuous with that of the uterine cavity, excepting that its epithelium is not prolonged into the orifice of the latter, but terminates by a sort of denticulated border, similar to the relation of the oesophageal epidermis with the stomach; the inter- nal surface also exhibits some wrinkles or rather some transverse elevations near the vulvar orifice. A raphe, or prominent ridge found on the median line, ex- tends the whole length of the anterior wall of the vagina, affording origin to all those rugas; but the raphe is not so well marked on the posterior parietes as on the anterior; the term columns of the vagina has been applied to these two ridges. The transverse rugae are much better developed in young virgins and aged females; but, on the contrary, during pregnancy, and for a short time after deli- very, they are nearly effaced. These transverse ruga) have by some physiologists been regarded as organs of special sensation, and as designed to increase friction by the irregularities which they present. The mucous membrane contains a large number of muciparous glands that secrete abundantly ; these are particularly numerous at the inferior part of the canal. The superior extremity of the vagina embraces the neck of the uterus, but the manner in which the two organs are connected has not been properly studied. Thus, 31. Dubois fell into an anatohiical error which I think it important to rectify, when he stated that the superior extremity of the vagina is attached to the circumference of the uterine neck, precisely upon the limit indicated by the connection itself, between the vaginal portion and the part above the vagina. At its upper extremity, the vagina is composed of little else than the mucous membrane and the fibrous tunic, the dartoid layer being nearly absent. The fibrous tunic extends to the body of the uterus, when it becomes blended with the tissue proper of that organ, without any well-marked line of demarcation. The mucous coat alone is inflected upon the external surface of the neck, a little lower in front than behind, and descends to the external orifice, where it joins the lining membrane of the cavity of the neck. The adhesion between the ex- ternal surface of the mucous coat of the vagina and the external surface of the neck, is very close toward the lower extremity, but at the upper part is very loose and easily destroyed, as may be readily proved upon the dead body. If, in fact, the vagina and uterus be entirely removed, it will then be seen that under the influence of a slight traction, the portion of the neck which projects into the vagina, and on that account termed sub-vaginal, becomes almost completely effaced. The same effect is produced at an advanced period of pregnancy (see Pregnancy), when the uterus, as it rises in the abdominal cavity, draws neces- sarily, upon the upper vaginal attachments. OF THE ORGANS OF GENERATION. 51 In thus folding upon itself in order to embrace the neck, the mucous mem- brane of the vagina forms a circular groove or cul-de-sac, described as the ante- rior and posterior cul-de-sac. The posterior one is, generally, deeper than the anterior, owing probably to the insertion of the vagina behind, upon a more ele- vated point of the neck. The inferior extremity, or vulvar orifice, presents, in front, a transverse rugous prominence, that seems to diminish the entrance. Structure of the Vagina.—The walls of the vagina are formed of an erec- tile, spongy tissue, interposed between two very strong fibrous laminae, the exter- nal of which is the thicker; around the erectile tissue, a condensed layer of moderate thickness is found, analogous to the structure of the dartos membrane. According to Kobelt, this erectile tissue is composed of several superposed layers of venous network which proceed from the bulb, the finest ramifications extend- ing into the mucous membrane. This true spongy body extends continuously through the entire limits of the vestibule and of the vagina, and seems connected with the veins of the parenchyma of the uterus. The great vascularity of the walls of the vagina explains, to a certain extent, the dangers consequent upon their rupture. Surrounding the lower extremity of the vagina are a few mus- cular fibres, that constitute what is erroneously called (see below) the constrictor vaginae muscle. In some females, this is quite strong and well developed. Finally, under the name of bulb of the vagina, a swelling or cavernous body is described, that separates the orifice of this canal from the roots of the clitoris : moderately thick in the centre, where it is placed between the meatus urinarius and the junction of the crurae clitoridis, it gradually swells out, as it recedes from this point, and terminates below in an enlarged extremity on the sides of the vagina, being deficient, however, on the posterior wall of this canal. The length of the bulb when injected, is about one inch and three-eighths of an inch; its greatest width, from one-half to three-quarters of an inch, and its thickness from about three-eighths of an inch to one-quarter of an inch. (Kobelt.) The bulb of the vagina is composed of an erectile tissue analogous to that of the bulb of the urethra in the male, and communicates freely, as shown by M. Deville, with the cavernous tissue of the clitoris, by means of several veins of consider- able size. The bulb of the vagina is surrounded, as it were, by a layer of muscular fibres (constrictor cunni), in regard to the arrangement of which authors differ. Ac- cording to Kobelt, there are two constrictor muscles. It takes its origin by a large and flattened base from the aponeurosis of the perineum, almost directly at the middle of the space which separates the anus from the tuberosity of the ischium; thence it rises, becoming at the same time narrower towards the cli- toris, and covers or rather embraces in the shape of a half cylinder the entire length and width of the bulb of the vagina. A closer examination, says Kobelt, shows that this muscle is composed of two flattened layers, the deeper of which glides in between the upper border of the bulb and the root of the clitoris, and so appears above the urethra to unite with the muscle of the opposite side; the upper layer, on the contrary, which is also flat, rises upon the back of the clitoris, and is connected with its fellow by a flat and narrow tendon. FEMALE ORGANS OF GENERATION. Fig. 13. This muscle, which is. in fact, at a considerable distance from the vaginal orifice, has been erroneously regarded as a sphincter of the vagina. JNow its power to diminish the orifice of the vagina is but momentary, and only by com- pressing the bulb when greatly distended at the moment of coition. Its proper office is, in fact, that of a compressor of the bulb, whilst its upper extremity tends, at the same time, to depress the gland of the clitoris towards the vestibule. Vessels.—The vaginal arteries come from the hypogastric; the veins are very numerous and plexiform, and discharge into the hypogastrics; the lymphatics empty into the ganglions of the pelvis, and the nerves arise from the hypogastric plexus. The vagina serves in the female both as the organ of copulation and as the canal for the passage of the menstrual fluid, and for that of the product of con- ception. Art. II.—Of the Uterus. The uterus is the organ of gestation, in which the ovum is destined to re- main, from the period of its escape from the Fallopian tube, until the moment of final delivery. In form, it resembles a small gourd, or a pear flattened from before back- wards, having its base turned up- wards and the apex downwards. The axis runs from above downwards, and from before backwards, corresponding nearly with that of the superior strait. It is situated in the excavation, usually on the median line, between the bladder and rectum, being re- tained in position by the round and the broad ligaments on the sides, and below by the vagina, upon which it rests. The organ is divided into two parts, the superior of which, called the body, is the largest, and comprises more than half the total length; the other, or inferior portion, styled the neck, is smaller; a slight circular constric- tion serves to indicate externally the point of union of the body with the neck. As we have said before, the neck of the uterus is embraced about its middle by the mucous membrane of the vagina, being thereby divided into two portions, of which the one situated above the insertion of the vagina is called the superior vaginal; and the other, which projects into the upper part of that canal, is termed the inferior vaginal portion of the neck. The connections of the uterus are very loose and extensible; it therefore exhibits a great degree of mobility, and may easily be moved in every direction. The Internal Genital Organs. a. The uterus, seen on its anterior face. b. The in- tra-vaginal portion of the neck of the uterus, c. c. The Fallopian tubes. d. The pavilion, or fimbriated ex- tremity of the tube. e. e. The ovaries, r. The liga- ment of the ovary, g. a. The round ligaments, h. The vagina, laid open. On the right, the fimbriated extremity of the tube is seen applied to the ovary. OF THE ORGANS OF GENERATION. 53 Its volume varies with age, being quite small prior to the fifteenth year, but augmenting rapidly at this era; the womb returns very slowly to its primitive dimensions in women who have borne children, and finally, in advanced age, it often appears to waste away, and to dwindle down to the size it had prior to the fifteenth year. Its dimensions after puberty are as follows, viz.: The vertical diameter varies from two and three-fourths to three and one-eighth inches; the transverse one, at the fundus, one and three-eighths to one and a half inches, and at the neck, about half an inch in every direction. Certain physiological conditions produce a great augmentation in its volume. For instance, I have frequently observed at the approach of the monthly courses, that it presented twice the ordinary size at least, and in some women the increase in volume is so marked at this period, as to be mistaken for the commencement of a pregnancy. (See Diagnosis of Pregnancy.) The uterus likewise varies in situation at different epochs; thus it surmounts the superior strait in the foetus, and rests in the abdominal cavity, so that the Fallopian tubes and ovaries occupy the iliac fossae, the fundus uteri correspond- ing to the fifth lumbar vertebra. After birth, in consequence of the develop- ment of the pelvis, it appears to sink gradually into the excavation, and, at ten years, the fundus is on a level with the superior strait, but subsequently gets below this point. The womb is generally inclined to the right or left in aged females, or is turned backwards on the rectum. The axis of the uterus approaches that of the inferior strait in many women, especially in those having a short vagina. It must further be observed, that the direction described by us as normal, is far from being constant in all women, as a great variety of circumstances may change it; thus, in some cases, the fundus may be thrown so far forwards as to render the anterior wall the most inferior part, thereby constituting what pathologists have described as an anteversion; in others, the superior border is thrown towards the most inferior portion of the sacrum, the neck being carried behind the posterior face of the pubis, thus pro- ducing a retroversion; again, it is often turned towards one side of the excava- tion, the neck being directed to the opposite side: this is lateral version. Another singular anomaly in the relative direction of the axis of the body and that of the neck of the uterus remains to be described. In the normal condition, the axis of the neck seems to be identical with that of the body, and to be simply a continuation of it. Now, in some subjects, the body of the uterus is found to form with the neck an angle which approaches more or less to a right angle, as though one of these parts had been strongly bent upon the other, like the body of a retort upon its beak. This inflexion make take place anteriorly, posteriorly, or laterally, and has been styled accordingly anteflexion, retroflexion, and lateroflexion. This alteration in the relation of the axis of the body with that of the neck of the womb may occur accidentally, and we have several times observed it as a consequence of anteversion or retroversion, but, certainly it is often congenital, and then, should it remain after puberty, and especially should it increase in ex- tent, it might become a cause of sterility.1 1 It is the opinion of M. Follin, in which he is fully sustained by the anatomical re- searches of MM. Boulard and Verneuil, that congenital inflextons are not merely a common 54 FEMALE ORGANS OF GENERATION. The weiuht of the womb, in girls at puberty, is from six to ten drachms; but in women who have had children, it ranges from an ounce and a half to two ounces; and from one to two drachms in very aged females. The uterus exhibits an external and an internal surface. § 1. External Surface. The external surface presents for our study two faces, two borders, a base, and an apex. The anterior face is slightly convex, is covered by the peritoneum on its supe- rior three-fourths, and lies in a mediate relation with the posterior face of the bladder, from which it is frequently separated by some folds of the small intes- tine ; whilst, at the inferior fourth, it is in contact with the bas-fond of the bladder, to which it is united by some loose cellular tissue. This latter connec- tion explains the frequent participation of the bladder in the uterine displace- ments, however inconsiderable they may be, as also how in certain cases vesico- uterine fistulas may be produced after difficult labors. The posterior face is much more convex than the preceding, being covered throughout its whole extent by the peritoneum; it is in a mediate relation with the anterior surface of the rectum, the intestinal convolutions, however, often separating them; it may be readily examined through this gut. The lateral borders are slightly concave, affording an attachment to the broad and the round ligaments; but, as M. Cruveilhier remarks, these ligaments are attached to the anterior edge of the borders, and hence all the thickness of these margins is found behind the broad ligaments, and consequently the latter are on the same plane as the anterior face of the womb. exception, but constitute the normal condition in the foetus at term. M. Boulard has already examined a large number of foetuses with a view to the elucidation of this point, and in all, without exception, the uterus was anteflexed. The organ resembled a bishop's crozier, or the index finger when bent. Pursuing his researches, he found that the uterus was more or less inflexed in all women who had not conceived. Of twelve women, one had an anteflexion, and one a retroversion. In three living females, not mothers, he pro- fesses to have discovered anteflexion; therefore he is convinced that this deviation is normal, and simply a persistence of the foetal condition. We have examined for ourselves the pieces presented to the Biological Society by MM. Verneuil and Boulard, and are satisfied that, in at least a majority of cases, the womb of the foetus is in a more or less decided state of inflexion. "We are also disposed to regard it as a necessary consequence of the elevated position of the body of the womb. Situated as it is above the superior strait, and deriving a tendency forward both from the direction of the axis of this strait, and the pressure of the mass of intestines, the body is ne- cessarily urged forward, whilst the neck, which is much elongated and placed wholly in the excavation, retains the direction of the axis of this canal, which presents an anterior concavity. But we are far from believing that these inflexions continue in the adult female at least as a general rule. We believe that in proportion as the entire organ descends into the lesser pelvis, the above-mentioned causes of the foetal inflexion disappear and that in an immense majority of cases, the uterus presents its habitual rectitude at the period of puberty. Whatever value this explanation may have, the researches of MM. Follin, Boulard and Verneuil are, nevertheless, of great interest, and appear to me of a nature to modify greatly the generally received idea relative to the pathological importance of these uterine inflexions. OF THE ORGANS OF GENERATION. 55 The base, fundus, or superior border of the womb is convex, looking upwards and forwards, and covered by the convolutions of the small intestine. It never attains the level of the superior strait in the unimpregnated state, and therefore it is only possible to feel it through the inferior abdominal wall, by using great pressure. At the junction of this base with the lateral borders of the body the two angles are formed, from which the Fallopian tubes and ligaments of the ovary arise. The inferior extremity, or the uterine neck, is located in the upper part of the vagina, and merits the accoucheur's most particular attention. Of the Neck of the Uterus.—Very remarkable differences are found be- tween the neck of the uterus in a woman who has borne children, and that in one who has never been a mother; we shall, therefore, consider it successively in each, because the modifications it undergoes during pregnancy can only be appre- ciated after a careful study of the ordinary condition. 1st. In the woman who has never been a mother, the neck of the uterus is from an inch to an inch and three-eighths in length, and is separated from the body by a narrow, constricted portion, which can easily be distinguished, even on the exterior of the organ. At the central part, where it is a little enlarged and fusiform, it is about three-quarters of an inch in the transverse diameter, and half an inch in the antero-posterior one. Near the junction of the superior third with the inferior two-thirds, it is embraced by the upper end of the vagina, which descends a little lower on the anterior than on the posterior face, whence the subvaginal portion of the neck is somewhat longer behind, but the contrary is true for that part above the vagina. The cervix is terminated by an extremity that is less voluminous than the other portions of its extent, so as to present a conical form to the finger. This ex- tremity bears the name of the os tinea-, or tench's mouth.1 The os tincae pre- sents two lips, separated by a small transverse fissure, somewhat swollen in the middle, called the external orifice of the neck. The orifice, from being com- pletely closed up, is sometimes difficult to find in a young marriageable girl. But, according to Dubois, if the index encounters it, we may recognize the part by comparing the sensation then experienced with that produced by applying the pulp of the finger upon the extremity of the nose, and feeling the depression be- tween the alae nasi. The anterior lip is the thicker, though both are very nearly of the same length, the anterior one, perhaps, descending a little lower than the other.3 These lips are smooth and polished throughout, neither presenting any 1 This conicity of the neck has been regarded by some authors as a cause of sterility, but I feel assured that the cause has here been confounded with the effect. The conical form of the neck is, in fact, the normal one in young girls, and is generally destroyed by the first labor. If, on the contrary, the female has never had a child, this form remains through life ; its persistence is not therefore the cause, but the effect of sterility. 2 Most authors teach that the anterior lip of the neck descends lower than the posterior. In detaching the uterus from a dead body no great difference, however, is observed in this respect; but, on the contrary, if we touch a female, the distinction is much better marked. I believe this results solely from the fact of the neck being directed a little posteriorly, so that the surface of the os tincae is not horizontal, but inclined backwards; and, therefore, the anterior lip is necessarily somewhat lower than the posterior. Besides, the finger in passing from below upwards, and from before backwards, must first encounter the anterior lip, and is then obliged to go higher and further behind to reach the posterior one. 56 FEMALE ORGANS OF GENERATION. inequalities nor any depression; in fact, the whole external surface of the neck is equally smooth, and without elevations. The cervix is slightly directed backwards, so that, if prolonged, it would ter- minate near the coccyx, or the most inferior part of the sacrum. It is situated in the upper half of the excavation, yet the finger can easily reach and pass over its whole exterior surface. 2d. In the female who has had several children, the neck has not the same aspect, and the length is so variable that it is not possible to announce it in ad- vance ; though we may say, in general terms, that it is shorter in proportion to the larger number of children the woman has borne, a portion of it seeming, as it were, to have been destroyed at every labor. Two females, one of whom had seventeen, the other nineteen children, have been under my care; the neck in each of them was completely destroyed, in its intra-vaginal portion. No prominence was found at the superior part of this canal, and the finger only encountered two little tubercles, as large as a lentil, separated by an open orifice, by which latter alone the neck could be recognized. This diminished length of the infra-vaginal portion of the neck in women who have borne many children, is due to the strong traction upon the upper extremity of the vagina in the preceding pregnancies, produced by the elevation of the uterus; in consequence of this traction, and the laxity of its adhesions with the middle part of the neck, the vagina becomes detached from it at that point, and adheres to it only at its inferior extremity. When this has occurred, it is plain that the portion which projects into the vagina must be much less considerable than before. Although it still preserves a certain length, the regular form that it previously had is wanting, for it is no longer a fusiform body, with an exterior surface polished and smooth everywhere, but a kind of irregular teat, covered on its external face by more or less numerous elevations. Sometimes it is more swollen at the inferior portion, whilst the upper part ap- pears to be hollowed out in its whole circumference by a deep excavation. The orifice of the os tincae is sufficiently patulous to admit the extremity of the finger, or even one-half of its ungual portion may occasionally be introduced. The lips are unequal, presenting a variable number of notches. Being rarely found on the middle part of the lips, these depressions are continually met with about the level of the commissures, and more frequently on the left side than the right.1 They result from the lacerations that have occurred in former labors, at the moment when the head cleared the os uteri; and the lochial discharges have prevented the lips of these little wounds from uniting, and they have cicatrized separately. The depressions are sometimes so numerous as to subdivide the lips into six or eight small tubercles, separated by as many fissures of variable depth. In case the woman has not had children for several years, and more especially 1 The frequency of these depressions on the left side may be, I think, readily explained. At the period of the head's passage through the neck, it is evident that, if a laceration be produced, it will be at the point which sustains the greatest effort. Now, the left occipito- iliac positions being much the more frequent, the occiput, which constitutes the largest ex- tremity of the head, will consequently correspond to the left commissure of the neck Fur- ther, the uterus is habitually inclined to the right, so that the line of its contractions is directed from right to left, and, therefore, acts more energetically on the left side of the cervix. Hence, the most violent efforts occur at this point. OF THE ORGANS OF GENERATION. 57 if she has had but one or two of them, these characters are much less deter- mined, the orifice is nearly obliterated, and the neck has gradually resumed its primitive form; nevertheless, the fissure of the orifice is always sufficiently marked, as well as the inequalities on the lips, to indicate antecedent labors. These marks may become more and more faint, but they never disappear altogether. § 2. Internal Surface. The uterus presents an internal surface circumscribing its cavity. This latter is divided into the cavity of the body, and that of the neck. A. The cavity of the body is triangular in shape, presenting an orifice at each Fig. 14. Cavity of the Uterus and the Fallopian Tubes. A. Superior border or fundus of the womb. b. Cavity of the womb. o. Cavity of the neck of the uterus. D. The canal of the Fallopian tube cut open e. The fimbriated 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 i. The cavity of the vagina, h h. The ligaments of the ovaries o g. The round ligaments. Fig. 15. of its three angles; the inferior one of which establishes a communication between the cavities of the body and neck, and hence is called the internal or uterine orifice. The other two are the orifices of the Fallopian tubes; they are scarcely visible, and occupy the bottom of the funnel shaped cavities found at the superior angles of the womb. In the state of vacuity, no cavity, to speak correctly, exists in the womb, for the uterine walls are in con- tact throughout their extent: the cavity, like that of the pleura for example, has a real existence only when the walls become separated by a liquid effusion. Fig. 15 will afford an idea of the dimensions of the uterine cavity when empty. The congenital deficiency of a cavity in the body is very rare, but yet no trace of it existed in a uterus pre- sented to M. Cruveilhier by M. Rostan, although that of the neck remained. In aged women, however, it is not very rare to find the cavity partly effaced by more or less extensive adhesions. B. The cavity of the neck is fusiform, flattened from before backwards, and presents an assemblage of rugse on its anterior and posterior walls, which constitute a median vertical column upon each wall, occupying the 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 tbe body. d. Cavity of the neck. 58 FEMALE ORGANS OF GENERATION. whole length of the neck, and from which a number of smaller columns pass off at various angles, representing a fern in relief. The term arbor vitce has been applied to these rugosities. After delivery they frequently disappear, but sometimes they still persist. The uterine cavity likewise exhibits a variable number of transparent vesi- cles, mistaken by Naboth for eggs, hence they have been called the ovula Kabothi. These vesicles are nothing more than simple muciparous follicles, and they are particularly abundant in the neighborhood of the neck. They secrete a gelatinous mucus, which may accumulate in the cavity of the neck, and so obstruct it as to render fecundation impossible. The internal surface of the uterus is much more vascular in the body than in the neck. This difference is particularly well marked in women who have died during the menstrual period. The cavity of the body is of a rose color, and that of the neck of a pearly gray hue, Avhich is probably due to the slight vascularity of this part in comparison with that of the lining membrane of the body. § 3. Structure of the Uterus. In the ordinary condition of the womb, this structure is difficult to make out, but it becomes much more evident during the period of gestation. The constituent parts of the organ are : a peculiar tissue, an external perito- neal membrane, and an internal mucous one, together with numerous vessels and nerves. A. Peculiar Tissue.—This tissue is of a grayish color, and is very dense in structure, creaking like cartilage under the scalpel. In general, the neck appears less firm in consistence than the body, resulting, as M. Cruveilhier supposes, from the former being the more frequent seat of sanguineous fluxions. (See Menstruation.) The uterus is more flexible, and of a brighter red hue, in some particular cases: such as a suppression of the menses, and also during the period imme- diately following or preceding the courses. The proper tissue of the womb is composed of fibres disposed lengthwise. The nature of these fibres has led to numerous discussions, but at the present day they are generally considered to be muscular in character, and, since this muscular nature becomes clearly evident towards the end of gestation (see Pregnancy), we must acknowledge that, notwithstanding the fibrous appearance of its tissue in the unimpregnated condition, the fibres composing it are not the less muscular in their structure. This organization is concealed by the state of condensation; of atrophy, maintained either by inertia or want of action; but which becomes distinct, in consequence of the very considerable determination to the uterus, of its distension, and of the development of its fibres during pregnancy. According to most anatomists, the direction of these fibres in the state of vacuity is very irregular, and their inter-crossing is nearly inextricable, as every one must confess, in this particular condition, says M. Cruveilhier. But as the structure of the uterus, except in gestation, is not of any consequence (practically speaking) to the accoucheur, we refer to the article Pregnancy for the more particular study thereof. B. The External or Peritoneal .Membrane—The peritoneum havin^ covered OF THE ORGANS OF GENERATION. 59 the posterior face of the bladder, is reflected upon the anterior one of the uterus, covering only its superior three-fourths; and having reached the fundus uteri, and gained the posterior wall, it covers this entirely, is prolonged on the vagina for a short distance, and is then reflected upon the rectum. The broad ligaments are produced by the transverse elongations of this membrane; and its falciform folds, seen in the interval that separates the bladder from the uterus, are called the vesico-uterine, or the anterior ligaments; and those formed by it, between the rectum and uterus, are called the posterior, or the recto-uterine ligaments. The adherence of the peritoneum is quite loose on the borders of the uterus, but it becomes more intimate towards the median line. C. The Internal or Mucous Membrane.—The existence of this membrane was for a long time contested, and there can be no doubt, that if a membrane resem- bling the majority of those which line all the mucous cavities be sought for in the uterus, it will be sought in vain. Still its existence is rendered very probable by the functions of the organ, for, as Cruveilhier has remarked: 1st. Every organic cavity communicating with the exterior is lined by a mucous membrane. 2d. Anatomy demonstrates that the vaginal mucous membrane is continued into the cavity of the neck, and then into that of the uterus. 3d. When examined by a lens, the internal surface of the uterus exhibits a papillary disposition, but the papillae are imperfectly developed. 4th. This internal surface has follicles or crypts scattered over it, from which mucus can be squeezed out, and which, if their orifices be obstructed or obliterated, become distended by the liquid, and form little vesicles. 5th. It is continually lubricated by mucus. 6th, and lastly; the internal surface of the uterus, like all other mucous membranes, is subject to spontaneous hemorrhages, to catarrhal secretions, and to the mucus, fibrous, and vesicular vegetations, called polypi; and it is generally admitted that, wherever there is an identity of action, there is also an identity of nature. These physiological probabilities are at present fully confirmed by anatomical research, the numerous preparations in the possession of M. Coste leaving no doubt whatever as to the existence of the mucous membrane. I shall therefore borrow from this able physiologist the principal facts which pertain to its description. The thickness of the uterine mucous membrane varies in different parts of its extent. Towards the middle of the body, it forms one-fourth of the thickness of the walls of the uterus, that is to say, its usual depth at this point is from one- eighth to three-sixteenths of an inch, amounting to about the one-fourth of the thickness of the uterine parietes. It thins off rapidly towards the point of union of the body with the neck, as also towards the apertures of the Fallopian tubes. Its greatest thickness in the neck does not exceed the one twenty-fourth part of an inch. The thickness of the mucous membrane is clearly exhibited by the assistance of a perpendicular section of the uterus. It is then found to be injected, and varying in color from a deep or bright red, to a semi-transparent reddish or pearly gray: the muscular tissue, on the contrary, is almost always of a reddish-gray color, and is besides easily distinguished by the numerous vascular openings upon the surface of the section, and from which blood may be caused to exude by pres- sure. In addition, there is always a whitish line of demarcation between the 60 FEMALE ORGANS OF GENERATION. two tissues, which becomes most distinct when the injection of the mucous membrane is greatest. Its consistence is less than that of the tissue proper of the uterus, being very friable, and easily crushed. Fig. 16. It adheres very strongly to the substance of the uterus, and is sepa- rated from it with great difficulty: it is also incapable of any gliding mo- tion upon the parts which it covers, on account of the entire absence of a submucous cellular tissue. Its internal surface presents a mul- titude of small orifices, rather regu- larly arranged, which, though barely perceptible to the naked eye, become very evident with the assistance of a lens. About forty-five of them are contained in a space equivalent to the square of one-eighth of an inch. They are the orifices of glands. M. Robin has given an excellent description of the elements which „,,, . . .. enter into the composition of the mu- This figure represents the arrangement of the mucous L membrane and of the tissue proper of the uterus, as also cous membrane; they are : thxrrluveftfd^en8lT" ,„■♦,, L Fibro-plastic elements; 2. Cel- a. Cavity of the neck and arbor vitse. b. Cavity of o ci the body. c. Mucous membrane, d. Intervening mem- lular tissue; 3. Some nucleated fibres; brane. .. Represents the marked thinning off of the 4. Amorphous matter, forming a me- mucous membrane towards the neck. _. ' ° dium of connection; 5. Glands; 6. Capillary vessels. We shall limit ourselves to a brief account of the uterine glands. Two species of glands exist in this mucous membrane, one being found only within the body of the uterus, whilst the other is confined to the neck 1. According to M. Coste, who was the first to describe them, the glands of the body are especially visible when death has occurred during menstruation- they then appear as minute canals of about the one two-hundred-and-fiftieth part of an inch in diameter, placed vertically beside each other. They are however disposed so compactly, that the mucous membrane as seen by a lens appears to be formed of them almost exclusively. Their adherent extremities terminate in culs-de-sac and repose upon the muscular tissue. The bodies of the glands are rendered somewhat flexuous by the mucous membrane being too thin as it were in the state of vacuity, for the length of the tubes. They contain' a whitish' viscid fluid which may be squeezed from them, especially at the menstrual period! 2. The glands of the neck (glands, or ovula of Naboth) are found in all the interval between the line separating the cavity of the neck from that of the body and the neighborhood of the borders of the os tine*. Their orifices are readily seen upon, and especially between, the folds of the arbor vita These glands have the form of a minute cylinder, terminating in a rounded OF THE ORGANS OF GENERATION. 61 cul-de-sac, which is inflated into the form of a lentil or vial, and enclosed in the tissue of the mucous membrane, even descending a little between the fibres of the muscular structure. The excretory orifice is always smaller than the glandular tube. Pressure causes the escape from it of a transparent, viscid, tenacious, and completely homogeneous fluid. We shall treat hereafter of the modifications which these glands undergo during gestation. D. Vessels.—The arteries of the uterus come from the hypogastric and ovarian arteries. Both series describe a number of flexuosities in the tissue of the organ. The veins empty into the corresponding trunks. The lymphatic vessels are very numerous, and run to the pelvic and lumbar ganglia. The nerves are derived from the great sympathetic, some of them proceeding from the renal and others from the hypogastric plexuses; to the latter are united some fibres from the sacral plexus. It is an important practical remark of M. Jobert, that the entire intra-vaginal portion of the neck is destitute of a supply of nervous fibres, whilst the portion above the insertion of the vagina receives a great number of them, which form species of plexuses, furnishing ascending or uterine branches and descending or vaginal ones. The latter are extremely numerous, and ramify to infinity in the substance of the vagina. This distribution, which would explain a number of physiological and patho- logical facts, needs confirmation from new researches, for recent preparations deposited by M. Boulard in the Museum of the School of Medicine, give it a formal denial. Development.—According to some authors, the uterus is bifid in the embryo as late as the end of the third month, but M. Cruveilhier says he has never ob- served this bifurcation. During the intra-uterine life, the volume of the neck surpasses that of the body, and, at this period, its largest portion corresponds to the vaginal extremity. After birth, it remains nearly stationary, until puberty, and then it acquires in a very short time, the dimensions observed in the adult woman. The organ often becomes atrophied in old age. § 4. Ligaments of the Uterus. We have already spoken of the anterior and posterior ligaments. The broad and round ones still remain to be described. The Broad Ligaments.—As elsewhere stated, the double lamina of the peri- toneum, which covers the anterior and posterior faces of the uterus, is prolonged transversely, the two folds resting against each other, and forming by their union a transverse partition, extending from each side of the uterus, which divides the pelvis into two cavities; the anterior of which lodges the bladder, and the poste- rior the rectum. Outwardly, and below, these ligaments are continuous with the peritoneum that lines the excavation; their superior border is free, and is ex- tended from the angles of the uterus to the iliac fossae—presenting three folds, called the wings. The anterior wing is not admitted by some anatomists; it is but slightly developed, and is occupied by the round ligament. The middle one encloses the Fallopian tube, and the posterior contains the ovary and its ligament. 62 FEMALE ORGANS OF GENERATION. The two serous folds that constitute the broad ligament, are separated by a loose and very extensible lamellated cellular tissue, continuous with the fascia propria of the pelvis. The broad ligaments disappear during gestation, their two laminse assisting to cover the anterior and posterior faces of the developed womb. Bodies of Eosenmuller.—Bj the inspection of pieces prepared by M. Follin, we have become assured of the existence of an organ between the two laminae of the broad ligament, which has not been even noticed by French anatomists, but which certain German anatomists figure under the name of the organ of Rosen- muller, who was the first to discover it. Its general arrangement is not yet well understood, its development is involved in obscurity, and the details of its histo- logy had not hitherto been described. The researches undertaken by M. Follin in reference to this subject show, that the organ is composed of seven or eight tubes folded upon themselves, terminating in blind extremities, and all converg- ing towards the tube which serves as a point of entrance for the vessels of the ovary. The tubes are generally closely approximated to each other, so that their inflexions frequently correspond. When examined by transmitted light, the as- semblage of canals is distinctly seen in the broad ligament near the fimbriated extremity of the Fallopian tube. Sometimes these tubes are not very apparent, and their number is much less, yet some are always to be found. They exist at all ages, but are much more readily distinguished in the broad ligaments of the fa-tus, or of children, for then the slight development of the bloodvessels does not obscure them, nor are they hidden from observation by the fat, which infil- trates the laminae of the broad ligaments in adults. The size of the tubes is variable: and they often present dilatations, and some- times true cysts filled with a citrine fluid. M. Follin has not been able to discover an excretory orifice to these tubes, either in young girls or adult women. Their structure resembles that of the glandular tubes of many simple glands. They are provided with a central cavity, which presents the dilatations so often observed in tubes of this class. Externally, the tube is formed of cellular-tissue- membrane with longitudinal fibres. The internal surface of the tube is covered with pavement epithelium. Some observations are calculated to produce the impression, without however confirming it, that this assemblage of tubes has, in its origin, some relation with the corpora Wolffiana. Attached to the free edge of the broad ligaments, it is not uncommon to find five, six, or even more small cysts which have escaped the notice of authors. They are generally connected with the ligament by a very slender pedicle of variable length, but which is sometimes so short, that the cyst appears to be ses- sile, and directly adherent to the ligament. (See Fig 17.) It is difficult to understand the mode of development of these cysts. They may, perhaps, have some relation with the tubes of which the bodies of Rosen- muller are composed. It has however seemed to us worth while to call attention to them, particularly as they are stated by M. Broca to be present in the great majority of cases. The round ligaments, or supra-pubic cords, are evidently continuous with the OF THE ORGANS OF GENERATION. 63 tissue of the uterus, to which their proper substance is precisely similar; arising from the lateral border of this organ, below and a little in advance of the Fallo- pian tube, it runs upwards and outwards by raising up the small ligament. Ac- Fig. 17. The figure exhibits the small cysts appended to the free edge of the broad ligaments. One of the Fallopian tubes is represented with a double fimbriated extremity, as in the case described by G. Richard. A. Uterus, b. Fallopian tubes. c. The additional fimbriated extremity. d, e. The normal fimbriated extremities, f, a, h. The cysts described above. cording to M. Deville, this fringe, or ligament, is bent downward in the anterior fold of the broad ligament, and reaches the internal orifice of the inguinal canal, into which it enters, accompanied by a prolongation of the peritoneum, bearing the name of the Canal of Nuck. It then divides into a number of fibrous fasci- culi, which are lost in the cellular tissue of the mons veneris and that which fills the dartoid sack, described (page 39) as existing in the labia externa. According to Madame Boivin, the round ligament on the right side is the shorter and larger of the two. They contain a great number of veins, which are liable to become varicose. These ligaments serve to retain the uterus in position, and to prevent its dis- placements ; and it is probably to them that the pains in the groins, experienced by some women, during chronic affections or displacements of the womb, may be referred.. They are, in a great measure, composed of cellular tissue and vessels, but containing also some muscular fasciculi, the superior of which are prolonged from the uterus, and the inferior come from the internal oblique muscle. The superior muscular fibres are much more evident during pregnancy. Finally, the vesico-uterine and utero-sacral ligaments, formed, as we have stated, of folds of the peritoneum, which, after having covered the uterus, are reflected upon the posterior surface of the bladder and the anterior surface of the rectum; these ligaments are, so to speak, reinforced by collections of fibres which appear to be prolongations from the tissue proper of the womb, and which are attached anteriorly to the posterior surface of the bladder, and posteriorly to the anterior surface of the rectum. Art. III.—Of the Fallopian Tubes. The uterine or Fallopian tubes are two canals, varying from four and a quarter to five inches in length, and placed in the thickness of the superior border of the broad ligament. They extend transversely from the lateral angles of the womb 64 FEMALE ORGANS OF GENERATION. nearly to the iliac fossa on the corresponding side. Their volume is made more evident by inflating them. (G. Richard.) It may then be ascertained that be- yond the uterine parietes, the tube has a diameter of about three-sixteenths of an inch; towards the middle of its course it increases to about one quarter of an inch, and just before the ostium abdominale, to rive-sixteenths of an inch. Their calibre is very variable at different points. The elasticity of the walls is how- ever so great as to allow of their increase to an enormous extent, as is proved by the cysts which are frequently found in them. The internal orifice of the tube (ostium uterinum), is stated by M. Richard to be the one-sixteenth of an inch in diameter; from thence, the calibre of the canal increases gradually to its external orifice. Near the free extremity it spreads out and becomes fringed. This termination constitutes the pavilion, or fimbriated extremity (the morsus diaboli). It is generally* taught that one of these fringes, which is longer than the others, attaches itself to the extremity of the ovary. On the contrary, M. Cru- veilhier believes that this adherence takes place through the intervention of a groove, the concavity of which looks downwards and backwards, and facilitates the communication between the ovary and the cavity of the tube. All the fringed folds are attached to a small circle which is more contracted than the part of the tube which it terminates. This small circle is called the external orifice of the tube. The internal or uterine orifice is the name given to the one by which it opens in the uterine cavity. The peritoneum forms the external tunic of the tube; a mucous membrane and an intervening coat complete its structure. Most authors describe the mucous membrane as continuous with the uterine mucous membrane on the one hand, and with the peritoneum on the other, thus presenting the only example of continuity between a mucous and a serous membrane. Now, according to MM. Robin and Richard, both these opinions are equally fallacious. M. Richard states, that the mucous membrane of the womb and that of the oviduct, have an entirely different physiological office to perform, and that they present an appearance and organization which indicate at once their line of de- marcation. The first is of a rose color, is smooth, polished, and exhibits to the naked eye a multitude of minute dark points, which are the orifices of its innu- merable glands; the second is of a paler hue, and is roughened, even in this region, with short and rigid folds, having a longitudinal arrangement. Accord- ing to the same author, the pretended continuity of the mucous with the serous membrane is only apparent, and that there exists on the contrary a well-defined limit between the two membranes. When the serous membrane which accom- panies the body of the tube has reached the external surface of the fimbriated extremity, it terminates suddenly, at a distance of from one-sixteenth to three- sixteenths of an inch from the edge of the fringe, by a slightly sinuous and often reflexed border. This line, which is the limit of the peritoneum, describes a circle around the fimbriated extremity, but is prolonged upon the external surface of the tubo-ovarian fringes, and thus reaches the obtuse extremity of the ovary. Until of latter time, the middle coat of the tubes had been regarded as a pro- longation of the tissue of the uterus. M. Robin states that this fs incorrect, and that the tube is simply attached to the uterus so as to complete the conducting OF THE ORGANS OF GENERATION. 65 canal. If the womb of a pregnant female be dissected, the oviduct may be traced with ease through the thick walls of the organ. In its course through the uterus, the tube preserves the volume which it had upon entering it. It remains of a whitish color, whilst the uterine tissue is of a reddish gray. A thin cellular layer is interposed between the two structures, and allows them to be separated with ease. Muscular fibres are discoverable in the uterus, whilst in the oviduct nothing but cellular tissue and fibro-plastic elements are to be met with. The uterine extremity of the tube terminates at the internal surface of the muscular structure of the womb, by a slight thinning off of its walls. A special artery, derived from the numerous branches with which the uterus is supplied, and two veins, which join the ovarian veins, constitute the vascular apparatus of the tube. It is provided with nerves from the spermatic and hypo- gastric plexuses. The Fallopian tube serves the double purpose of a canal for transmitting the fecundating principle of the male, and for carrying the germ furnished by the female from the ovary to the uterus. The use of the fimbriated extremity is to embrace the ovary at the moment of fecundation, and probably also at each menstrual period, and to apply itself over the point from whence the germ is detached. At this time, the vessels of the Fallopian tubes are engorged—the mucous membrane assumes a well-marked red color—the walls are thickened, and the canal is enlarged. The tubes are at the same time affected with peristaltic contractions, which are probably intended to propel the ovule into the uterine cavity. The anomaly presented by the existence of supernumerary pavilions, or fim- briated extremities, upon the same tube, as described by M. Gustave Richard, is here deserving of notice. In the bodies of twenty women, selected at random, he observed it five times. One or several of them were found attached to the tube either immediately behind the normal fimbriated extremity, or at distances varying from three-quarters of an inch to an inch and a quarter beyond it; all of them were formed like the one which terminated the oviduct by the fringe- like division of the mucous membrane. By floating the fringes under water, an opening was discovered conducting into the tube, through which a stylet might be introduced and brought out through either the internal or external orifice of the tube. According to Dr. Hamilton, of Edinburgh, the Fallopian tube undergoes some modification during gestation, to which he attaches great importance, as a charac- teristic sign of pregnancy. This change consists in the formation of a little pocket, or sac, about an inch from the fringed extremity. This partial dilatation of the tube, previously described by Roederer under the name of antrum tuba?,, is certainly an exceptional fact. I have never observed it; and M. Montgo- mery has encountered it but once in fourteen uteri, examined in the state of gestation; so that it cannot have all the importance that certain authors wish to ascribe to it. Art. IV.—Of the Ovaries. The ovaries (testes muliebres) are the analogues, in the female, to the testicles of the male : that is, both of them secrete a product indispensable to reproduc- 5 m FEMALE ORGANS OF GENERATION. tion. Two in number, they are situated on the sides of the uterus, in that por- tion of the broad ligament called the posterior wing, just behind the Fallopian tube. Tluv are maintained in position by those ligaments, as also by a special one, denominated the ligament of the ovary. The ovaries vary in situation, according to the age of the individual, and the state of the uterus. In the foetus, they are placed, like the fundus uteri, in the lumbar region; but, during gestation, they rise into the abdomen along with the body of the uterus, upon the sides of which they lie. Immediately after delivery the ovaries occupy the iliac fossae, where they some- times continue throughout life; again, it is not at all uncommon to find them turned backwards, and adherent to the posterior face of the womb. The ovaries vary in size, both from age, from the plenitude or vacuity of the uterus, and from health or disease. Being proportionably larger in the foetus than in adult age, they diminish after birth, augment in volume at puberty, espe- cially at the monthly periods, and dwindle away in old age. During pregnancy and after delivery, they acquire in some cases quite a considerable volume. Fig. 18. Ovary of the Young Female after Puberty. a. Body of the ovary, b. Utero-ovarian ligament. C. Tubo-ovarian ligament, d. Fallopian tube. e. Fimbriated extremity of the tube. Before the age of puberty, the external surface of the ovaries is of a light rose color, and is smooth and free from inequalities. In women who have men- struated for several years the surface is rough, fissured, covered with small blackish cicatrices, and sometimes with ecchymotic spots. Some of these cica- trices are linear, others are triangular or radiated; they are of a red color when recent, but become brown in the course of a few months. Sometimes a complete union fails to take place between their edges, leaving a small opening which com municates with the ruptured cavity. After the period of life at which the menses disappear, the external surface presents numerous wrinkles, which are not as has been supposed, the result of old cicatrices, but are due simply to the atrophy of the ovaries, and the plication of the external envelope which is the consequence. The ovaries are ovoidal in shape, a little flattened from before backward and of a whitish color. The external extremity of the ovary is adherent, as we have said, to one of the fringes of the fimbriated extremity of the Fallopian tube; the internal extremity OF THE ORGANS OF GENERATION. 67 is attached to the uterus by the ligament of the ovary, which is inserted at the corresponding angle»of that organ. The ligament of the ovary, which we have already considered, was for a long time regarded as a canal, designed like the Fallopian tube to convey the fecun- dated ovule into the cavity of the uterus; modern anatomists, however, believe it to be solid. From the researches of Gartner, of Copenhagen, and of M. de Blainville, it appears that in some quadrupeds, and especially the sow, a canal is almost always to be found extending from its external orifice by the side of the meatus urina- rius (corresponding with a similar orifice on the other side of the meatus), through the substance of the muscular fibres of the vagina to the neck of the uterus; here the canal becomes narrower, but continues on, following the body of the uterus and imbedded in its fibrous structure, and finally leaves it to pass in a direction parallel to the corresponding angle into the substance of the broad ligament. M. Follin found, whilst injecting the duct of Gartner in the sow, that he in- jected at the same time a long tortuous tube, situated in the substance of the ligament, at the point occupied in the human female, by the collection of glan- dular tubes which I have described. I have been able to determine the fact that in the sow this duct does not open by a large orifice at the lower part of the vagina, as has been represented, but in reality by a very narrow one. It is not ter- minated at its entrance into the broad ligament by a few brush-like divisions, as stated by M. de Blainville, but is continuous with a very fine tortuous tube which extends to the external extremity of that ligament. The duct of Gartner is furnished internally with a pavement epithelium, and communicates through- out its course with many glandular tubes finer than itself. (Follin.) We have sought for this duct of Gartner in the human female, but found nothing which could be reconciled with the description given by him of it; how- ever, we cannot avoid remarking that since these researches N. C. Baudelocque has observed in a woman a canal which seemed to be produced by a bifurcation of the Fallopian tube, and which, after passing through the entire uterine walls, opened into the upper part of the vagina near the neck of the womb. Madame Boivin and some others have met with a similar canal, and Mauriceau and Dulaurens considered it of quite frequent occurrence. The arteries which supply the ovary are the spermatics, and proceed directly from the aorta. The numerous small venous branches originating in the ovary, are collected into a common trunk, called the spermatic vein, which empties into the inferior vena cava, though sometimes into the renal vein. The numerous lymphatic vessels with which it is provided contribute to the formation of the spermatic plexus, which itself empties into the lumbar plexus, and thence passes to the thoracic duct. The.nerves are derived from the great sympathetic. § 1. Structure of the Ovaries. The ovary consists, 1st, of a dense fibrous envelope, covered by, and intimately united to, the peritoneum; 2d, of a spongy, vascular tissue, the meshes of which 68 FEMALE ORGANS OF GENERATION. Fie. 19. >eem. to be formed of very delicate prolongations of the exterior envelope, analo- gous to glandular tissue. • Baer has given to the sub-peritoneal fibrous envelope the name of the stratum superficiale, and that of the stratum intimum seu proprium to the proper ovarian tissue. He designates both of these lamina? (which he considers of the same nature) under the title of stroma. The glaudular substance exhibits a number of small cavities, in which some little follicles, described by Graaf, and bearing his name, are found enclosed. Some of these follicles or vesicles are plunged into the very interior of the organ; others, that are larger and better developed, occupy the surface, where they are more or less imbedded in the stroma,producing sometimes little round- ed elevations on the latter, which give a tuberculous aspect to the whole ovary. In such eases, they are only covered on the free surface by the proper tunic This figure represents a longitudinal section of the 0f the OVary, which occasionally becomes ovary, showing the arrangement and different degrees . , i -i • 1 of development of the Graafian vesicles. SO thin there, as to exhibit the Serous lamina alone. The number of well- marked vesicles varies from fifteen to twenty in the adult female, but with the aid of a microscope a much larger number cau be brought into view, which, although still very small, will be gradually developed as the others shall have accomplished their mission. § 2. Of the Ovarian Vesicles. These vesicles are composed of two portions: 1st, of a containing part, the envelope; 2d, of a contained one, the nucleus. The former consists, 1st, of some foreign parts, those not proper to the vesicle itself, but appertaining to the ovary, and which are subtended and transformed by it into teguments; and 2d, of a proper capsule for the vesicle. a. The tegument {indusium, Baer) only invests the prominent part of the vesicle, being formed of a peritoneal lamina and of a thin layer of the stroma or proper ovarian tissue. b. The capsule (theca, Baer) is composed of two laminse, the external and the internal. The former is thin but tenacious, very retractile, semi-transparent, and formed, like all thin membranes, of a dense cellular tissue; some vessels ramify in its substance, and their extremities go to the internal layer. This latter is softer, thicker, more opaque, and slightly or not at all retractile. Its internal surface is lubricated, exhibiting granulations, and some extremely deli- cate villosities, whilst the outer surface is intimately united to the external layer; the little vessels that penetrate it immediately subdivide into very delicate ramus- cules. assuming a pencillous arrangement, so as almost to constitute a third layer which is essentially vascular. c The Nucleus.—The parts entering into the composition of the nucleus are 1st. a granular membrane which encloses the humor of the Graafian vesicle; and OF THE ORGANS OF GENERATION. 69 Fig. 20. 2d, a liquid produced by the aggregation of three humors of a different aspect, viz., a limpid mucosity, clear, though a little oily, a number of small rounded granulations, transparent in their central cavity, and slight- ly opaque at their periphery, and some oil globules. 3d, and lastly, an ovule floating in the midst of this liquid. 1. The granular membrane (See Fig. 20, g'). A delicate membrane is found applied on the internal face of the Graafian vesicle, formed of granules, or rather of cellules, and bearing the name of the granular membra ne. It tears with great facility, from its extreme tenuity, and hence many authors have denied ita existence. Upon one part of the mem- . . _ A. The ovule, o. The granular cumulus, g'. brane (that corresponding to the free Side of The granular membrane, k. The cavity of the the Vesicle) the granulations, Or Cells pro- Graafian vesicle, m. The mucous surface, v. , . . The vascular layer. F. The fibrous layer, p. ducing it, are more numerous or more com- The peritoneal coat. pact, and in the centre of this compact mass, which has been called the proligerous disk, the ovule is found. The granulations, constituting the proligerous disk (see G, Fig. 20), are so closely united, both with each other and with the latter, that upon opening the Graafian vesicle, even where the granular membrane is destroyed, this portion remains adherent to the ovule, forming round it, as it were, a granular bed. This membrane is entirely destitute of vessels. " It is extremely probable," says M. Coste, "that M. Pouchet was deceived by appearances, which led him to regard the vessels distributed upon the innermost layer of the Graafian vesicle, as belonging to the granular membrane." The Ovule in the Graafian Vesicle. § 3. The Ovule. Since the labors of Graaf, the majority of authors agree with him, that the ovule is constituted by the vesicle just described; but the honor of having first discovered the ovule, as a distinct organ in this vesicle, belongs to Charles Ernest Baer. The ovule is completely formed in the ovary during the earlier years of life. It is imbedded from the period of its maturity, as stated above, in the midst of a mass of granulations, which are more compact than those which fill the remainder of the vesicle. It therefore occupies a fixed position in the vesicle, and is almost constantly met with at a point opposite to that whence the large vascular trunks spread out upon the ovarian capsule, that is to say, at the point which projects from the surface of the ovary. When examined with a lens, it appears as an opaque rounded body, at least more opaque than the liquid enclosed in the same vesicle; it is extremely minute, although the diameter of the little sphere it represents is subject to variations. " The largest human ovules I have seen and manipulated," says Bischoff, "did not exceed the tenth of a line, being barely perceptible to the naked eye." When placed under a microscope, it is seen to consist of an exterior envelope, TO FEMALE ORGANS OF GENERATION. Fig. 21. A Non-fecundated Human Ovule. a. The vitelline membrane, or trans- parent zone. b. The vitellus, or yolk. o. The vesicle of Purkinje, or the germinal vesicle, d. Tbe germinal spot. called the vitelline membrane (Coste), transparent zone, cortical membrane, or chorion (Baiir), of a substance aptly compared to the yolk of an egg, and desig- nated as the vitellus, and of another vesicle (placed within the latter) called the germinal vesicle. A. Vitelline membrane.—If the ovule be exa- mined by a magnifying glass of sufficient power, an obscure sphere will be brought into view, sur- rounded by a large clear ring, the nature of which it is difficult to make out. M. Coste has given the name of the vitelline membrane to this ring. It is evidently a thick membrane, the external and in- ternal outlines of which assume the appearance of two circular lines enclosing a transparent ring. Many persons have merely considered it as a layer of albumen surrounding the yolk, but any one may easily convince himself that it is at least a resisting membrane, by cutting the ovule, or by compressing it by means of an instrument called the compressor; "for after proceeding in this manner," says Bischoff, ''there cannot be a doubt that the transparent zone is an elastic, thick, hyaline, and transparent mem- brane, without a determinate texture." Though entirely destitute of cells and vessels, it is nevertheless a living enve- lope ; because, as soon as the ovum in the mammalia arrives in the cavity of the uterus, it becomes the seat of an active vegetation, and produces villosities which are more or less ramified. The latter, as they become developed, insinuate them- selves into the tissue of the uterine mucous membrane, and thus attach the ovum to the place which it is to occupy for the future. The vitelline membrane is entirely closed, and presents, contrary to the opinion of Barry, neither slit nor circular opening, whereby the spermatic animalculae might find entrance into its cavity. (Coste.) b. Yolk or Vitellus.—The cavity of the vitelline membrane is occupied, in great measure, by a granular liquid, that does not adhere to the exterior envelope, and even escapes from it readily when the latter is broken. According to Bischoff, the yolk of the human ovum is formed of a coherent, indistinctly granular, transparent, and viscous mass, which does not run out when the egg is cut or crushed; each portion of the zone reserving its particular seg- ment or yolk, or the latter escaping altogether. "In certain cases?' says he, "the vitelline granulations are not united in a single mass. I have seen the yolk divided in two, and, on one occasion, into five parts of different volume." The vitellus usually fills the interior of the zone completely, and has the same form, but sometimes the vitelline sphere is smaller than that destined to receive it. Some authors likewise believe that a very delicate membrane exists, which encloses and unites the yolk in a single mass; but Messrs. Coste and Bischoff agree in rejecting the existence of this, and contend that the granulations of the vitellus are placed in juxtaposition with the transparent zone, which forms its sole and only envelope. OF THE ORGANS OF GENERATION. 71 C. Germinal Vesicle.—In the midst of this yellow body, in very young girls, or on one of the neighboring points of the peripheral envelope in the matured ovules, a small, perfectly transparent, and colorless vesicle is seen like a clear spot, surrounded by a mass of a deeper yellow. Purkinje had described it in the eggs of birds, and gave his own-name to it, but M. Coste is entitled to the honor of having first demonstrated its existence in the ovum of mammiferae, and of thus having established the perfect identity between the latter and the egg of birds. This is the vesicle of Purkinje, or the germinal vesicle. It is slightly oval, and consists of a very delicate, transparent, and colorless membrane, which encloses a liquid that is frequently as limpid and transparent as itself, though it sometimes contains a few granules. Notwithstanding its extreme tenuity, this vesicle still offers a certain consistence, since it has been seen intact, after leaving the ovule, and being completely separated from the granular liquid in which it was placed. It is always very small, and scarcely measures the sixtieth of a line in diameter. D. The Germinal spot.—If the germinal vesicle be attentively observed, an obscure rounded spot will be seen on some part of its periphery; this was first discovered by Wagner, who gave it the name of the germinal spot. It seems to be formed by the aggregation of fine small granules, or little globules, the obscure hue of which is brought out by the clear coutents of the vesicle. Wagner has sometimes met with two, or even more, germinal spots in the mammiferse. Before fecundation, therefore, the ovule is composed: 1st, of an exterior en- velope, the vitelline membrane, or transparent zone; 2d, of a vitellus, or yolk, contained in this vesicle; 3d, of a little vesicle enclosed in the first and swim- ming in the vitelline fluid—the germinal vesicle; 4th, and lastly, of the germinal spot.. CHAPTER III. OF THE ORGANS OF GENERATION. ARTICLE I. OF THE MODIFICATIONS UNDERGONE BY THE OVARIAN VESICLES. The Graafian vesicles, which were barely visible in the young girl, although they may be shown to exist immediately after birth, are destined to undergo in the adult female a considerable development. Until the age of puberty they are of small size, and concealed in the centre of the stroma; but at this epoch, some fifteen to twenty of them, which appear more advanced than the others, increase in size, and approach the external surface of the ovary. At the time when the young girl becomes nubile, one of the latter vesicles seems to have received a great increase of vitality; it undergoes a remarkable hypertrophy, and forms a projection upon the surface of the ovary; this projection becomes greater and FEMALE ORGANS OF GENERATION. greater until after some days it forms a tumor of the size of a cherry, or even of a small nut, upon the ovarian surface. This considerable augmentation of size is due to the distension of the walls of the vesicle by an increased secretion of the fluid which it contains. In propor- tion as the development proceeds, the walls of the vesicle become thin and trans- parent ; the vessels which supply them being compressed by the dilatation, lose their volume and become obliterated and atrophied, especially upon the point of culmination, where the resistance is least. When at last it has arrived at its full development, the ovarian capsule appears to remain stationary, until an over- excitement, produced either by the maturity of the ovule, or by sexual inter- course, occasions its rupture. (Coste.) Then, the walls of the vesicle, although more and more distended, begin to lose their transparency, on account of the hemorrhage which ensues. This is sometimes limited to the production of small extravasations upon the, as yet. entire walls of the vesicle, though most frequently a true effusion takes place within the cavity. The effused blood and the super- abundant secretion increase still more the distension of the walls, which is finally carried so far that rupture becomes imminent, and it is possible to distinguish at the most projecting part of the tumor, the point where it is about to ensue. This point is generally indicated by a small reddish spot, of about a line in extent, produced by a strong injection, or even by a slight effusion of blood in the tex- Fig. 25 Fig. 23. FU-. 22. Showing the ovary, and a Graafian vesicle at its highest degree of development, and just before its rupture.1 a The hypertrophied vesicle (drawn from nature, and of its real size.) b, c, c. Radiated cicatrices left by previously ruptured vesicles. Fig. 23. The ovary, with the ruptured vesicle and the large clot that fills its cavity. (Drawn from nature.) ture of the walls of the vesicle. (Raciborsky.) The thinned walls finally give way and tear gradually; the membranes of the vesicle itself being the firs! to yield, and after them the peritoneal layer. As a consequence of this rupture, the ovule is expelled, and carries along with it a part of the granular contents of the vesicle; it enters the Fallopian tube, the fimbriated extremity of which is i This figure, borrowed from M. Raciborsky, is the exact copy of a preparation which he had the kindness to show me. But since that time (1843) I have never met with so enor mously developed a vesicle, and I am disposed to believe that this great size is rather pathological than normal. OF THE ORGANS OF GENERATION. 73 prepared to receive it, and after traversing its canal arrives at a later period in the cavity of the uterus. The walls of the follicle collapse after the rupture, and its cavity becomes filled with a small quantity of blood, which is found fluid or coagulated according to the time at which the examination is made. The walls of the torn vesicle contract gradually, and the clot, which sometimes at first is the size of a small cherry, is slowly absorbed; the originally spacious cavity diminishes, the margins of the rupture approximate, so as even to become united occasionally by cicatrization, and order is finally restored. The evolution just described, which is terminated by the rupture of a vesicle and the spontaneous expulsion of an ovule, is not an isolated fact; on the con- trary, it excites numerous sympathies in the remainder of the generative appa- ratus and throughout the organism of the female. We shall first study the gene- rative organs and the modifications which they undergo before, during, and after this evolution. The ovary, which produces the hypertrophied vesicle, is notably enlarged. It is of a deep red color, and its vascular apparatus is remarkably congested. The Fallopian tube itself shares in the congestion, being often of a violet-red color, especially at its fimbriated extremity, which has a sort of velvety appear- ance. It is also endowed at this epoch with a special erethism, in virtue of which it applies its floating extremity upon the ovary, in such a manner as to receive the ovule and conduct it into its cavity. The uterus undergoes such important changes that, before the discovery of spontaneous ovulation, it was erroneously supposed to play the principal part in the phenomena which we are about to study. I shall continue to draw from the beautiful works of M. Coste, from which I have already borrowed so freely in the preparation of this chapter, the principal features of the ensuing description. Whilst the ovarian vesicle is undergoing the rapid evolution which we have just described, the vascular apparatus of the womb becomes developed and in- jected in an unusual manner; immediately beneath the delicate layer of epithe- lium which covers the surface of the mucous membrane, it forms in particular elegant reticulations, with irregular, lozenge-shaped intervals, surrounding the orifice of each of the numerous glandular tubes of which this membrane is almost entirely composed. This network is so fine as to give a violet hue of greater or less intensity to the internal surface of the womb, and is formed of very delicate venous ramuscles. The utricular glands increase perceptibly in size, and the muscular structure of the uterus, in consequence of the congestion which it undergoes, acquires greater extension, is of a more lively red color, and becomes more spongy and supple. The entire volume of the organ is increased, the neck is tumefied, and its orifice narrower; the lips of the os tincae are warmer and their color deeper. The mucous membrane, in consequence of this development of its vessels, and especially of the glandules of which it is composed, has its thickness so much in- creased in proportion to the size of the uterine cavity, as to be thrown, in a great many subjects, into soft, projecting folds or circumvolutions, which are so pressed together as to leave no vacant space in the cavity of the organ. M. Coste has several wombs in his possession, whose mucous membranes measure at certain 74 FEMALE ORGANS OF GENERATION. points, from two to three-eighths of an inch in thickness; still, to whatever de- gree the hypertrophy may be carried, it never presents the floating villi which Baer and Weber thought they had observed ; neither, except in some patholo- gical cases, does it ever exhibit the pseudo-membranous exudation which is ac- knowledged by almost all physiologists. (See Deciduous Membrane.) This great vascularity of the mucous membrane, and the high vascular con- gestion which the entire organ undergoes, is at first accompanied with the exuda- tion of a few drops of blood, which by admixture below with the vaginal mucus, which is itself at this period increased both in quantity and fluidity, communi- cates to it at first a rosy, and then a light reddish hue. After two or three days. a flow of blood, derived principally from the superficial network of the mucous membrane, escapes through the neck and mingles with the vaginal secretions. Henceforth, the effusion presents all the characters of a true hemorrhage. There can be no doubt that the chief source of this hemorrhage is the super- ficial vascular network of the mucous membrane; and in women who have died at this period the blood may be seen to transude through microscopic fissures. It is, therefore, a true exhalation of blood like that of epistaxis. The flow preserves the same characters during the two or three, be they more or less, days of its duration; then, as the quantity of blood diminishes, it re- sumes gradually the mucous and serous characters peculiar to the vaginal secre- tion. It is impossible, in the present state of our knowledge of the subject, to deter- mine precisely at what moment Fig- 24. during the flow of blood the rup- ture of the Graafian vesicle takes place. The result of numerous autopsies admits of the supposition that this moment is variable, and the curious experiments of M. Coste leave no doubt whatever as to the influence which venereal excite- ment is capable of exerting upon it; this influence is so great, that it may determine the rupture of an hypertrophied vesicle, which, with- out sexual intercourse, would have remained intact for several days longer. However, it may be ad- mitted, as a general rule, that the rupture occurs during the last days Uterus laid open, so as to exhibit the Hypertrophy of the of the flow. Mucous Membrane at the Menstrual Period. nil,. „..■ „ t r. n , . , . „ . . ,. „ ihe series of phenomena of which A. Mucous membrane of the neck. b. Mucous mem- ,-■ . , brane of the body, much swollen, c. Thickness of the *'ie ovary IS the seat, is not termi- section of the mucous membrane, d. Tissue proper of nated by the rupture of the vesicle the uterus, e, p. Diminution in the thickness of the mu- , i •. • 7. ! cous membrane at the neck and at the orifices of the Fal- a " reniains for US to State what lopian tubes. becomes of its walls after the ex- pulsion of the ovule. OF THE ORGANS OF GENERATION. 75 Of the Corpora Lutea.—Immediately after the rupture of the Graafian vesicle and the consequent expulsion of the ovule, an effusion of blood, according to some, and of plastic lymph, according to others, takes place into the emptied cavity; moreover, the walls, which were greatly distended, retract strongly upon the effused matter, and form with it a more or less compact mass, which after a time assumes an orange-yellow color. From this latter circumstance, the tumor has acquired the name of the yellow body, or corpus luteum. Although for a long time considered by nearly every author as an irrefragable proof of a previous conception, it is at present well known that this body may exist in a virgin girl, provided she has previously menstruated. Very different opinions have been promulgated as to the mode of formation of the yellow body, as also in regard to the precise period at which it commences. According to Robert Lee, the mass of this body is formed exteriorly, around the empty capsule of the vesicle, and consequently it has intimate connections with the ovarian stroma; but this opinion is inadmissible. Montgomery and Patterson teach that an effusion of blood, or of a yellowish albuminous matter, which con- stitutes the corpus luteum, takes place between the internal and the external membranes of the Graafian vesicle; whence the yellow body will have its inner face lined with the internal membrane of the vesicle. From the observations of Baer and Valentin, the yellow body results from the hypertrophy, or a kind of puffing up, of the internal membrane of the vesicle, which throws out a species of vascular processes that serve to fill up the whole cavity of the follicle, excepting at the part occupied by the ovule. In the latter view, as well as in that entertained by Montgomery, the development of the corpus luteum will aid in rupturing the vesicle, by the distension it produces, and will soon after determine the expulsion of the ovule, by pressing it gradually towards the thinnest part. Both suppose that the corpus luteum is completely developed when the vesi- cular rupture and the discharge of the ovule take place, which, however, appears altogether inadmissible to me. I am convinced to the contrary, from the speci- mens which M. Raciborsky has had the kindness to show me. In a female, who died during menstruation, I was enabled to prove the recent rupture of a vesicle that was very much hypertrophied; its cavity, however, did not contain a yellow body. This does not, therefore, precede the rupture of the vesicle. In my opinion, M. Raciborsky has perfectly described the phenomena, consecutive to this-rupture, in the interesting treatise published by him (De la Ponteperiodique chez les Femmes et les Mammiferes, 1844); and as his opinions are not as yet very widely disseminated, it may prove useful to publish them in this work. " If the ovaries be examined eight, ten, or twelve days after the cessation of the menstrual discharge, a small, rounded tumefaction, surmounted by a red spot like an ecchymosis, and presenting in its centre a slight linear fissure, will be found on the surface of one of these organs. The margins of the fissure are agglutinated, even this early, in the majority of cases; but it is still easy to sepa- rate them by using lateral tractions. If the ovary be then opened at the ecchy- mosed spot, the interior will exhibit a pouch, already smaller than the cavity of the vesicle before the rupture, but entirely filled by a clot of blood, which, when placed in alcohol, has the consistence of a solid body, though somewhat spongy 76 FEMALE ORGANS OF GENERATION. in its nature The clot is usually about the size of a medium cherry (see Fig. 23), and may be raised from its cavity without difficulty. The parietes of the vesicle exhibit, at this period, a yellowish hue, that disappears in spirits of wine- The surface of the internal membrane is at once slightly plaited and downy; the plaiting being produced after the rupture of the vesicle, by the rapid contraction of the highly elastic external membrane, thus throwing the internal one, which is devoid of such elasticity, into folds. The re- traction is arrested by the resistance of the clot, then the folds, that existed on the internal mem- brane, disappear in consequence of the reciprocal adherence, and the cavity diminishes. In the meanwhile, the most soluble molecules of the clot are absorbed, and then a further retraction of the external tunic takes place. The internal one, con- tinually forced to follow the diminution of the clot, and to become moulded upon it, forms anew a cer- tain number of folds, which are lost in a similar manner by adhering to each other, and thus dimi- nishing the surface of the internal membrane. The ovary laid open longitudinally, ° . , . and showing the corpus luteum at a Afterwards, a new absorption of soluble parts, a certain stage of its development. further retraction of the tunics, a fresh diminution of the cavity, &c. &c. Whence, at the end of a month, the only remnant of the pouch, that could once have contained a small cherry, is but a little spot, that would hardly enclose its stone." (See Fig. 25.) The internal tunic of the vesicle becomes hypertrophied whilst undergoing the forced plaiting, caused by the incessant retraction of the external one, thus con- stituting a radiated mass, which, from the imbibition of the coloring principles of the blood, assumes a very characteristic orange-yellow color. This coloration is not produced, as 31. Montgomery and several others sup- posed, from the deposit of a substance of new formation, either externally to, or within the vesicle, or between the two tunics that constitute its walls, but is simply the result of imbibition. Finally, the absorption of the clot being com- plete, the two opposed walls of the pouch, in time, approach each other, and thenceforth form merely a single slate-colored line. The vesicular cavities are reduced to this condition in from four to six months. Both M. Coste and M. Raciborsky acknowledge the folding of the internal membrane of the vesicle, but the theory of the former in relation to it differs so much from that of the latter as to make it our duty to explain it briefly. Immediately after its rupture, the ovarian follicle becomes filled with a o-ela- tiniform matter, which often receives a red color from the blood which escapes from a few opened vessels; the matter itself assumes at a later period a greater consistency. By the spontaneous retraction of the walls, as we have already ex- plained, the internal layer is promptly thrown into folds, and the rugae which result from this rapid retraction of the external layer are so numerous so promi- nent, and so compact, as to bear some resemblance to the circumvolutions of the brain. (See Fig. 20). Contemporaneously with this folding, the internal layer becomes hypertrophied and inflamed; it assumes a red color, and encroaches OF THE ORGANS OF GENERATION. 77 more and more upon the cavity which it finally fills, just as though it had given rise to granulations. Ere long, however, the plastic matter which at first filled the follicle, having been gradually absorbed, the juxtaposed circumvolutions con- tract intimate adhesions with each other, and the replete follicle forms a large tumor upon the surface of the ovary. Long before the folds or circumvolutions which tend to fill up the cavity of the ruptured follicle are so tumefied as to come into contact, their tissue loses the inflammatory redness which it at first possessed. But as M. Coste does not recognize the formation of a clot of blood in the vesicular cavity, he cannot admit with M. Raciborsky that the yellow hue of the mass just described is due to the imbibition of its coloring matter. On the contrary, he considers the color to be due simply to the nature of the molecular granules which enter into the struc- ture of the internal layer. These granules, he says, are remarkable not only from their number, but on account of their light yellow hue. Therefore, as after the folding of the internal tunic, they are both very numerous and very com- pactly bestowed, the yellow tinge, which is very light for each taken separately, becomes deep for the entire mass. The two opinions may therefore be recapitulated thus : 1. Effusion of a coagu- , lable fluid, which is blood, according to M. Raciborsky, and plastic lymph, ac- cording to M. Coste. 2. Folding, and progressive hypertrophy of the internal tunic. 3. Yellow coloration of the latter, either by the coloring matter of the blood (Raciborsky), or by the condensation of the molecular granules of the internal layer (Coste). These two theories, which include nearly all the others, yet differ upon an important point. According to MM. Raciborsky, Pouchet, Dalton, &c, there is at first an effusion of fluid blood, which soon forms a clot of greater or less density; M. Coste, on the contrary, regards this effusion of blood as pathological, or, at most, as an exceptional occurrence. It is truly difficult to comprehend why there should be this divergence of opinion in regard to a fact which ought to be so easily determined; therefore, without wishing to decide the question, we shall content ourselves with saying, that in the numerous cases which we have had occasion to examine, we have always found either fluid blood, or a clot, within the ruptured vesicle. We may also add, that the fluid or coagu- lated condition of the blood, did not appear to us to be always in relation with the age of the corpus luteum. Whatever be the fate of the ovule after its expulsion, whether it receive, or not, the vivifying influence of the seminal fluid, the remains of the torn capsule always undergo the primary changes described above. As the formation of corpora lutea always follow the rupture of a Graafian vesicle, and as this rupture is most frequently spontaneous, it is evident that medical jurists have committed an error in regarding their existence in the ovary as a certain indication of an anterior fecundation; but some modern physiolo- gists have also been wrong in supposing that the study of the corpora lutea could have no medico-legal importance whatever; for, although the supervention of pregnancy modifies the corpora lutea in no respect at the commencement of their formation, it exercises an incontestable influence upon their ulterior development. M. Coste, who has followed their evolution step by step in the two cases, has derived from his attentive observation sufficient means of distinguishing a corpus 78 FEMALE ORGANS OF GENERATION. luteum succeeding to a pregnancy, from one pertaining to a female who has not conceived. Not less than a month, says he, is required in & pregnant woman for the filling up of the follicle, and the commencement of adhesion between the folds; and forty days, nearly, will have elapsed, before the connections are firmly esta- blished. At this time, their assemblage forms a compact and resisting tumor, of nearly an inch in its longest diameter, and five-eighths of an inch in its shortest (Fig. 26). Having thus arrived at its maximum, it remains stationary for some time, until toward the end of the third month its period of diminution commences. The tumor is gradually absorbed, loses its volume, and seems to enter again into the organ upon the surface of which it had been raised; at the same time it becomes more compact, denser, and more shining. In the course of the fourth month it is nearly one-third, and towards the end of the fifth, nearly one-half smaller. From the sixth to the ninth month it will have lost nearly two-thirds of its volume; still, however, it forms after labor a tubercle of not less than five-sixteenths of an inch in diameter. The latter now diminishes with considerable rapidity, but nearly a month is required for its reduction to a small and hard nucleus of indefinite duration. There is nothing absolute, however, in the rate of retrogression of this phenomenon. For, as in some women who died between the sixth and eighth month of their pregnancy, the corpora lutea were fouud as voluminous as in others at the fourth month, so evident traces of it may sometimes be discovered several months after labor. When the corpus luteum is produced under other influences than those to which impregnation gives rise, its development, adds M. Coste, is by no means so great, and its rate of diminution is more rapid. Whilst, for example, from five to six months are required for the completion of the chief modifications during pregnancy, the capsules are almost entirely effaced in from twenty-five to Fig. 26. Represents a corpus luteum derived from a female who died in the sixth month of pregnancy. thirty days, in women who have not been impregnated. The phenomena pre- sented at the commencement, in the last case, are the same as in the former but the vesicles suddenly soften, and are frequently entirely absorbed before the cir- OF THE ORGANS OF GENERATION. 79 cumvolutions of the internal layer have acquired sufficient development to come in contact, or to contract adhesions. M. Coste has never known the corpora lutea of a non-pregnant female, who had died suddenly, to resemble those observed in the second or third month of pregnancy; they have neither the size nor the den- sity of the latter (Fig. 26.) In a word, adds the learned embryologist, a corpus luteum which is as large as the ovary itself, which forms a solid and resisting tumor, exhibiting upon section the capsule of the ruptured vesicle filled with the strongly-adherent internal circumvolutions, must belong to a pregnant female. If the circumvolutions are but feebly united, having between them a layer of plastic matter which serves as a medium of adhesion, the corpus luteum corre- sponds to the second month of pregnancy; if, on the contrary, the circumvolu- tions are blended into a compact mass, preserving at the same time a size similar to the preceding, it may be regarded as derived from a woman who had died toward the end of the third month of gestation. From this time the mass becomes more and more compact, remains stationary for a while, and then tends to decrease until the end of gestation. We have represented in the same plate, several corpora lutea resulting from menstruation, together with others observed at a more or less advanced period of pregnancy. By comparing the physical differences presented in the two cases, we may readily appreciate the truth of the observations just stated. For Figures 3, 4, 5, and 6, I am indebted to the kindness of my learned master, M. Rayer. EXPLANATION OF PLATE I. Fig. 1. a a. Corpus luteum four weeks after menstruation. Fig. 2. Corpus luteum thirty days after menstruation. Fig. 3. Represents the ovary of a young woman, who, after passing the night with her lover, committed suicide by throwing herself from the third story; death took place twenty-four hours after, a. Small rupture produced by the bursting of the vesicle. Fig. 4. Longitudinal section of the same ovary showing the interior of the vesicle. Fig. 5. Represents the ovary of a non-primiparous woman, who died in the fifth month of pregnancy, of pneumonia complicated with abortion. Fig. 6. Ovary of a woman twenty years of age, who died in the ninth month of gestation. In reviewing the facts whose history we have just traced, we see that towards the age of puberty, the ovary becomes the seat of an active congestion, and, it might be said, of a new vitality; all the living powers of the organ seem to be concentrated upon one of the Graafian vesicles, which suddenly assumes a con- siderable development, and in so doing, raises the envelope of the ovary, and forms a tumor, which is superadded to the organ. The walls of the vesicle become weaker and weaker as their distension increases, until they finally give way; in consequence of the rupture, the ovule is expelled and carries with it a portion of the granular fluid with which it was surrounded. This expulsion constitutes the phenomenon known of latter time as spontaneous ovulation. The void left in the vesicle is soon filled with blood and a gelatinous matter, which is secreted by the 80 FEMALE ORGANS OF GENERATION. internal walls of the follicle; the inner membrane of the latter becomes hyper- trophied and thrown into folds by the retraction of the external tunic, and soon constitutes the corpus luteum. As accessory phenomena, it is known that the uterus and its annexes partici- pate to a greater or less degree in the ovarian activity, and we have briefly de- scribed the peculiarities which they present during the accomplishment of the process; we shall have occasion to return to it in future. Our attention should, however, be first directed to the great resemblance between this succession of physiological acts, and the series of phenomena which comparative physiology and anatomy have shown to take place in mammalia at the rutting season. In them likewise, the approach of the male is not necessary to the discharge of the ovule, and the spontaneous ovulation is accompanied with almost identical changes in the genital organs, and manifests its influence upon the entire or- ganism by the same assemblage of phenomena. In the human female, as in the mammalia and birds, the spontaneous ovulation, accompanied with the same cortege of symptoms, occurs at more or less regular intervals. In the rabbit, it is the tumefaction and almost varicose injection of the vessels of the vulva. To this coloring and tumefaction is added, in the bitch, an odorous secretion, which allures the males, and puts them upon the track of the females. Finally, in monkeys, a more or less abundant hemorrhage occurs, which, in the case of the macaquae and the cynocephalae, coincides with so monstrous a swelling of the vulva, that, in certain cases, the surrounding parts are infiltrated as though in- flamed in consequence of the sting of bees. We shall study hereafter the pecu- liarities of these returns in the human species. The vesicular evolution, accompanied with the array of phenomena just de- scribed, is reproduced at intervals which vary for different animals, but in the human female recurs at much shorter periods. Every month, in fact, in the normal condition, a new Graafian vesicle is found to increase in size, to become excessively distended, and finally bursting and discharging the ovule, to become the seat of the successive transformations presented by the corpus luteum. Every month, therefore, this curious phenomenon of spontaneous ovulation is renewed; and the dark-colored cicatricules of various form, which are observed upon the surface of the ovary of nubile women, give rise to the supposition exclusive of direct observation, that the operation of which they are the consequence must have recurred a great number of times. Of the phenomena which we have just described, the flow of blood had, until of late years, chiefly claimed attention. This flow, as well as the vesicular evo- lution of which it is the consequence; occurs for the first time between the a°-es of twelve and fifteen years, and is afterward periodically renewed every month until the time of life at which the female loses her aptitude for fecundation that is to say, until she attains the age of from forty-five to fifty years. Known under the names of the monthly sickness, the monthlies, courses, &c., this periodical excretion constitutes menstruation; a phenomenon which, though doubtless of importance, is nevertheless far from being the capital fact amongst those which we have studied, for it may be absent, without the vesicular changes bein^ notably affected thereby, whilst, on the other hand, it never appears without having been preceded and accompanied by the development of a Graafian vesicle. OF THE ORGANS OF GENERATION. 81 It is therefore a secondary phenomenon, intimately connected with those which are accomplished in the ovary. The details into which we are about to enter, in reference to menstruation, will complete the history of the ovarian follicles. ARTICLE II. OF MENSTRUATION. [Menstruation is, as we have said, a periodical flow of blood from the genital parts, having its source in the walls of the uterus. Its first appearance, which is always determined by the ovarian evolution of which it is one of the epiphe- nomena, reveals the aptitude of the female for fecundation, and constitutes one of the earliest signs of puberty or nubility; I say one of the earliest signs, for it very rarely occurs suddenly, and without having been preceded by precursory phenomena. These phenomena are both local and general. The first, which are purely physical, occur more especially in the generative organs. Thus, the pubic region becomes covered with hair; the pelvis, which hitherto differed but slightly from that of the male, increases in size in every direction, and gradually assumes the shape which we have indicated as peculiar to the well-formed woman; the breasts are rapidly developed, and the nipple is more projecting, turgescent, and sensitive; the skin which surrounds the latter is also of a darker color than be- fore. The outlines of the body at the same time become rounded, in conse- quence of the greater abundance and more harmonious distribution of the cellular tissue. * These physical changes are rarely found unconnected with an alteration in the moral state of the young girl. Her voice assumes a softer tone, her looks are more timid, and often embarrassed in the presence of persons with whom but a few months previously, she had sported as a child. She experiences desires, which are the vague expressions of the development of the senses, which she cannot yet understand. A melancholy sadness, and ^a taste for solitary places congenial to reverie, replace the boisterous pleasures of childhood. The congestion which precedes the hemorrhage is indicated by new symptoms. The young girl complains of lassitude, of a sensation of swelling and tension in the lower part of the abdomen, of lumbar and sacral pains, of weight in the loins, of heat in the hypogastrium and peritoneum, of a slight itching and tumefaction in the genital parts, and a painful swelling of the breasts. In many cases, the excitement of the genital organs is so great as to produce a violent general re- action; and, according to Boerhaave, the first appearance of the menses is accom- panied with fever. Strange nervous disturbances not unfrequently occur, and I have sometimes observed attacks of genuine hysteria. These symptoms may last from one to eight days, and are followed by a more or less abundant flow of mucus; in the course of a few days, this becomes mixed with a little blood, and soon gives place to a flow of almost pure blood. The hemorrhage continues for several days; then, as the amount of blood mingled with the vaginal mucosities 6 82 FEMALE ORGANS OF GENERATION. diminishes, the flow becomes less colored, and after resuming the characters of the vaginal secretions, ceases entirely. Quite frequently, the first menstruation takes place without having been pre- ceded by any of these discomforts. Sometimes the eruption of blood occurs whilst playing or dancing, and sometimes during sleep. In most young girls, the eruption returns after the lapse of a month, and fol- lows subsequently its regular periodical course; frequently, however, it is not until after three or four periods, and sometimes even later, that the courses be- come regular. At other times, again, a long interval elapses between the two first menstruations: thus, M. Raciborsky, having noticed the period between the two first menstrual epochs in eighty-seven females, found that in all but fifty- eight, more than a month elapsed between them. In two women, the second menstruation occurred six weeks after the first; in four, two months; in five, three months; in four, four months; in one, five months; in one, eight months; in three, a year; finally, in one, two years. These irregularities in the return of the second period may, doubtless, be due to a morbid condition requiring treatment, but they may also depend upon an atony of the genital organs, which does not allow the physiological development of the Graafian vesicles to continue. This temporary atony does not interfere with the general health of the female, nor prevent the future performance of the function; it often disappears under the excitement produced by a change of life, or by the first conjugal approaches. (Raciborsky.) In some young girls, the functional troubles and abdominal pains, which we have regarded as so many precursory phenomena of the first appearance of the menses, may not be followed by the flow of blood, and, after having lasted for several days, they diminish and cease entirely; they may recur thus every month, for a certain time, with no other result than a momentary disturbance of the general health, and it is only, so to speak, after several fruitless attempts, that the courses become established in a complete and regular manner. The symptoms which heralded the first menstrual flow do not usually recur at the subsequent periods, or, at least, they continue to diminish with each monthly return. In some females, however, they always appear with their original inten- sity, and I have often remarked, in reference to these cases, that the acute pains and colics which prelude the flow of blood, disappear, or even cease en- tirely, immediately after the first conjugal approaches, and especially after the first labor. In a still greater number, the return of the menstrual period is throughout life indicated by some slight pains, a little uneasiness, or merely by a more or less marked disturbance of the general condition; the temper is less even, the woman becomes more excitable, more irascible, in a word, less amiable. The time at which the first appearance of the menses occurs varies exceed- ingly from the influence of climate, habits of life, and constitution. The follow- ing table, extracted from the work of Miiller, with notes by Jourdan, gives an idea of these variations in different countries :— OF THE ORGANS OF GENERATION. 83 AGE. 2 « ■E os =3 H m H OS O O o W ►J b M o fa __£ CD M £ ° m as CD fc O H " o « a cq -1 5 years, 7 " 8 " 9 " 10 " 11 " 12 " 13 " 14 " 15 " 16 " 17 " 18 " 19 " 20 " 21 " 22 " 23 " 24 " 25 " 1 1 2 11 29 96 129 138 212 204 140 133 95 43 33 8 8 4 5 14 26 47 50 76 79 58 38 21 9 5 1 5 6 10 13 9 16 8 4 2 10 19 53 85 97 76 57 26 23 4 3 8 21 32 24 11 18 10 8 1 1 4 10 20 29 38 41 20 20 12 4 2 1 7 18 34 40 55 77 81 72 35 26 24 14 2 1 4 4 13 14 20 13 13 6 8 3 1 1 1 15 27 35 13 6 2 1 Total, . . . 1285 342 68 450 137 200 487 100 100 According to this table, the greater number of first menstruations occur, at Paris, between the ages of fourteen and fifteen years, but it may be remarked, that the most common variations fall between the ages of eleven or twelve, and seventeen or eighteen years. Warm climates, a residence in cities, and the habits which are contracted there, together with robust constitutions, seem to favor the precocious develop- ment of puberty; a low temperature, residence in the country, a feeble and deli- cate constitution, appear, on the other hand, to retard the appearance of the menses. Numerous exceptions to the averages above indicated are mentioned by authors Thus, as examples of tardy and precocious menstruation, we see by the table that five women menstruated for the first time at the age of twenty-three years six at twenty-four, and two at twenty-five. In some very rare instances, the firs appearance has been delayed for a much longer time; thus, M. Kleeman men- tions the case of a woman who was married at the age of twenty-seven years, and who did not menstruate until two months after her eighth confinement; she then continued regular until the age of fifty-four years. Pecklin speaks of a strong and healthy married woman, who had never menstruated, although she was forty years of age; her courses made their appearance upon one of the first nights succeeding her second marriage, and recurred regularly for two years, at the ex piration of which time she became pregnant. If we compare these cases of tardy menstruation with the numerous instances of women who become mothers without ever having menstruated, and of nurses in whom the suppression of the menses did not prevent conception, we shall find 84 FEMALE ORGANS OF GENERATION. a full confirmation of what was stated in the preceding chapter, in regard to the secondary importance of the menstrual discharge. We cannot accept all the observations of very precocious menstruation; but, laying aside the numerous cases in which the nature of the discharge has not been so well determined as to allow of their reception without questioning, there are some whose genuineness is undoubted, inasmuch as the appearance of the discharge was attended with all the attributes of puberty. Thus, Dr. Susewind knew of a child of seventeen months, which had menstruated since she was a year old; the hemorrhage returned regularly every month, and the breasts and mons veneris were those of a girl of fourteen or fifteen years of age. The child observed by Lenhossek menstruated when nine months old, and at two years she presented all the external signs of puberty. The girl mentioned by D'Outre- pont, who had four teeth when two weeks old, was regular from the age of nine months; she had at that time long black hair and prominent breasts. A woman observed by Carus, menstruated when two years old, became pregnant at eight, and died at an advanced age. In a memoir by M. Dezeimeris, many other similar facts, derived from Schcefer, Louis Robert, Le Beau, Descuret, Comarmond, Clarke, Lombstein, &c, &c, are recorded. These premature menstruations are certainly due to the same causes which de- termines their appearance in most women about the age of fifteen years. Being always accompanied by the development of the breasts and the other marks of puberty, they are the evidence, that under the influence of an anomalous vitality of the ovaries, the Graafian vesicles have undergone a very precocious develop- ment. When once well established, the menses assume their regular periodicity, which is generally preserved up to the time of their cessation, without other interrup- tion than that which is occasioned by nursing or pregnancy. They return about every month, as their name indicates, yet the interval between them is far from being the same for every female. The average of the catamenial period is stated by Roser and Wunderlich at twenty-eight days; in a large number, according to Brierre de Boismont, it is thirty days; and in some instances the intermenstrual period is longer than thirty days, extending to five or six weeks, and sometimes even to two months. In some women the returns occur upon the same day of each month; in a much greater number, the end of the solar month is antici- pated by two, three, four, or five days. Sometimes the period is much shorter, the returns occurring at an interval of twenty-four, twenty-two, twenty, and even fifteen days. These frequent variations in the duration and return of the catamenial period are a refutation in advance of the opinion of those authors who think that all women menstruate generally at the same epochs, and that there are times in each month when no one is unwell; it is evident that the retardations or the anticipa- tions of which we have spoken, must have the effect of bringing the return of some female upon every day of the year. The flow also commences almost in- differently, during the day or night. The periodicity of the catamenia generally continues until the age of from forty to fifty years, at which time they usually cease. We shall hereafter treat of the peculiarities which often attend their cessation. OF THE ORGANS OF GENERATION. 85 The duration of the flow varies between one and eight days; according to Brierre, it most commonly lasts for eight days; and next in order of frequency, we have three, four, two, five, one, six, ten, and seven days. Many observers have noted three or four days, as expressing the most usual duration. In some very exceptional cases, it lasts for a few hours only; in others quite as rare, apart from pathological conditions, it is prolonged through twelve or fifteen days. The quantity of blood lost is variable for the same woman, and especially so when observed in different individuals; we may here add, that it is very difficult in any case to estimate it exactly. If the two cotyles of Hippocrates be eighteen ounces (550 grammes), as translated by Galen, his estimate (provided Galen's rendering is correct) is evidently exaggerated, at least for our time and climate. If we appreciate the amount of blood lost by the quantity of stained linen, I think the estimate of Haen, who set it down as averaging from three to five ounces, will be found to come nearest the truth. The quantity of the discharge appears to be greatly influenced by the diet, habits of life, and climate; it is greater with rich and indolent females who use a succulent diet, than with those who are placed in an opposite condition. Ac- cording to most authors, very warm climates exert a marked influence upon it, and, for my own part, I am acquainted with several ladies who menstruate much more abundantly in summer than in winter. It is said that women from the country, who become domestics in Paris, soon find their courses to diminish, and sometimes even cease entirely. Such may be the case with many of them, but it is due chiefly to the influence upon their constitutions of the want of fresh air, exposure to the sun, and of the exercise, to which they had been accustomed from childhood, rather than to any change in their diet; for, in general, the nourishment which they receive from their employers, is much better than that with which they were obliged to content themselves in their own poor families. The amount of the discharge is not the same throughout the duration of the menstrual epoch; ordinarily, it flows moderately on the first and second days, increases on the third and fourth, and then gradually declines. Neither is the discharge always continuous; it sometimes diminishes and even stops entirely for several hours, sometimes for one or two days, and afterwards reappears either spontaneously or under the influence of a walk or a ride. Moral emotions, some- times the process of digestion, and, above all, the action of cold, may determine its momentary or final diminution or suppression. The seat of the hemorrhage, and the nature and qualities of the menstrual blood, have been the subject of very different opinions. What we have already said, whilst describing the changes in the uterine mucous membrane, during the ovarian evolution, leaves no doubt as to the source of the menstrual fluid. It exudes, manifestly, through microscopic fissures on the internal surface of the mucous membrane of the uterus. This fact, which is placed beyond a doubt by numerous autopsies of women who died during menstruation, had been already proved by the accumulation of blood in the cavity of the womb, where the neck was imperforate, and by the touch, and the speculum, whereby it has been both felt, and seen to flow from the orifice of the uterus. Certain facts have been adduced in order to prove that, in some cases, the S6 FEMALE ORGANS OF GENERATION. menstrual blood proceeds from the vagina. I think that the greater number of these observations have been either badly made, or wrongly interpreted. I do not deny the possibility of exhalations of blood from the walls of the vagina; but if they present the periodicity of the menses, they can be regarded in no other light than as a misplacement of the latter. The fact related in the note below appears to me to possess great interest in reference to this subject.1 1 I have recently (November, 1849) seen in connection with my excellent confrere, Dr. Thirial, a young girl, twenty-one years of age, who had menstruated only twice and for three days at a time; and in whose case the hemorrhage must of necessity have had its origin in the mucous membrane of the vagina. This young girl, who had been for a long time violently in love with an officer, finally yielded herself completely to his wishes. After several attempts, renewed with much ardor, but which each time proved fruitless, the young man finally discovered, and acquainted her with the fact, that she was not formed like other women, and advised her to consult a physician. She applied first to M. Thirial, who solicited my opinion. A very careful examination enabled me to ascertain as follows : The countenance, stature, and development of the limbs and breasts, differed in no respect from what is usual in young girls at her age. Her general health had always been good. In the month of May last, her courses appeared for the first time, and continued three days; she had, however, for several years before, experienced symptoms of uterine congestion. In the month of July, they showed themselves again for the last time. The attempts of her lover were twice followed by a considerable flow of blood, which lasted two days, but she attributed it much rather to the amorous violence to which she had been subjected than to a periodic return of the menses. The mons veneris is completely destitute of the hair with which it is usually covered. Upon the lateral and inferior regions, immediately above the external orifice of the inguinal canal, a tumor is observed on each side which elevates the integuments. The tumor has the size, form, and consistence of an ovary or a testicle; it is but slightly painful; under a very moderate pressure it retreats through the inguinal canal, and disappears in the abdomen, but as soon as the pressure is removed from the internal orifice of the canal, it reappears, sometimes spontaneously, sometimes on the slightest movements, or the least effort of coughing or respiration. On no occasion was I able to perceive the signs which ordinarily accompany the reduction of an intestinal or epiploic hernia. The vulvar opening was bounded by the greater and the lesser labia, but both were much less developed than usual. The finger, which could be introduced only with difficulty into the vulvar orifice, was arrested at the depth of three quarters of an inch, so that it was only by forcing up the extremity of the vagina, that the first phalanx could be made to enter that canal. Upon introducing the extremity of a speculum, it was impossible to discover any open- ing, or any point which would afford passage to the end of a stylet. I was able to ascer- tain, at the same time, that the membrane pressed upon by the extremity of the speculum, possessed all the ruga?, and other characters of the vaginal mucous membrane. On examination by the rectum,I found: 1. That the rectal pouch, or dilatation, was much larger than in the normal condition; 2. That above the extremity of the vagina, when pressed upward by my thumb, the index introduced at the same time by the anus and carried as high as possible, could discover neither fibrous cOrd nor tumor; nothing, in fact, which could lead to a belief of the existence of the upper part of the vagina and of a uterus; 3. Having introduced a sound into the bladder, the finger in the rectum perceived with the greatest ease that nothing intervened between its palmar surface and the vesical sound, except the normal thickness of the two walls of the rectum and blad- der The sensation was identical with that experienced when the index is introduced into the vagina in order to direct a sound in the urethra. From this examination I thought myself justified in concluding: 1, that the tumors found OF THE ORGANS OF GENERATION. 87 As we have already said, the menstrual blood which is at first small in quan- tity, becomes mixed with the mucosities which are secreted abundantly by the vagina for a day or two preceding the appearance of the catamenia. The amount of blood soon increases, and the flow becomes almost exclusively sanguineous. It is very difficult to say whether the blood is furnished by the arteries or veins, or by both together. In all probability, says M. Coste, the blood exudes through the walls of the very delicate ramuscules which form the vascular net- work of the innermost layer of the uterine mucous membrane.1 Now, when gestation has progressed to some extent, these ramuscules become so greatly developed that many of them acquire the calibre of a quill. At this time their true nature may be ascertained, and the fact settled, that they" belong to the venous system; so that the menstrual hemorrhage which they supply must evidently have its source, in great part, at least, in the reservoir of dark blood. The physical characters of the menstrual blood vary according to the time at which it is examined, since it is mixed at the beginning, at the middle, and at the end of the flow, with different amounts, of vaginal mucus. The portion which escapes during the second period, not only resembles com- pletely in external characters that which is obtained directly from a vein or an artery, but is shown to be identical by chemical analysis. . Its slight coagulability has been regarded as an evidence of a want of fibrine; but, though it coagulates rarely, as a general fact, yet there are occasions in which clots exist in the vagina, and in the cavity of the uterus itself.2 The presence of fibrine has been chemi- cally demonstrated, so that though the coagulation of the menstrual blood be of rare occurrence, the fact is certainly due to its being uniformly mixed with a considerable amount of vaginal mucus The eruption of the menses is generally attended with a peculiar odor, pro- ceeding at that time from the secretions of the vulva; it increases in intensity during the flow, and has been compared by some persons to the smell of the marigold. Can it be that the strange fears with which menstruating women are regarded in some countries, are attributable to this odor, which in uncleanly in- dividuals is very strong ? Although this is probable, I should think it futile to discuss the incredible stories upon which are based the popular notions of the noxious properties of the menstrual emanations. Certain females discharge by the vulva, at the menstrual epoch, a kind of in the inguinal regions were the two ovaries; 2-, that the lowest extremity only of the vagina was present; 3, that the upper four-fifths of that canal were completely wanting; 4, that, most probably, there was no uterus ; 5, that the hypogastric and lumbar pains which were experienced quite regularly and -almost monthly, were the expression of periodical ovarian operations ; 6, that the blood of the menses which had appeared twice in this young woman, had its origin in the mucous membrane of the vagina. 1 It has been erroneously said that the blood exudes from orifices found at the ex- tremities of these minute vessels; but the diameter of their canal is smaller than that of the blood corpuscles, and could not afford them passage. The walls of the capillaries are ruptured near their terminal extremity, and through this solution of continuity the blood escapes. It is not, therefore, a true exhalation. 2 It is, however, right to observe, that the presence of clots in the menstrual discharge is frequently due to an alteration of the structure of the uterus, or, at the least, to a func- tional derangement. ss FEMALE ORGANS OF GENERATION. membranous bag, which would seem by its form to have been moulded upon the uterine cavity, and which bears a strong resemblance to the membranous pouch (deciduous membrane), which is expelled with the ovum in some cases of abor- tion. The nature of the pouch is, in fact, the same in both cases, being formed of cellular tissue, which is both vascular and glandular; its internal surface is always smooth, provided with epithelium, and often abundantly perforated with glandular orifices. The external surface, by which it adhered to the organ from which it was separated, is shaggy and torn. It is evidently an exfoliated portion of the mucous membrane. This exfoliation usually occurs in such women only as are afflicted with diffi- cult or very profuse menstruation, accompanied with violent pain, or in such as experience a delay in the appearance of their courses. According to M. Coste, this phenomenon is the result of an excessive congestion, a sort of apoplexy of the mucous membrane; for, says he, coagula are almost always found infiltrated in the substance of the expelled membrane. I would add as probable, that in some cases, at least, this exaggerated congestion may have been the consequence of an abortive conception, or perhaps of solitary venereal excitements. However this may be, the facts would seem to lend some support to the theory of those who, like M. Pouchet, regarding menstruation and the heat of animals as identical, have supposed that.at each menstrual epoch an abundant exhalation took place on the surface of the uterine cavity, and gave rise to the formation of a pseudo-membrane. Nothing of the kind has ever been proved by anatomical investigation; for the internal surface of the uterus, at whatever moment examined during the catame- nial period, always retains the characters peculiar to the mucous membrane, re- maining smooth, and covered with epithelium. Sometimes, however, the latter exfoliates, and bears away with it a portion of the substance of the niuqous mem- brane, in which case, the torn glandular tubes rendered free and floating by the separation, form, as it were, a forest of white filaments, and give accidentally to the internal surface of the uterus the villous and shaggy appearance which some authors have erroneously considered as normal. This circumstance is, however, altogether exceptional, and results from the membranous exfoliation of which we have just spoken. Cause of Menstruation.—Few questions have given rise to more lively discus- sions than the cause of menstruation; I think it useless, however, to mention here the numerous and more or less whimsical hypotheses which have succes- sively appeared in reference to it. The fact is, that after having read all that has been written on the subject, the mind rests entirely satisfied in its ability to refer this singular phenomenon to one unchangeable and easily-verified fact, namely, the successive evolution of the Graafian vesicles. We owe this satisfac- tory explanation to the admirable labors of Negrier, Coste, Pouchet, Raciborsky, Robert Lee, and Bischoff, so that the credit of so beautiful a discovery belongs almos t exclusively to France. That the cause of the menstrual discharge is the evolution of a Graafian vesicle, would be an indisputable proposition, provided we were able to show : 1, that the examination of women who died during or shortly after the menstrual period, has uniformly revealed the above-named changes in the ovary; 2, that the ab- OF THE ORGANS OF GENERATION. 89 sence of ovaries involved of necessity the absence of menstruation; 3, and lastly, that there is a complete analogy between the anatomical and physiological phe- nomena of the heat of animals, and those which accompany menstruation in the human female. 1. Since attention has been directed to this subject, no one has succeeded in_ instancing the case of a single woman, who died at the menstrual epoch, whose ovary did not present a vesicle in a greater or less degree of development, or else one which had been already ruptured. The facts related by Coste, Negrier, Pouchet, Raciborsky, and others, are now so numerous, that it would be impos- sible to reproduce them in a work like the present. I might myself add, if it were necessary, a considerable number of cases to the others. This universal coincidence affords from the outset a very strong probability of the relation of causality which we wish to establish; but it would become an absolute certainty, were it possible to prove that the absence of the ovaries involved of necessity the absence of the menses. , 2. In the case of animals, on which the experiment can be repeated at plea- sure, not a doubt is permitted, that the extirpation of the ovaries causes the dis- appearance, forever, of all symptoms of heat. Analogy alone would lead us, in the absence of positive facts, to suppose that menstruation, also, would cease after castration. But although well-observed instances of the performance of this operation on women are happily very rare, there is yet one which derives a great value in the present discussion from the name of the author. The following is an abridgment of it. A woman, says Percival Pott, had two small tumors, one in each groin, which were so painful as to render working iuipbssible. It was decided to extirpate them. After having divided the skin and the subcutaneous tissues, a membranous sac was exposed, which contained a body resembling an ovary; a ligature was thrown around it, and it was removed. The same opera- tion was performed on the opposite side. The woman recovered; but the men- struation, which before had occurred with the greatest regularity, never after- wards appeared; the breasts, which had been voluminous, subsided; she also became thinner, and assumed a more muscular appearance. From the statement of M. Roberts it would appear that in Central Asia, ves- tiges are still to be met with of the cruelty of the ancient kings of Lydia, who castrated women, either that they might put them in charge of their seraglios, or in order to gratify their unbridled passions. After arriving at Serai, he obtained a nocturnal rendezvous with three persons known as Padjeras. The necks of these individuals were not developed, nor had they any nipple; the orifice of the vagina which was entirely obliterated, presented no trace of a cicatrix; their hips were narrow, the pubis entirely destitute of hair, the nates were flattened, &c.; they had no hemorrhoidal flux, no epistaxis nor menstrual discharge, neither had they any sexual desires. They were very muscular, and there was something masculine both in their external appearance and in the character of the voice. M. Roberts was unable to ascertain precisely the nature of the operation to which they had been subjected in their childhood, for they had no remembrance of it; but if we may judge by the results, which are altogether similar to those produced by castration in animals, it becomes more than probable that the same alterations are due to the same cause. 90 FEMALE ORGANS OF GENERATION. 3. Admitting, finally, the incontestable analogy between the symptoms of heat and menstruation, it will be sufficient to prove, in order to deduce therefrom a favorable argument, that the former is always connected in animals with the ovarian evolution. Now certain experiments do not allow of hesitation. By these it is in fact proved (Coste), that the females never enter into heat except when the preparation for the spontaneous ovulation is going on in the ovaries, that the venereal erethism continues throughout the entire duration of the pro- cess of evolution, and that it ceases when the rupture of the capsule has taken place. Finally, it is universally known that castration prevents the females from entering into heat, whilst those which have been deprived of the womb, but not of the ovaries, lose nothing of the ardor with which they receive the male. Menstruation is, therefore, intimately connected with the evolution of the ovarian vesicles, and cannot occur without it; and every time that it appears, we may feel entirely satisfied as to the existence of the vesicular development. But, as an additional phenomenon, the uterine hemorrhage may be wanting without hindering, in any degree, the regular march of the process going on in the ovary. In a word, the spontaneous ovulation which ordinarily gives rise to an exhalation of blood from the internal surface of the womb, may have its influence restricted to the ovary alone; and to assume the non-appearance of the menses as a ground for denying aptitude for conception, would be incurring the risk of frequent deceptions. Thus it happened that science possesses numerous examples of young girls who became pregnant before they had ever menstruated, as also of women who coiiceived, notwithstanding a suppression which had lasted for several months. On the other hand, the regularity of the menstrual function does not neces- sarily imply the entire fulfilment of the vesicular evolution. In certain cases, the latter process has been seen to remain incomplete, and the vesicle, after having attained a certain degree of hypertrophy, to be suddenly arrested in its development, to remain stationary for some time, and then abort without rup- ture. I have chanced to meet, says M. Coste, cases in which the menstrual flow had passed over entirely, without the ovarian follicle, whose evolution had com- menced and even progressed to its final period, having ruptured, or accomplished the result toward which it tended. The cause of menstruation being ascertained, how shall we account for its monthly periodicity ? In other words, why is it that ovulation in the human species recurs about every month ? To this question science is unable to reply, for it is probably one of the impenetrable mysteries of nature. But why should our ignorance upon the subject be a cause of wonder ? Do we know why certain trees produce new flowers every month ? why this animal is prepared for fecun- dation every two or three months, whilst that one is so but once a year ? The processes which we have studied are intimately connected with fecundation, and are, so to speak, its preludes. Why, when the whole book is unintelligible to us, should we expect to comprehend the preface ? Cessation of the Menses.—As we have before said, the menses continue in the majority of women until about the age of 45 years. According to a table of Brierre de Boismont, 40 years is the age at which the greater number of women OF THE ORGANS OF GENERATION. 91 cease to be regular. In 60 women observed by M. Petrequin, it was between 35 and 40 years in i, between 40 and 45 in \, between 45 and 50 in J, and between 50 and 55 in |. In 110 women mentioned by M. Raciborsky, the average age of cessation was 46 years. The latter author cites from Dr, Lebrun of Varsovia, and Faye of Skeen, results which go to prove that in Poland the average term is 47 years, and in the neighborhood of Christiana 48; all which tends to show that in cold climates menstruation terminates late in life. It may be admitted, therefore, that the average duration of the menstrual function is from 25 to 30 years. But like their commencement, the period at which the menses cease is subject to great variation. Desormeaux mentions a lady with whom they stopped at 23 years of age, nor is it rare to find them suppressed between 35 and 40. On the other hand, they are often prolonged much beyond the ordinary period, and with them, the women retain the power of conception up to 60, 65, and even, as some authors relate, to 70 years. I leave to the lovers of the marvellous those in- stances in which menstruation continued until 80, 90, and even 106 years. It is infinitely probable that, in the cases of this nature, the pretended menstrual returns were really due, as Haller remarks, to uterine disease. I would add, that we should place in the same category those examples of women who, after having ceased to menstruate about the age of 45 or 50 years, have had their courses to reappear several years after, and continue with regularity. According to most authors, those women who menstruate very early also cease to do so sooner than others. This remark appears, both to M. Raciborsky and myself, to be inexact, when not applied to individuals living under different climates. With the former author, we think that precocious menstruation is due to an excess of vital power in the individual, and that, exceptional circumstances excluded, the influence of this vital activity is felt later in life, and prolongs the aptitude for procreation in the woman. So that, in general, it ceases as much later as it begins at an earlier age. The cessation of the menses, and of the vesicular evolution of which they are an epiphenomenon, produces in the generative apparatus and entire organism of the woman, effects the opposite of those which their first appearance had deter- mined. The ovaries become atrophied, and diminish in size in every direction, and their external envelope becomes folded and wrinkled, so as to present an appear- ance which, says M. Raciborsky, we can compare to nothing better than the sur- face of a peachstone. The Graafian vesicles appear as pouches of a grayish or opaque white color, with wrinkled walls; the fluid which they contained is absorbed; sometimes their cavities are effaced, their thickened walls are in contact, and look like a sort of tubercle, in the centre of which barely a trace of the former cavity is visible. Sometimes no part of the vesicles can be discovered, and the ovary, which has become transformed into a fibro-cellular substance, is so flattened as to be hardly distinguishable at the extremity of its ligament. We have already spoken of the deep folds and wrinkles of its external membrane. Finally, the womb and the breasts, whose vitality became suddenly so active towards the age of puberty, seem struck with the same blow which destroyed the 92 FEMALE ORGANS OF GENERATION. ovarian orgasm; they waste gradually away, and become, so to speak, foreign to the general life of the body. This cessation of the ovarian functions rarely takes place suddenly, but is almost always announced several years in advance by more or less marked irregu- larities or intermissions. Frequently, the returns of the menses suffer postpone- ments, which may be prolonged for several weeks or months, and then, after renewal, be deferred for a still longer period. Sometimes the epochs are marked .by a very small discharge, and last for a very short time ; again, on the contrary, the quantity of blood lost may be so considerable as to give rise to apprehension. With certain women the flow is so excessively prolonged that the menstrual periods are only indicated by its increase; a mucous flux of a yellowish-white color, which is quite abundant, and either continuous or periodic, replaces the flow of blood in the interval of the epochs, and sometimes remains for a long time after they have ceased. Finally, a general and indefinite feeling of uneasi- ness, lumbar and pelvic pains, colics, itching at the genital parts, flashes of heat in the face, and sudden and spontaneous alternations of chilliness with profuse perspirations, are added to the local phenomena above indicated. In the majority of cases, all these troubles are quite slight and disappear promptly; but, in some instances, diseases before latent then declare themselves. It is this fact which, though much rarer than is commonly supposed, has obtained for this time of life the name of the critical period. Its dangers have been won- derfully exaggerated, and modern researches prove, in opposition to the opinion of physicians who have preceded us, that the organic affections of the breasts, of the uterus, and of the ovaries, begin much more frequently before than after the cessation of the menses. Finally, it is shown by statistics, that the mortality in women, between the ages of 40 and 50 years, is not greater than at any other period of life. PAET II. OF GENERATION. Generation is effected in the human species through the medium of two sexes distinguished by the possession of different organs. The sexual characters being therefore peculiar to distinct individuals, the male and the female, these evidently must first approach each other before generation can take place. This first act constitutes copulation. The consequence of the approach is an applica- tion of the fecundating principle of the male to the germ furnished by the female, in other words, conception or fecundation. The ovum having been fecundated, remains, and is developed in the organs of the mother during the whole term of gestation. Lastly, at the expiration of a nearly uniform period, the new being is expelled, to maintain thenceforth a separate existence; this final act is termed the accouchement or labor. We have already described the genital organs of the female, and it is not our province to notice those of the male. We shall be equally silent upon all that relates to sexual intercourse, though it is our purpose to treat briefly of conception, and in detail of gestation, and especially of labor. BOOK I. OF CONCEPTION. Conception takes place during sexual congress; but to understand how it occurs, requires that we should know first what materials are furnished by each individual, how and where these are brought into contact, and lastly, what is not yet, and probably never will be explained, how from this contact a new individual is produced. 1. The spermatic fluid, a glutinous, consistent, and whitish liquid secreted by the testicle, is the fecundating principle furnished by the male. It is heavier than water, and, when shaken with it, forms an emulsion. Its odor is peculiar, and has been justly compared to that emitted by bone filings, or the flower of the chestnut tree; Wagner states that the odor is due rather to the secretions with 94 GENERATION. which it is mixed than to the sperm itself, the latter, when pure, not appearing to possess any particular smell. By chemical analysis it is shown to contain albumen, salts of phosphoric and chlorohydric acids, and a peculiar animal substance called spermatine. When examined under the microscope, with a magnifying power of three or four hundred diameters, the spermatic fluid exhibits: 1. A great number of little bodies, lying quite close to each other, and which are still moving with more or less activity if the fluid has been taken from a recently-killed animal; these minute bodies have been designated as the spermatic animalcules, or the sperma- tozoa. 2. Of certain little granular globules, which are sometimes very few in number, at others more numerous, but always less so, however, than the animal- cules; Wagner calls them the spermatic granules. 3. These two principal elements of the sperm swim in a small quantity of clear, transparent, and per- fectly homogeneous liquid,—the spermatic liquid. At the time of the ejacu- lation, this liquid is mixed with a variable quantity of the fluids secreted by the prostate gland and the glands of Cowper, which latter evidently serve merely to lubricate the parts, to render the sperm more fluid, and, consequently, its expulsion more easy. The spermatic animalcules attract particular attention by their varied form, their vital properties, and their development. They are met with in all animals capable of reproduction. In man they are very small, scarcely surpassing the eightieth or the hundredth of a line in diameter. The body is small, oval, somewhat flattened like an almond, and transparent, having a diameter equal to the three or four hundredth part of a millimetre (-001 of an inch). The tail is filiform, thicker at its origin than at any other part, and is large enough to present clearly its double outline; towards the extremity it becomes so fine that it cannot be traced, even by means of the highest magnifying power, whence it may be possible that its delicate extremity is still further elongated, and that the spermatozoa may be much longer than they appear. It is impossible, says Wagner (from whose able works I extract this para- graph), to decide whether the spermatic animalcules have an animal organization, that is, whether they are true animals with an independent life, or not; and all that is either known, or plausibly supposed on this point, may be reduced to a few obscure indications, that are wholly insufficient to establish any positive opinion. The movements which they exhibit prove nothing, because it is exceedingly difficult to ascertain whether they are voluntary or not. Again, the duration of the movements also varies in the different classes of animals; in the mammalia, they have been observed for twenty-four hours after death. The spermatozoa do not appear in the human species before puberty; at this period, the testicles receive a large supply of blood, and increase in size; the parietes of the seminiferous tubes become thickened, their capacity increases and they are filled with granules; then cysts or cells containing globules begin to form, and finally the spermatozoa appear in these cells. They are always found in the testicles of men of sixty to seventy years of age, though they are then fre- quently absent from the vas deferens; the vesiculae seminales, however generally contain them even at this time of life. OF CONCEPTION. 95 The germ furnished by the female is evidently existent in the ovary at the marriageable period, and this germ is the ovule. (See p. 69 for its description.) 2. It is unnecessary in our day to prove that an absolute contact of the semen of the male with the ovule of the female is indispensable to fecundation, for in- numerable experiments upon living animals, and numerous facts observed in the human species, have long since demonstrated that, whenever any obstacle pre- vents the approach of these two elements, a conception cannot take place. But at what point does this contact occur ? Already had the pre-existence of the ovule in the ovary, the occasional occurrence of ovarian and abdominal pregnan- cies, and the experiments of Nuck and Haighton, which had rendered fecunda- tion impossible by ligating the Fallopian tubes, tended towards the conclusion that it occurred in the ovary; still this fact was not actually demonstrated, and it needed the definitive proof of finding the spermatozoa on the ovary itself. At present, there cannot be a further doubt on this point, for Bischoff has been for- tunate enough to see them there. " I had often seen," says he, "living and moving spermatozoa in the vagina, the womb, and the Fallopian tubes of bitches; but, on the 22d of June, 1838, I had the good fortune to perceive one on the ovary itself of a young bitch, in heat for the first time; she was covered on the 21st, at seven o'clock in the evening, and again the following day, at two o'clock, p. m., and at the expiration of half an hour, that is, twenty hours after the first copulation, I killed her, and found some living spermatozoa, endowed with very active movements, not only in the vagina, the entire womb and tubes, but even between the fringes of the latter in the peritoneal pouch that surrounds the ovary, and on the surface of this organ itself." Since that period, Wagner and Barry have made the same observations. Now such results evidently prove that fecundation sometimes takes place in the ovary; but are we thence to conclude, that it is possible in that organ alone ? If spontaneous ovulation be now an incontestable fact, may it not be supposed that the ovule, after having left the ovary, can encounter the spermatic fluid and become fecundated, whether it be in the Fallopian tube, or even in the uterine cavity ? And unless we admit (what analogy renders improbable) that the ovule, once out of the ovarian vesicle, is not capable of fecundation, we are constrained to believe that the latter may be accomplished at whatever part of the genital organs the contact takes place. But the question arises, how does the fluid ejaculated by the male get as far as the ovary? We answer that, in the great majority of cases, it is evident that the sperm, having first reached the uterus, upon the heck of which it was thrown by the membrum virile, travels through the tube until it arrives there. This course is certainly due, 1st, to the movements proper of the womb and the tubes; for in the latter, a rapid contraction is observed, following the direction from the vagina towards the ovary, which, of course, is calculated to assist the progression of the sperm; and 2d, to the movements proper of the spermatozoa, which thus of themselves facilitate their own advancement. We have seen, however, that there is in some cases another route of commu- nication between the ovary and vagina. In such instances as those cited by Mauriceau, Dulaurens, De Graaf, Baudelocque, and others, where the Fallopian tube divided near the angle of the womb into two canals, the shortest and largest 96 GENERATION. of which was inserted at the angle, whilst the smallest and longest opened into the neck of the womb near its internal orifice, it is conceivable, that this acci- dental canal might afford another passage to the sperm than that through the cavity of the womb. 3. This first point being once established, the question naturally arises, what was the influence exercised by the sperm upon the ovule of the female during the contact ? Now, numerous experiments clearly prove that the sperm owes its fecundating properties to the presence of the spermatic animalcules, and that, whenever it is deprived of these, it immediately becomes unsuited to its proper function. But, unfortunately, it is far more difficult to ascertain the part acted by the spermatozoa, though there have been three hypotheses started in regard to that subject deserving our consideration. The most ancient one is, that during fecundation they penetrate immediately to the ovule, and are there developed as a miniature embryo, or, at least, they constitute the central nervous system of the future being. This old opinion has been recently sustained by Barry, who asserts that the ovule of rabbits, when at maturity, is furnished, both before and during fecundation, with a fissure or opening in the vitelline membrane, and once he was even fortunate enough to see a spermatozoon penetrating this fissure. Again, according to certain authors, the fecundating power does not belong to the spermatozoa, but to the seminal liquid interposed between them. In this hypothesis, the animalcules are the transporters of this fluid, and the object of their movements is to conduct it to the ovule. Lastly, in the opinion of Bory-Saint-Vincent, Valentin, and Bischoff, the sper- matozoa are solely destined to maintain the chemical composition of the sperm by their active motions. They suppose that the spermatic fluid is a substance endowed with a chemical sensibility of such a character that, like the blood, it can only preserve the fecundating power while it remains in motion; whence these active elements are enclosed in it whose presence is indispensable—elements, the movements of which are never more active than just at the moment when the semen leaves the place of its secretion, and which appear to exercise the most favorable influence for the maintenance of its composition. These are a summary of the most recent opinions; and we merely present them as they are, without any commentaries, not desiring to decide in so delicate a matter. Besides, whichever one may be adopted, the mind remains unsatisfied; for it must be acknowledged there is still a mystery that all the most ingenious hypotheses have not been enabled to clear up, and which will probably escape all our researches. When fecundation takes place in the ovary, whether before or after the rup- ture of the Graafian vesicle, the Fallopian tubes, which had participated in the stage of turgescence of all the other genital organs, retain their free extremity in contact with the ovary, and the ovule, having escaped from the vesicle, imme- diately engages in their canal; being pressed onwards by the peristaltic contrac- tions of the tube, it advances step by step through this duct, and finally arrives in the uterine cavity, where its development unceasingly progresses until the regular term of pregnancy. (See the chapter on Ovology.) Nearly the same phenomena take place, when the contact of the fecundating fluid with the ovule is deferred until after the latter has passed into the tube. OF CONCEPTION. 97 It is extremely difficult, not to say impossible, to ascertain the exact period at which the fecundated ovule reaches the cavity of the womb. In animals, we may note without difficulty the time of fecundation; but this, of course, is gene- rally impossible in the human species, and this obstacle renders nearly all our observations uncertain and incomplete. Further, very numerous researches have clearly proved that the ovule in mammalia does not always arrive at the same moment in the womb, and it is exceedingly probable that the same variations exist in the human female. In the present records of our science, there is no one conclusive fact that proves the ovule to have ever been seen in the womb of a woman prior to the tenth or twelfth day after her conception. Baer examined a woman, who committed suicide eight days after conception; the deciduous membrane had commenced forming, and some vessels, coming from the mucous membrane, were penetrating it, but he could not detect any trace of the ovule in the uterus. (British and Foreign New Review, Jan. 1836, p. 328.) The same occurred in the case cited by Weber (Disquisitio anatomica uteri et ovariorum puelloz, septimo a conceptione die dcfunctoz instituta). Dr. Pockels speaks, it is true, of an ovum of eight days, found in the uterus, and in which the foetus could easily be distinguished; but the description furnished by him evidently applies to an older product. (Allen Thompson, in the Edinburgh Med. and Surg. Journal, vol. lii, p. 122.) Ovules of eleven days were the youngest observed by M. Velpeau. After the exit of the ovule, the Graafian vesicle soon retracts upon itself, and thus contributes to the formation of the corpus luteum before spoken of (p. 75). We shall hereafter describe the modifications which the ovule undergoes during its passage through the tube, and after its arrival in the uterus. Conception is an act that takes place unconsciously, and altogether involun- tarily; although some females, more especially those who have had children, imagine that they can distinguish a prolific connection from others. They say a much more voluptuous sensation is then experienced, a spasm much better marked; and I have met with too many females who acknowledged having made this observation, not to believe there is some truth in the assertion. The same ignorance that prevails as to the causes of fecundation, likewise exists with regard to those opposing its accomplishment. For, though vices of conformation or faulty position of the uterus, as also obliterations of the neck or tubes, may explain the sterility of some individuals, it is wholly impossible to understand why some women are barren, although well formed—why, in a con- siderable number of cases, married females have not had children during their first marriage, whereas they subsequently became enceinte, when even it has been observed that the first husband had children by a former bed. The period at which fecundation is most likely to take place, appears to be that immediately following the flow of the menses; thus M. Raciborsky has as- certained that the conception took place a little before or after their appearance, in fifteen females, who could designate precisely the time of the sexual approach. It is indeed evident, that everything seems admirably prepared at this period for the reproduction of the species; but I am far from concluding, as M. Raci- borsky has done, that the aptitude for fecundation in the human race is limited 7 98 GENERATION. to a few days, either preceding or following the menstrual terms. Experience has convinced me that sexual intercourse may be fruitful, even when it takes place in the middle of the interval between the two menstrual epochs. Whether it be that the ovule discharged by the spontaneous ovulation preserves its aptitude for fecundation for a long time, or that the excitation produced by coition may be communicated to the ovarian vesicles, and cause modifications in them alto- gether similar to those experienced in the menstrual evolution, the fact itself appears to me to be settled beyond a doubt.1 1 M. Coste, who also admits the possibility of conception without regard to the period at which copulation takes place, is prepared, he says, to demonstrate by undeniable proofs, that the ovum detached from the ovary during, or towards the close of menstruation, loses all capacity for fecundation within a very few days after being set free. Conception is, therefore, only possible at other times than near or during the menstrual epochs, when other circumstances happen to produce in the ovary an operation similar to that which takes place at the period of heat. Now is this possible ? Comparative physiology replies in the affirmative, by demonstrating it to be so as regards certain animals, thus rendering it at least very probable for the human species also. In animals living in the savage state, says the learned professor of the College of France, the ovaries accomplish their functions only at rare intervals; but, when domesticated, the maturation of the eggs may become so frequent in certain species, that the ovulation oc- curs almost daily. Thus the wild pigeon, which deposits her eggs but once or twice a year, sets seven or eight times, when she takes up her abode in our dovecotes. Under the influence of an appropriate nourishment, our domestic fowls lay almost every day for eight months in the year. The rabbit of the fields brings forth but once or twice yearly, whilst living at large; but in the domestic condition, she will reproduce as often as seven times, if care be taken to wean the young at the proper moment. There are therefore conditions of shelter, of temperature, and of alimentation, which, by acting on the organism of animals, may cause their ovaries to exercise their functions more frequently in a given space of time. To this it may be added, that in mammalia, the cohabitation of the males is one of the most active accelerating causes of the de- hiscence of the vesicles. Thus,, for example, a female rabbit when placed alone in a cage where she is completely protected from the attempts of the male, enters ordinarily into heat about every two months, and when the time of this periodic excitement is past, she refuses obstinately to submit to coition; but if, instead of separating her from the male, whom she then repels with violence, he be allowed to remain with her, for a few days only, it may be regarded as certain that she will not resist long, because the solicitations to which she will be incessantly subjected will provoke the return of a condition which, in the absence of this excitement, would have been much longer in appearing. There are, therefore, natural and entirely spontaneous epochs for the maturation and dis- charge of ova, and there are also others which may be styled artificial, because it is pos- sible to produce them through the means of external agents. Now, is it possible to suppose that the human female, who commands all these conditions at her will, is, by an inexplicable exception, enclosed within the impassable boundaries of her menstrual periods ? And if, in spite of her first vigorous resistance to the attempts of the male, the rabbit finally yields to the influence of his companionship, why in woman, who of all the females of the mammalia is endued with the most constant readiness for coition, should not the sexual allurements have the same result? This accidental evolution of a vesicle is not followed by the menstrual flow which ordi- narily accompames it; all which is very comprehensible, for we must not forget that the same cause which provokes the discharge of the ovule, is also that which fecundates it, and that in doing so, it arrests the tendency to hemorrhage before it has time to appear. (Coste, Histoire generale et particuliere du developpement des corps organises ) The same thing, in fact, happens when fecundation occurs a few days or hours only before the appearance of the menses. OF GESTATION. 99 I shall not undertake to refute the opinion of those who believe that either sex can be created at will; yet I think it not improbable that the physical con- stitution of the husband or of the wife may have some influence in determining the sex of the child. The admirable observations of M. Girou seem to me to have proved that with the inferior animals, at least, the stronger the male is in comparison with the female, the greater is the chance of producing a male, and vice versa. The observations I have been able to make on the human family since reading the statistical results of M. Girou, have generally confirmed their conclusions. Here terminates what I had proposed to say in reference to fecundation. It will be seen that I have limited it to a very brief exposition of the most generally received views of this point of physiology. The size, and especially the object of the work, seem necessarily to exclude more ample details. BOOK II. OF GESTATION. Pregnancy is the condition of a woman who has conceived, and bears within her womb the product of conception. This state commences at the instant of fecundation, and terminates with the expulsion of the body which results from that function. It continues for two hundred and seventy days, or nine solar months. This term, however, is not invariable, as it is by no means rare for the pregnancy to terminate sooner, and in some very few instances we find it of longer duration, though some persons have denied this latter fact, and everybody recalls the sharp discussions carried on in France about the middle of the last century, and still more recently in England, on the question of retarded births. We have already stated that the ovule originally exists in the ovary; that short time before or after conception it is expelled from thence; and that it then traverses the tube, so as to reach the uterus, where it is developed and continues to grow during the whole term of gestation. When the succession takes place in this manner the pregnancy is said to be a good, normal, or uterine one; but, on the contrary, if the ovule be arrested at some point of its passage, and is developed elsewhere than in the womb, the pregnancy is denominated bad, extra- ordinary, or extra-uterine. The first, or uterine pregnancy, has been divided into,—the simple, where only a single foetus exists; the compound, or double, triple, &c, where there are two or three children; and the complicated preg- nancy, or that in which the positive existence of a foetus is coincident with that of a pathological tumor of the abdomen. Again, the term false pregnancy has been improperly applied to certain diseases simulating pregnancy, where this state does not really exist. 100 GENERATION. CHAPTER I. OF SIMPLE UTERINE PREGNANCY. In pregnancy, there are two orders of phenomena to be studied,—those pre- sented by the female, and those which belong to the product of conception. We shall first consider the former. The history of pregnancy in the female comprises all the anatomical and phy- siological modifications that are developed in the uterus and all other organs of the economy; the influence that it exerts on the physical, intellectual, and moral health of the individual; and also the means of preventing or curing the trouble- some accidents which may result from it. ARTICLE I. ANATOMICAL CHANGES.' The most remarkable are those which the uterus undergoes, and we shall commence our description with them. These modifications may either be in the volume, form, situation, or direction of the womb; and hence, on account of their great importance, we shall succes- sively study them in the body and in the neck; then we will point out the changes which the structure and relations of the organ undergo. § 1. Changes in the Body of the Uterus. a. Volume.—We have already learned that under the influence of the hemor- rhagic congestion which the uterus undergoes at each menstrual period, the bulk of the organ is increased. If conception takes place within the few days pre- ceding or following the flow of the blood, the excitement produced by the fruitful coition maintains, and soon increases the hypertrophy of its walls. Thus, we shall find further on (see Decidua), that the mucous membrane especially be- comes almost doubled in thickness, so that when the fecundated ovule arrives in the cavity of the womb, it finds it entirely filled with this membrane, which is swollen to such an extent as to be thrown into folds from want of room to deve- lope itself (See page 73.) The same thing precisely occurs in those exceptional cases in which fecunda- tion takes place some time from the menstrual period. Here the hypertrophy also begins under the influence of the evolution of a Graafian vesicle; only the evolution, instead of being spontaneous, is the result of a more or less prolonged venereal excitement. As soon as the ovule arrives in the womb, the latter begins to develope and its volume continues to increase until the end of pregnancy; but this profession is not uniform, for, according to the observations of Desormeaux, it fs much slower m the early months, and more rapid in the latter. An accurate idea of this increase maybe formed from the following table, which represents the usual dimensions of the uterus at the principal periods of pregnancy. OF SIMPLE UTERINE PREGNANCY. 101 Vertical Diameter. Transverse. Antero-Posterior. Third month, . . . Fourth " ... Sixth " ... Ninth " ... 2\ inches. 3| " 8| " 12| to 14^ " 2| inches. 3| " ,2| inches. 3| " 6J " 8| to 9} " The development of the uterine walls is not purely mechanical, as has been supposed, nor is their distension the result of the development of the ovum, which, by pressing upon the different points of the internal surface, would tend to separate them more and more. If we consider the small volume of the ovule in the first weeks of pregnancy, as compared with the thickness of the walls of the uterus at the same period, we shall not fail to be convinced that the expansive force of the ovum would be unable to overcome their resistance. The development of the ovum and that of the uterus are simultaneous, but effected by forces which are inherent in each; in a word, the growth of the ovum acts as a physiological cause, but not as a mechanical agent in the development of the walls of the uterus. B. Shape.—The shape of the uterus changes simultaneously with the altera- tion in its volume. Being flattened, at first, on its two faces, the womb grows rounder and soon becomes pyriform, then spheroidal, and towards the end of pregnancy it has the form of an ovoid, which is slightly flattened from before backwards. The anterior face, however, is much the more convex, and the posterior one is depressed, so as to accommodate itself to the prominence of the lumbar vertebrae. At the end of pregnancy, the superior extremity of the uterine ovoid is quite regularly rounded; that side of the fundus, however, which is occupied by one of the extremities of the foetal ovoid, being often more elevated than the other, which is filled with fluid only. Now, as in the most usual presentations, the trunk of the foetus is generally inclined towards the right, the right side of the fundus of the uterus is commonly the most elevated. (Hergott.) Sometimes both sides are alike in this respect, and there is a depression upon the middle and upper part of the organ. Such is the shape of the uterus in the majority of cases; but the situation and number of the foetuses, and the structure and primitive form of the organ, may produce important changes in the shape which it assumes during gestation; and which will claim our attention hereafter. c. Situation.—It is evident that the uterus cannot thus change in shape and size, without undergoing a simultaneous alteration in its position; for example, during the first three months of gestation, the womb remains sunken in the ex- cavation, but as the volume increases in all directions, the fundus of the organ rises towards the superior strait, whilst its inferior part and neck subside still more towards the floor of the pelvis. This depression of the organ is produced by its yielding to the laws of gravitation from its own increased weight, as also by the augmented pressure of the intestinal mass upon the larger surface, created by the change in the fundus. Hence, both its increase of volume and its weight, augmented by the pressure of the intestinal mass, which now has an 102 GENERATION. extensive point d'appui on the fundus, contribute to produce the first chaDge in position. ' At the same time, the uterus remains in the sacral cavity from the greater space found there, and, the fundus being turned a little backwards, causes the neck to advance slightly. Besides, the presence of the rectum on the left most generally obliges the organ to deviate towards the right, and the neck, in a cor- responding manner, to the left; consequently, during the first three months, the cervix is directed downwards, forwards, and a little to the left. About the third month and a half, or the fourth month, the uterus, no longer finding sufficient room in the excavation for its continued development, rises above the superior strait, then to the level of the umbilicus, and reaches the epigastric region towards the end of pregnancy. In tracing out the gradual elevation of the fundus uteri, it will be found, at the fourth month, to rise two or three fingers' breadth above the pubis; at five months, it is within one finger's breadth of the umbilicus; and from the fifth to the sixth month, it approaches and passes the umbilical depression, so that at six months it is half an inch above this ring; three fingers' breadth at seven months; and four to five at eight months; it still continues ascending in the commencement of the ninth, but in the last fortnight of gestation, the womb seems to sink down, being, in fact, on a lower level than before. This last is a remarkable occurrence, though it has been said in explanation that the uterus, as if overburdened with the weight of the foetus during the latter period, col- lapses to some extent, and enlarges in the transverse and the antero-posterior diameters. This may be true as regards some females who have previously had children, for not unfrequently they say to us at this time, "It has all gone to the sides;" but I believe a more general explanation of the fact may be given; for, in the great majority of cases, if females be "touched" near the end of preg- nancy, a voluminous tumor, covered by the inferior and more especially by the anterior part of the uterine body, will be readily felt occupying the excavation. This is the head of the foetus, which has descended in consequence of its own weight, carrying the wall of the uterus before it, and become engaged in the excavation, sometimes even as low down as the floor of the pelvis. Now, does not this circumstance, which may be remarked whenever the head presents regularly, and when there is no malformation of the pelvis, furnish us a sufficient reason for the depression of the entire uterus ? How, in fact could the superior do other than follow the inferior part of the organ ? D. Direction.—-In passing up into the abdominal cavity, the uterus is obliged to follow the direction of the axis of the superior strait, and being thrown off by the lumbar column, and finding much less resistance from the anterior abdominal wall, it necessarily inclines forward; but, owing to the lumbar projection, it cannot possibly remain on the median line, and hence it leans towards one side of the abdomen, the right one, remarkable as it may seem, at least eight times in ten. Most authors, since the days of Levret, have endeavored to explain this great frequency of the right lateral obliquity. Levret himself taught, that the uterus always inclines towards the side where the placenta is inserted; for this point, he said, being the thickest and most vascular part of the whole or^an is also the OF SIMPLE UTERINE PREGNANCY. 103 heaviest, and this increased weight, augmented by that of the placenta, must necessarily draw the organ to that side; but experience has shown that the placenta is far from being always inserted on the side towards which the uterus is inclined. Again, according to Desormeaux, the presence of the iliac portion of the colon, which is usually filled with fecal matter, prevents the womb from leaning to the left, when it commences ascending out of the excavation, and thrusts it into the right iliac fossa, whilst the mass of the small intestines is pushed to the left side by the ascent of the womb (where the direction of the mesentery would naturally draw them), and this assists both to maintain and to increase the inclination of the uterus to the right. But, as M. Paul Dubois has justly remarked, any influence which the colon, placed on the left, mav have, is fully compensated by the presence of the ccecum on the right; and, from the observation of M. Velpeau, the mesentery is directed from left to right, and not from right to left, as Desormeaux has it, doubtless by mistake. The habit of using the right arm, and of lying upon the right side, has also been brought forward in explanation of this right lateral obliquity, but subse- quent observation has not sustained the assertion ; thus, for instance, in seventy- six females, all of whom had the uterus inclined to the right, thirty-eight rested on the right side, twenty on the left, fourteen alternately on both sides, and four on the back. And we may further remark that, down to the present time, it has not been observed that the uterus is placed upon the left side of the abdomen more frequently in those women who habitually use the left arm than in others. Madame Boivin, in my estimation, has given the best explanation of this fact; she asserts that the round ligament of the right side is shorter, stronger, and con- tains more muscular fibres than that of the left, and she attributes the right in- clination of the organ to the more powerful action of this ligament. Professor Cruveilhier thinks that the shortness of the round ligament on the right, is the effect and not the cause of the uterine obliquity; " for I have frequently had occasion," he remarks, " to observe that the shortening which occurred on the left, in left lateral obliquity, was constantly accompanied by a remarkable increase of volume." I must confess that I do not comprehend upon what M. Cruveilhier founds this opinion. M. Velpeau endeavors to refute this assertion, by saying that then the right angle of the womb should not be as much removed from the inguinal canal as the left, but the contrary is observed; but he commits a slight error here, for the ligaments in question do not terminate in consequence of the development of the uterus at a point corresponding to the lateral borders of the empty organ, but much more in advance,1 so that they are inserted on the anterior lateral region of the womb; and further, if the right inclination is due to the traction of the 1 The uterus is developed during pregnancy, at the expense of the posterior wall particu- larly. The truth of this becomes clearly evident by marking the point at which the tubes are inserted at the end of gestation, when two-fifths of the antero-posterior diameter of the organ will be found in front of, and three-fifths behind this mark. I examined, with Messrs Bonami and Helot, the womb of a female who died in the seventh month of pregnancy, under the care of M. Recamier, in whom the round ligaments were inserted so far forward, that four-fifths, at least, of the antero-posterior diameter were behind a transverse line drawn between their points of insertion (April, 1843). In this 104 GENERATION. right round ligament, as Madame Boivin teaches, the uterus, in inclining to this side, will naturally make a movement of rotation on its own axis, which carries its anterior plane a little to the right, and its posterior wall somewhat to the left. Now, this is precisely what does take place. e. Thickness of the Parietes.—The earlier authors on this subject entertained very different views concerning it: some, judging the thickness of the body by that of the neck during labor, concluded that the uterus could not be distended without a great diminution in the depth of its walls; others, having had better opportunities of examining the wombs of females who died soon after the ac- couchment, observed the very considerable thickness exhibited by the uterine parietes at that time, and therefore adopted the opinion that the latter become much thicker during gestation. Both sides were in error, for numerous autopsies, made since that period, of women who died during gestation, have established the truth of the following propositions, namely: 1. In the three first months, the uterine walls augment a little in thickness, doubtless in consequence of the development of their vascular and muscular ap- paratus. 2. Towards the fifth month, they are about the same as in the normal state. 3. At term, the parietes are thicker than in the natural condition, at tbe point corresponding to the insertion of the placenta, thinner at the neck, and they present but very little difference throughout the remainder of their extent. We may here notice some further exceptions: thus, M. Moreau, having mea- sured the thickness of the walls in a woman deceased at term, found it one-sixth of an inch at the fundus, one-fourth of an inch at the insertion of the placenta, and one-third of an inch at the neck. This singular anomaly may be explained, says M. Moreau, 1st, as regards the thinness of the fundus, by the enormous distension the uterus had undergone (being a twin pregnancy.) And 2d, the greater thickness of the neck resulted from the considerable retraction this part had sustained from the escape of the amniotic liquid before death. In one instance, Saviard found it one-third of an inch at the placental attach- ment, and only a line in other parts. My friend, Dr. Ripault, in performing the Cesarean operation, found the uterine wall only one or two lines thick. I have myself had occasion to examine a pregnant woman, in whom the parts of the infant were so easily distinguished through the abdominal parietes, that the hand seemed to be, only separated from them by a layer of a few lines in thickness. Again, the thinness may be par- tial; thus Hunter describes a uterus, the posterior walls of which exhibited this phenomenon in a remarkable degree. Since the thickness is not sensibly diminished, it is evident the whole mass of the uterine walls must greatly increase, so much so, indeed, that towards the end of gestation, the total weight of the organ reaches two and a half pounds, or even more. The empty uterus, in the case of M. Moreau, just cited, weighed (1750 grammes) nearly four pounds. woman, no obliquity of the uterus existed, and the organ appeared to be near the median line, at least in the dead body. I carefully measured the comparative length of the two round ligaments, and must acknowledge I did not find any difference between them. Should the absence of obliquity, in this case, be attributed to this fact? OF SIMPLE UTERINE PREGNANCY. 105 F. Density of the Walls —The uterine parietes, in the non-gravid state, are very hard and resisting, and have nearly the consistence of fibrous tissue, but during pregnancy this density diminishes and the walls become soft and flabby. The ramollissement begins to show itself as early as the first month, and consti- tutes at that period one of the best signs for proving a commencing pregnancy (see article on Diagnosis), because, instead of presenting the fibrous density of the ordinary state, the walls have a clammy softness closely resembling that of caoutchouc softened by ebullition, or that of an cedematous limb. This decrease in the consistence of the uterine walls constantly advances, so that, at a later period, a light pressure made on the anterior abdominal parietes will easily depress or deform them; consequently, the extremities and other inequalities of the foetus may be detected, and its movements may even cause an elevation of some part or other; the child, therefore, is not placed in a cavity having im- movable walls. The diameters of this cavity will vary with the position taken by the foetus, which can, in some cases, continue to change them until the end of gestation, the flexibility of the walls permitting its long diameter to pass through the small ones of the organ; and we can readily comprehend how this flexibility, this sup- pleness of the fibres of the womb, will aid in preventing the disastrous conse- quences which otherwise might result to the child from any violent blows on the abdomen, or from the shocks experienced by the mother. § 2. Modifications in the Neck of the Uterus. The modifications which the neck undergoes during pregnancy, are referable: 1, to the consistence of its tissue; 2, its volume; 3, its form; 4, its situation and direction. 1. As the softening of the tissue of the neck of the uterus seems to be an all-important fact, we therefore give it the first place. Now, everybody knows that, in the non-gravid state, the uterine tissue re- sembles the fibrous in its consistence; but immediately after conception, and from the sole fact of the active congestion which the genital organs then expe- perience, this consistence begins to diminish, although, from being coincident with the hypertrophy of the uterine walls, it is scarcely sensible during the first few days, whatever may be the extent of the neck examined. But towards the end of the first month we may ascertain that, independently of this original general modification, the most inferior, or rather, the most superficial part of the lips of the os tincae, begins to soften. It resembles more a swelling of the mucous membrane than a true "ramollissement" of the proper tissue of the lips; so that by pressing slightly on this thickened membrane the finger first detects a fungous softness, but soon reaches the proper tissue of the neck, which still maintains its normal consistence. The sensation then experienced by the finger greatly re- sembles that communicated when it is pressed on a table covered by a soft and thick cloth; and it is only towards the end of the third, or beginning of the fourth month, that the lips of the os tincae are softened throughout their whole thickness to the extent of a line or a line and a half. At the commencement of the fifth, the softening increases from below up- wards, and at the sixth embraces the moiety of the sub-vaginal portion. During 106 generation. the last three months it invades the superior part by degrees, and last of all the ring of the internal orifice, so that, at the end of gestation, the neck is so soft in certain females, that I have frequently seen students have great difficulty in distinguishing it from the walls of the vagina. This modification of the neck, which authors have scarcely spoken of, is one of the most important signs; because, after a little experience, it affords us one of the best means for ascertaining the different stages of pregnancy; being con- stant, and found in all females, unless the neck should be the seat of some patho- logical alteration. It is worthy of notice, however, that the softening is not so well-marked, and is much slower in its progress in primiparae, than in women who have previously had children; but in all, it steadily proceeds from below upwards. As before remarked, we may judge very nearly of the probable period of preg- nancy by the extent of softening, as it progresses from the inferior to the superior part of the neck; though there is one important remark to be made on this subject, namely, that whenever females have had a great number of chil- dren, the sub-vaginal portion of the neck loses the greater part of its length; the extremity then projecting into the vagina, and capable of exploration by the finger, being much shorter. Now, as the softening of the supra-vaginal portion of the neck is of much more difficult detection, it may be thought to be much less extensive than it is in reality, whence we may expect to find a great differ- ence in the extent of the softened part, if a comparison be made between the necks in two females, both advanced to the sixth month, one of whom is pregnant .for the second time, and the other had previously borne ten children. Where- fore it is necessary, in making this appreciation, to bear in mind the number of former pregnancies, as also the real length of the sub-vaginal portion of the cervix. 2. Volume.—Some singular ideas on this subject, have been promulgated by many authors, but the following appears to be the most constant rule : the neck doubtless participates in the hypertrophy of the uterine walls during the earlier months, though its development is far less considerable. The neck becomes thicker and grows more voluminous, especially at the superior part, but I have never observed its elongation to the extent of two inches, as Madame Boivin apparently believes, or to two and three-quarters and three inches, as M. Filugelli has more recently advanced; for, as elsewhere observed, these opinions result, in my estimation, from an error. The neck, in the commencement, being much lower, and directed more in front than in the ordinary condition, the finger can easily explore a larger extent of it, and thus an impression is created of an in- crease in its length which really does not exist; for frequent post-mortem exami- nations of females who died in the early months of pregnancy, have convinced me that, even if the neck is increased in thickness, its length does not undergo an appreciable augmentation up to the fifth month. But at the commencement of this latter period, according to most writers, the cervix begins to diminish. In the sixth month (they say) it begins to spread out at the superior part, so as to aid in the enlargement of the body of the womb, and this spreading at the upper part continues to advance in proportion as the term of gestation approaches, and consequently the length of the neck decreases from above downwards, so as merely to present at last, at the close of the ninth OF SIMPLE UTERINE PREGNANCY. 107 month, a ring of variable thickness. In fact, the diagnosis of the different periods was based on this gradual shortening, and, agreeably to the majority of the French accoucheurs, who have adopted the opinions of Desormeaux, the neck has lost at the fifth month about one-third of its length, one-half at the sixth, two-thirds or three-quarters in the seventh, three-fourths or four-fifths in the eighth, and the remainder is effaced during the course of the ninth month; and yet, I do not hesitsfce to pronounce all this an entire error, which was first pointed out by 31. Stoltz, in 1826, and to which I also have constantly asked attention since the year 1839. No; the neck does not shorten in the way which has so long been described; it preserves its whole length until the last fortnight of pregnancy; and it is an easy matter, especially in women who have previously borne children, to verify this remark, as we shall presently demonstrate. But during the last few weeks, its length, which until that time was intact, dimi- nishes very rapidly, and even disappears by a total effacement, and we shall in due season explain the simple mechanism of this phenomenon. But to return; I have frequently been enabled to prove, in primiparae, the truth of M. Stoltz's assertions; for in these women the neck does diminish a little in length, during the last three months, although by a process entirely dif- ferent from that described by Desormeaux. Thus, towards the seventh month, the ramoUissement has invaded the whole intra-vaginal portion; the parietes of the neck, having lost their consistence, are easily separated by the liquids secreted upon their internal face, and the upper part of this portion being turned outwards, enlarges in such a manner as to cause the whole neck to resemble a spindle in its shape; the superior extremity of which is formed by the internal orifice (still closed,) and the infe- rior is constituted by the external one, which is scarcely opened in primiparae, even at the end of gestation, as we shall hereafter show. _ _ a section, showing the Now, it is easily understood how this bulging of the neck of the uterus; the middle part of the neck can only take place just in propor- ^le^hK tion as the two extremities of the latter approach each separated from each other Other; thus, of course, detracting so much from its total |>y the fusiform cavity of ; ' '_ ° the neck. length. I do not believe, however, with M. Stoltz, that the approximation of the two orifices can be so great as to cause a material short- ening of the neck, though this certainly does exist to some extent. The short- ening of the neck is therefore real, though slight, in primiparae; being accom- plished, however, by a different mechanism from that taught by most authors. Its upper part does not spread out so as to contribute to the enlargement of the cavity of the body, but suffers a sort of collapse, which brings the two orifices nearer together, at the same time increasing its central cavity, and extending its transverse diameters at the expense of the vertical. What has been said con- cerning the rapid effacement of the neck during the last few days in multiparaej equally applies to primiparae; the process taking place by the same mechanism. 3. Form.—The principal modifications in the shape of the neck have already been presented, but they ought to be studied in a more special manner, accord- ing to whether they are found in primiparae, or in women who have previously been mothers. 108 . GENERATION. A. At the commencement, in primiparae, the cervix appears more contracted and more pointed, resulting, perhaps, from the augmentation of its superior part in volume; the orifice of the os tincae, which, before conception, presented a simple linear and transverse fissure, now assumes a circular form, constituting, as it were, a small lenticular fossa. A little later, as mentioned above, the middle part of the cavity of the neck enlarges, so as to give to the whole cervix the form of a somewhat elongated spindle, rather than that of a cone, which it previously had. It continues smooth and polished on the exterior surface, and the peri- phery of its orifice is rounded, without any irregularities or fissures; sometimes presenting a soft circumference, at others a thin and sharp border: the latter rarely happens, however, before a very advanced stage. At this time, it is very easy to ascertain what changes the neck has undergone, for although the external orifice is constricted, it is very much softened, and sometimes allows the finger to pass with a very slight effort and enter the cavity of the neck. The base of the last phalanx is then felt to be grasped quite tightly by the external orifice, whilst the extremity of the finger is at full liberty in the fusiform cavity of the neck. It may also be readily observed that the two orifices are still widely sepa- rated, for the entire length of the first phalanx and sometimes more, are capable of being contained in the cavity. Fig. 27. Fig. 28. Fig. 29. These three figures give an idea of the gradual dilatation which the cavity of the neck undergoes at various periods of pregnancy. B. The form of the neck is altogether different in women who have had chil- dren; thus the inequalities and protuberances exhibited by the inferior part will scarcely permit us to ascertain whether it becomes more pointed or not, and it is equally difficult to determine whether the external orifice has become more rounded; because, having been somewhat patulous before pregnancy, this orifice, in consequence of the numerous cicatrices found on it, presents a very irregular opening. The only point capable of demonstration in the early periods is, that the partially opened orifice will dilate still further, so as to admit readily the ex- tremity of the fore-finger. This spreading out of the os tincae, and the inferior part of the neck, con- stantly increases from below upwards, as the gestation progresses; it reaches the middle part of the cervix about the seventh month, and nearly gains the internal orifice by the ninth. The enlargement of the cavity of the neck advances simultaneously with the softening of its walls; and we can easily prove by experiment that the finger will each month penetrate deeper into it. The shape of this cavity resembles in some women that of a thimble, in others, of a funnel, with the base below and the OF SIMPLE UTERINE PREGNANCY. 109 apex above, the difference being due simply to the depth and number of the rup- tures which had existed on the external orifice before pregnancy. The part of the neck not yet softened and dilated constitutes the summit of the cone : that is, every portion of its length contributes in succession; so that the first, and often even the half of the second phalanx of the finger can pene- trate into its cavity towards the ninth month, the extremity of the finger being only arrested by the internal orifice, which is still closed and puckered like the knot of a purse. The ring at this orifice finally softens, becomes dilated, and permits the finger, which has passed through a canal an inch to an inch and a half in length, formed by the cervix, to come into direct contact with the naked membranes. If the length of the external surface of the neck be compared at this period with the canal in which the finger is introduced, the neck will be found much longer internally than exteriorly, for it is self-evident that the finger is arrested on the outside by the vaginal insertion, whilst within it traverses the whole space between the two orifices. The internal orifice sometimes opens too soon; thus Desormeaux declares that he touched the membranes at the end of seven months, over a space of an inch and one-third in extent. I also have verified the same fact, but only in women who were subject to floodings, or in those who submit to "the touch," in our public lessons, for, in these latter, the frequently repeated and careless introduc- tion of a great number of fingers, has appeared to me to greatly accelerate the softening and dilatation of the neck. On the whole, therefore, the neck is fusiform in primiparae, the external orifice is rounded, and so little dilated as to prevent the introduction of the finger with- out some considerable effort. In females who have had children, the external orifice is widely open, and the cavity in the neck is funnel-shaped, the base being below, and continues to increase until its apex reaches the internal orifice. This latter remains closed in both, in a vast majority of cases, until the beginning of at least the last month of pregnancy. These differences in the form of the neck in primiparae and of multiparse, are readily accounted for when we take into consideration the condition of the ex- ternal orifice before pregnancy in both cases. The os tincae of women who have already had children, has the continuity of its circumference interrupted by a greater or less number of ruptures, so that as soon as a small part of the neck has become softened, each of the divisions of the circumference being fixed only by its upper part, is turned outward, so as to give to the orifice the form of the large extremity of a trumpet. In the primiparous woman, on the contrary, the integrity of the ring is complete, and the os tincae may become softened without its orifice being muoh enlarged in consequence. We have stated that the whole length of the neck disappears at the last, by being confounded with the cavity of the body. The mechanism of this fusion is very simple; the ring at the internal orifice having at length lost all power of resistance from its ramoUissement, opens so as easily to admit the extremity of the finger (See Fig. 29), and this dilatation gradually augments under the in- fluence of those feeble contractions by which the uterus, in the last fortnight of gestation, seems to prelude the labor of childbirth, and as soon as this is suffi- ciently advanced to permit the inferior part of the ovum to engage in the cavity 110 GENERATION. of the neck, we can understand that the latter is promptly trespassed upon. Again, there is no projection found at the upper part of the vagina, unless, per- haps in those who have had children, a collar of variable thickness and softness, circumscribing an opening large enough to permit the finger to reach the mem- branes; whilst in primiparae, a sharp, thin ring, in the centre of which is a much more contracted orifice, will be encountered. 4. We have but little to remark concerning the situation and direction of the uterine neck during pregnancy, and our opinions do not differ from those held by the majority of writers on this subject; hence we shall merely state, in a few words, that during the first three mouths the neck is lower, is directed more in front, and a little to the left; and that this position is the necessary consequence of the inverse movement of the body of the organ, by which its fundus is carried backwards into the sacral cavity, and pushed to the right by the tumor, which the rectum, habitually distended with fecal matters, forms behind and at the left part of the excavation. In the last six months, the cervix, necessarily following the ascent of the body, mounts upward, and, at the same time, most generally looks backward and to the left, whilst the fundus is neary always carried forwards and to the right. I cannot pass over, however, a disposition of the neck occasionally met with at the end of gestation, that sometimes embarrasses persons not familiar with this kind of exploration: namely, in the last month, the head-(if that is the present- ing part) frequently presses before it, in engaging in the excavation, the anterior inferior portion of the uterus, and in case the female has a large pelvis, this descends even perhaps down to the inferior floor. The neck will therefore necessarily be carried behind the tumor which then fills the pelvis, and the plane of its orifice will look towards the anterior face of the sacrum, and, of course, in order to penetrate its cavity, the finger must be bent like a hook and be introduced from behind directly forwards. This posterior obliquity of the cervix, which differs essentially from that produced by an anteversion of the womb, sometimes renders it very difficult of access, even when the labor is some- what advanced. The difficulty is still further increased, in some cases, by the softening of the neck throughout, in consequence of which it becomes flattened and applied to this tumor, forming a kind of fold or doubling on its posterior part. Summary.—From what has been stated, we may now draw the following conclusions: 1st. That the tissue of the neck begins to soften at the very commencement of pregnancy, and the softening, although not very apparent in the earlier months, and limited to the most inferior part, gradually ascends, so as to invade successively the whole neck from below upwards, though it is much less marked and less rapid in its progress in primiparae than in other females. 2d. The cavity of the neck dilates simultaneously with the softening of its walls; and further, this enlargement causes it to be spindle-shaped in primiparae j and, in females who have already borne children, to resemble a thimble, the finger of a glove, or a funnel with its base below. 3d. The external orifice remains either closed, or else very slightly open, in OF SIMPLE UTERINE PREGNANCY. Ill pritniparas, up to the very term of pregnancy, whilst in others it is widely open, and constitutes the base of the funnel. 4th. The whole length of the neck disappears in the last fortnight, being lost in the cavity of the body. 5th. Contrary to the opinions generally adopted before the time of M. Stoltz's publication, the neck preserves its whole length until the last fortnight; it does not shorten from above downward during the last four months, but the fusion of the neck with the body takes place only within the last few weeks of gestation. § 3. Modifications in the Texture and Properties of the Uterus. A. Texture.—Among the many changes which the womb undergoes during pregnancy, the most curious of all are those exhibited in its texture; and we shall study these by successively examining the different parts of its constituent elements. 1. Serous Coat.—The peritoneum, forming the external membrane of the uterus, spreads out in all directions. The various folds formed by it in the neighborhood of the womb, a species of mesentery, as M. Dubois calls them, such as the broad ligaments and the anterior and posterior ligaments, are double. Many anatomists believe this doubling is even sufficient to accommodate the en- largement of the organ. But, to refute this opinion, it is only necessary to examine that portion of it comprised between the commencement of the two tubes, which cover the fundus; for this will afford a convincing proof that it cannot be furnished by the accession of neighboring parts of the peritoneum, because, as Desormeaux remarks, the insertion of the tube and ligament of the ovary upon each side presents an obstacle that will prevent the gliding of the adjacent membrane. The peritoneal tissue, however, .undergoes a considerable extension, and a more active nutrition must necessarily take place to prevent its attenuation, since that which covers the uterus during gestation quite equals in its thickness the serous membrane of the unimpregnated state. This extension of the peritoneum, without a decrease in thickness, is not a new fact in patho- logy, and it may be seen in every hernia of considerable size. The tissue uniting this membrane to the muscular substance appears to have diminished in density; for the peritoneal coat is movable on the muscular walls, according to M. Dubois, who has met with difficulty from this cause every time he has performed the Caesarean operation. 2. Mucous Coat —Although the existence of this coat in the non-gravid state, has been denied by many anatomists, it becomes very apparent during pregnancy. It then grows redder and more vascular, and its folds disappear; but this un- folding will not alone account for the extension which it undergoes, and it must, whatever be said to the contrary, receive, like the peritoneum, a more active nutrition. All the elements which we have mentioned (page 60) as entering into its com- position undergo, in reality, a considerable development. The nature of this work does not allow us to enter into all the details which the subject demands, and we prefer referring the reader to the excellent work published by M. Robin, in the Archives, for the year 1848. The glands of the body of the womb share in the general hypertrophy, and we 112 GENERATION. Fig. 30. shall be obliged to recur to this subject when we come to treat of the decidua, which is nothing else, as must be finally acknowledged, than the mucous mem- brane of the uterus modified by the progress of gestation. (See Decidua.) It is easy to convince ourselves, after the accouchement, that the glands of the neck had undergone an enlargement. Their secretion is much increased, and to it is due the gelatinous plug, that is to say, the elastic, dense, semi-transparent, and almost insoluble mass of mucus, which closes and fills the cavity of the neck during pregnancy. That such is the case may be demonstrated by examination of the bodies of women who die during pregnancy, when, if the mass be de- tached, prolongations will be found passing from it, and entering the orifice of the glands. (Robin.) 3. Middle Coat.—The fleshy portion of the organ, composed, in the uniin- pregnated state, of fibres whose structure is so difficult to unravel, becomes much easier of study in pregnancy; for although the muscular nature of its constituent tissue is very doubtful during the former condition, yet in the latter it becomes quite evident. From the able researches of Madanie Boivin, the following dis- position of these muscular fibres has been determined. She describes two planes of fibres as existing in the body of the uterus—the one exterior, the other inte- rior; the external plane is composed of fibres which run from the middle line outwards and downwards to the inferior third of the organ, where they terminate upon and aid in forming the round ligaments situated there, while the most superior ones are distributed to the Fallo- pian tubes and the ligaments of the ovary. An exact idea of the radiated disposition of the ex- ternal fibrous planes, at the superior and lateral parts of this organ, may be formed by imagining the long hair of the human head to be parted along the whole middle line of the cranium, and then combed smooth on each side in front, and tied very tight opposite each ear. Another muscular plane is found internally, having an entirely different arrangement; these fibres are circular and situated at the superior angles of the womb. They surround the inter- nal orifice of the tubes (a a, Fig. 30), describing concentric circles, at first very small and close, but gradually separating as the distance from the angles increases, so that the last and largest border upon the median line, and spread out in the direction of its length. Between these two planes, the external one composed of longitudinal, and the internal one of horizontal fibres, some other muscular fibres are found, the course of which it is impossible to trace. Only a single order of fibres, which are semicircular, exists at the inferior part. They commence at the median line of this region, and reunite on the sides near the round ligaments. I will remark, in terminating this short account of the uterine structure, its Muscular fibres of the uterus, a a. The internal orifices of the Fallopian tubes. OF SIMPLE UTERINE PREGNANCY. 113 great resemblance to that of all the hollow organs, in having, for instance, its longitudinal fibres on the exterior, whilst the circular and horizontal ones are internal. The fundus uteri is the part particularly concerned in the expulsion of the foetus, and it is there also that the muscular apparatus is the most deve- loped; its disposition is such, that all parts of the uterine surface tend towards the centre during contraction. Lastly, at the inferior part, where the resistance should be least, there are only the horizontal fibres, constituting a sort of sphincter muscle, which may be compared, on more than one account, to the sphincter of the rectum or of the bladder. Quite recently, 31. Deville, anatomical assistant to the Faculty of Paris, has studied the muscular arrangement of the uterus in a great number of cases of females who died a few days after labor, and the results at which he has arrived, differ much from those previously acknowledged. He has kindly exhibited his dissections to me, and I confess, after an attentive examination, that it were im- possible for me not to be of his opinion. This subject, in my estimation, requires further examination, but whilst awaiting an opportunity of dissecting for myself, the preparations of M. Deville appear so satisfactory, that I have obtained a drawing of them, and introduce here the description furnished by that skilful anatomist. Examined on its external surface, after the removal of the peritoneum and the compact resisting layer that separates this serous coat from the muscular fibres, the uterus seems to be composed of two orders of fibres, which are essentially muscular, one being transverse and the other longitudinal. The transverse fibres arise (this word to be received in a purely descriptive sense) from three sources : the round ligament, Fallopian tube, and the ligament of the ovary; also from the wings of the corresponding broad ligament. The mere removal of the delicate peritoneal envelope of these organs suffices to bring the transverse fibres into view, and at the same time to reveal their muscular character. The transverse fibres, together with certain vessels and nerves, constitute the intimate structure of the round and ovarian ligaments, as also the middle layer of the Fallopian tube, which is therefore essentially muscular, like the internal membrane, improperly called dartoid, of all the excretory canals. The presence of a great number of transverse uterine fibres lying in the thick- ness of the folds of the broad ligament, and extending to its base, is an impor- tant fact to be borne in mind; and the question arises, where do they terminate ? I confess that I have not been able to determine this in a satisfactory manner. However the truth may be, the transverse fibres coming from these divers origins spread out in a radiated manner over the whole exterior surface of the uterus, the anterior and posterior ones transversely, or a little downwards in an oblique direction, and the superior, obliquely upwards, so as to cover the organ completely. Near the median line, these fibres are crossed perpendicularly to their course by a longitudinal fasciculus, more or less sinuous in character, and three-eighths to three-fourths of an inch wide, which arises near the point of union of the body with the neck, ascends upon the fundus of the organ, and de- scends on the posterior face, to be lost at its inferior part opposite to or a little below the point of beginning, that is, near the union of the body with the neck. A positive continuity will be observed between the transverse fibres of each side 8 114 GENERATION. Fig. 31. and the middle longitudinal fasciculus, if the line, of contact be carefully examined. As the transverse fibres arrive near the median line, some curve downwards, others upwards, so as to become longitudinal, and thus constitute the median layer. This is particularly evident at its termination, both in front and behind, for the whole fasciculus divides there into two portions, one of which curves to the right, the other to the left, and becomes continuous with the most inferior transverse fibres of the body. This continual exchange of the two series of uterine fibres takes place with such great uniformity, that the longitudinal fasciculus has nearly the same thick- ness everywhere; but if this lamina be more patiently examined, it will be found to be composed of very short longitudinal fibres, forming the central part of a letter X, which the uterine fibres describe, as I have verified on many of my preparations, in the following manner: Let us take a layer of transverse fibres on the right side of the uterus, at the anterior inferior part (see Fig. 31); this fasciculus nearly approaches the median line, then curves upwards and becomes confounded with the longitudinal lamina; then, after a vertical course, varying from one-third of an inch to two inches, it again curves to the left, to reassume a transverse direction, thus representing a Z, or still more exactly, a branch of the letter X. Thus, the longitudinal median layer is produced by the union of the central and vertical branches of the X described by the uterine fibres. It sometimes happens, however, that the transverse fibres pass directly from The disposition of the muscular fibres on the anterior face of the womb. Fig. 32. The disposition of the muscular fibres on the posterior face of the womb. right to left, without forming the vertical branch, which fact should be borne in mind, lest this arrangement existing on the surface might give rise to a belief of the absence of a median longitudinal fasciculus; whereas, if the latter is not evident, it will only be ne- cessary to raise carefully this layer of median transverse fibres, to bring it into view. The uterus exhibits the same disposition of mus- cular fibres on the internal face, which will readily account for the error of Madarne Boivin, who described them as circular. Notable differences, however, exist be- tween the fibres on the two surfaces of the organ. The most remarkable on the exte- rior is the extreme breadth of the longitu- 9635 OF SIMPLE UTERINE PREGNANCY. 115 dinal fasciculus, which covers the whole fundus, extending from the orifice of the Fallopian tube on one side to the same point on the other. When this fasciculus reaches the anterior and posterior faces, it is intersected at right angles by the transverse fibres occupying the lateral portions just below the orifice of the tubes, which act there as on the exterior surface: that is, some of the fibres curve upwards, others downwards, becoming confounded with the longitudinal layer. Lower down, near the junction of the body with the neck, the longitudinal fasci- culus is very irregular. Sometimes it exists; sometimes, though more rarely, it does not. At this point, in fact, the continuation, or inter-crossing of the transverse fibres from one side to the other, occurs in an irregular manner, either forming the vertical branches of an X, or Fig. 33. taking an oblique direction, or again going directly across, the fibres preserving a transverse course. A third layer exists between the two just described, but I am not sufficiently acquainted with the disposition of its fibres to give an exact account of them. All these particular details do not interfere with the general law of inter-crossing, or passage of uterine fibres from one side to the other, and in this respect, the uterus may justly be ranged in the same class with all the other hollow muscular organs whose structure is also regulated by the fundamental law of muscular inter-crossing. Hence, it would not be difficult to demonstrate that the human uterus, as just described, approaches in its struc- ^^teltfibrr8 ture quite as well, perhaps better, to that of the same organ in other mammiferae, than the arrangement pointed out by Madame Boivin. But such a discussion would be out of place here. In conclusion, I will observe, that the same dispositions in the muscular ar- rangement are found in the neck and inferior part of the body. Inter-crossings occur there also, the fibres passing directly from one side to the other, or be- coming more or less oblique at the moment of crossing, and still oftener forming the branches of an x with the median vertical parts. This last disposition gives rise to the peculiar formation, which has improperly been called the arbor vitce. 4. Vascular Apparatus.—Towards the end of pregnancy, the uterus exhibits an astonishing development of its vascular system. 3Iy friend, Dr. Jacquemier, has for fifteen years paid much attention to this subject, and I submit the result of his labor. " In studying the development of the vascular system in its whole extent, we shall find," he says, " that the augmentation in the size of the arteries only becomes considerable as they approach the uterus. Whilst advancing be- tween 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, which ramify ad infinitum; they are not situated immediately below the peritoneum, but are separated from it by a delicate layer of muscular tissue. All these ramifications anastomose freely and penetrate through to the internal surface, where they generally terminate; but a large number of those, corresponding to the placental insertion, traverse the mucous 116 GENERATION. membrane, and," according to 31. Jacquemier, "enter the inter-utero placental deciduous membrane." The beautiful injections, which 31. Bonami has kindly shown me, evidently prove that these ramifications even penetrate the structure of the cotyledons as far as the fcetal face of the placenta. (See Placenta.) If the venous trunks be examined, from the point of quitting the uterus to their terminations in the hypogastric vein and in the vena cava inferior, a great increase in capacity will be noticed, for the ovarian veins are almost as large as the external iliacs, and the uterine are but little less. In the substance of the womb, the venous system presents itself as a series of canals, situated in the centre of the muscular tissue, at nearly an equal distance from the internal and the external faces: at this point, the uterus is traversed by a great number of canals coming from all directions, which anastomose, and form large sinuses at their junction; the whole constituting a grand plexus, several divisions of which are large enough to receive the extremity of the little finger. These canals are much larger opposite the insertion of the placenta than else- where, and they diminish in size as they recede from it. There is a certain portion of the uterine walls, determined by the placental insertion, where the venous canals of the uterus traverse the mucous membrane in order to be dis- tributed to the placenta. There, in the thickness of the mucous membrane itself, which has become the maternal placenta (or inter-utero placental decidua), these vessels form, through an enormous dilatation of all their branches, the large sinuses which exist at the adherent surface of the placenta. These sinuses communicate so freely with each other as to form, so to speak, a pool of blood, divided up by numerous partitions. A proportionally small number of orifices exist at intervals, through which this reservoir of blood communicates with the sinuses of the muscular walls. When the after-birth is detached, the whole placental surface of the uterus is found to be riddled with holes, which look as though they had been made with a punch. These orifices, which are oblique, like the section of a quill in making a pen, close of themselves through the depression of one of the membranous lips of the opening against the other. (See Placenta.) An enlargement of the arteries and veins like this cannot be the result of a simple unfolding, since their flexuosities are in a great measure preserved; they must, therefore, undergo a transformation analogous to that of the fleshy tissue. When we come to treat hereafter of the decidua, we shall find that the ar- rangement of the vessels of the mucous membrane properly so called, undergoes changes during the course of gestation; the vascular network of the internal surface, which is highly developed in the early stages, showing signs of a com- mencing atrophy at the end of the second month, and diminishing to vessels of very small calibre by the end of the pregnancy. A very delicate yet distinct web of areolar tissue envelopes the uterine arteries. The veins, on the contrary, have only their internal coat, which adheres inti- mately to the muscular substance, and no valves are found in their interior. From what has been stated, it is evident that the blood flows to the uterus in very large quantities, and consequently its heat and nutrition are augmented, for such an amount of blood must certainly contribute to the growth of its walls OF SIMPLE UTERINE PREGNANCY. 117 But the question then arises, is the circulation much more active, as many authors have thought? In reply, it would appear from the late researches of M. Jacquemier, that the venous circulation especially must exhibit an unusual slowness, but I confess the reading of this last part of his memoir has not con- vinced me on that point. (See art. Hemorrhage.) The lymphatic vessels also acquire a very considerable calibre and form several planes in the uterine substance, the superficial of which are the most developed; they divide into two groups, those of the neck, which run to the pelvic ganglia, and those of the body, going to the lumbar ganglia. The hypogastric absorbent trunks, according to Cruikshank, who has described and figured them, are. as large as a goose-quill, and the vessels themselves so numerous, that, when in- jected with mercury, the uterus appears to be a mass of lymphatic vessels. A common dissection, made a few days after delivery, will afford convincing proofs of their volume and number. 5. The nerves of the womb have, of latter time, been the subject of numerous researches, among others, by Drs. Robert Lee, Jobert, Rendu, and Boulard. Agreeably to the latter anatomists, whose conclusions closely correspond with those of the English accoucheur, the nerves are derived from three sources: 1st. From the ovarian plexus—few in number, and distributed to the angles and fundus uteri. 2d. From the hypogastric plexus—these are specially destined to the neck; and 3d. Some filaments of the great sympathetic, which accompany the uterine arteries, and are apparently lost upon the neck and lateral parts of the womb. Among the filaments constituting the ovarian plexus, there are a few which seem to follow the course of the bloodvessels passing near the ovary, and reaching the border of the uterus at its superior part. The filaments then penetrate into its substance along with the vessels—but it is impossible to trace them through the uterine tissue, either from the adherence of the vessels to this tissue, or from the tenuity of the filaments themselves, and the same is true of those accompanying the uterine arteries, which come from the nerves that follow the divisions of the hypogastric artery. The hypogastric plexus furnishes some nervous filaments as the urethra crosses its anterior part; these nerves are few in number, and ascend along the lateral portions of the neck (but not following the vessels), giving off branches here and there which enter the uterine walls, but 31. Rendu has not been able to trace them beyond the neck. These nerves differ essentially from the preceding, both in origin and distribution, for they come from a plexus whose branches are not distributed with the vessels, and which has frequent anastomoses with the sacral nerves or nerves of animal life. The whole body of the uterus, therefore, receives the nerves of organic life exclusively, whilst the nervous apparatus of the neck alone has communications with the spinal nerves. Like the lymphatic and sanguineous vessels, the nerves, according to some authors, undergo a considerable development during gestation. In the preparations exhibited by Robert Lee to the inspection of the Royal So- ciety, and also in the two figures given by him, large nervous bands are seen below the serous tunic, and these bands are so voluminous that many anatomists have doubted their true structure, and regarded them as furnished by a gelati- nous or cellular membrane, placed between the peritoneum and the muscular W 118 GENERATION. coat. Consequently, in accordance with this view, the uterine nerves do not form an exception, as was for a long time supposed, to the hypertrophy seen in all other parts of the organ during pregnancy—for they likewise are developed in every way, and return after the delivery to their normal size. (See, for futher details, the memoir of Dr. Robert Lee, " On the Ganglia and the other Xervous Structures of the Uterus.") I must acknowledge, for my own part, that I have never been able to discover anything like the above; and the case is the same with 31. Jobert, who does not believe in the growth of the nerves during gestation, since he has been unable to discover any difference between the nerves of the pregnant and those of the unimpregnated uterus. We said, whilst describing the non-gravid uterus, that notwithstanding the researches of 31. Jobert, we retained doubts as to the manner in which the nerves are distributed in the neck. Now the preparations deposited by 31. Boulard in the 31useum of the Faculty, have convinced us, that exceedingly fine filaments are prolonged even to the lowest parts of the os tineas, and, consequently, that no portion of the organ is entirely destitute of them. B. Properties.—In the ordinary non-gravid state, the sensibility of the uterus is so obscure that it may be touched, struck, or cauterized, with bare conscious- ness on the part of the female. During pregnancy, the sensibility is somewhat increased, but it still remains almost a nullity. Though I have heretofore stated, in accordance with other authors, that the sensibility becomes much exalted during gestation, it was, as 31. Jacquernier has pointed out, because I had attri- buted to animal sensibility what was really and exclusively due to the sensibility of the nerves of organic life. The latter, which in fact scarcely exists in the unimpregnated organ, is manifestly present during pregnancy. The body of the uterus appears to be almost insensible. I am aware that most women feel the motions of the child, but are these movements perceived by the walls of the abdomen, or by the uterine parietes? The fact that in women affected with ascites, the active motions are much more obscure than in other females, tempts us to accept the former hypothesis. I have, besides, frequently known women to pass through the whole course of gestation without feeling the motions; for instance, I saw a patient at La Charite, in August, 1839, who, although advanced to seven months, doubted her pregnancy because she had not felt the child stir. I saw her frequently afterward between this time and near the last of October, when her labor occurred, yet, although the child was quite strong and healthy, she had never observed its motions. We have said that the organic sensibility or irritability, which hardly exists in the unimpregnated state, becomes considerably greater during gestation; to it is due the kind of sympathetic relation which is established between the fibres of the neck and those of the body of the uterus, and in consequence of which, any rather active and prolonged excitement of the neck of the organ reacts upon the fibres of the fundus. Even the premature expulsion of the foetus is often a consequence of contrac- tions produced by excitations of the cervix, and it is owing to this cause, accord- ing to Delamotte, that repeated coition has frequently caused abortion, and that females who are used in our amphitheatres for practising «the touch," are so often delivered before term. OF SIMPLE UTERINE PREGNANCY. 119 This irritability of the cervix, and its influence upon the contractility of the body, is in some cases turned to profit in the practice of our art; thus it is well known, that one of the surest and most generally employed methods of inducing premature labor, consists in the introduction and retention of a foreign body in the neck of the womb. The uterus acquires some entirely new properties, independent of the sensi- bility which existed a little before, but became more highly developed during the gestation; I allude to the organic contractility, and the contractility of its tissue. The first is a faculty inherent in the uterine fibres, of contracting upon the body they enclose to effect its expulsion from the cavity; it is a true con- traction, precisely similar to the muscular contraction of the hollow organs (blad- der, rectum, stomach), and is never developed excepting under the influence of a stimulant or irritant of some kind. The second is a property by which the womb, after having been emptied, returns gradually to its former state, and thereby has its cavity nearly obliterated; it is a true elasticity. Its principal function is to cause a great diminution in the calibre of the vessels which ramify in the substance of the uterine walls, and an obliteration of those that have large open mouths on the internal surface of the organ after the separation of the placenta, and which would prove a source of fatal hemorrhage to the mother, if nature had not provided against so terrible an accident by this contractility of the tissue. The exercise of the organic contractility is always accompanied by pain, which is usually very great in the human species, but does not exist at all in wild animals, and is only observed to a very feeble degree in our domesticated ones. As a general rule, the uterine contraction is not painful in the different species of animals, unless an accident or some disease renders a greater energy of action necessary on the part of the organ, and the pains then experienced by the female are altogether similar to those of women. If, therefore, the contraction is only painful accidentally, as it were, in animals, and merely in consequence of a particular morbid condition of the uterine fibre, are we not justified in referring the pain in the human species to the same cause ? Now can this predisposition be the result of the refinements of civilization ? It would of course be impossible to prove this, but there are strong grounds, at least, for believing that such is the fact, when we reflect that our domestic animals, which, like ourselves, have been translated from their primitive normal condition, often suffer much more during parturition than those in a savage state. This organic contractility resides especially in the fibres of the body; its intensity is exceedingly variable in different females, being very strong in some, and scarcely existing in others; but its energy bears no relation to that of the external muscular system, for some strong muscular women have extremely weak contractions during labor, and oftentimes the contrary is observed. The exercise of this function takes place independently of the will, at least, in a great majority of cases, which, indeed, we can readily understand must be the fact, from the origin and nature of the nerves distributed to the body of the uterus, since we have just learned that its fundus receives filaments from the great sympathetic alone. I am well aware the books furnish some cases of women who had the power of suspending the contraction at will, but if the facts 120 GENERATION. have even been well observed, they have failed perhaps to receive the most rational interpretation. In the cases related by Baudelocque and Velpeau, in which the labor ceased when the students were summoned to witness it, and began again when these numerous observers retired, the will had probably less to do than the imagination and modesty, with the alternations of retardation and acceleration; for though the influence of the will may be reasonably doubted, it cannot be denied that moral disturbances appear to affect the contractility of the uterus; thus, a violent emotion has often sufficed to arouse it long before the ordinary term of gestation, and it is not at all uncommon for the contraction to diminish or disappear for several hours, or even days, under the operation of such causes. Dewees knew the pains to be suspended in this manner for two weeks in a woman who was greatly affected by his sudden and unexpected arrival. Betschler cites a case in which the pains were suddenly suspended by a violent tempest, so that the neck, though widely dilated, closed again, nor did the labor recommence until nineteen days had elapsed. Every day, indeed, we witness a suspension of the pains for half an hour, and sometimes even for several hours, upon visiting women whose modesty is shocked by our presence. The exercise of this function is seldom of long duration, lasting for a few seconds only—rarely beyond one or two minutes, and then the organ, which was so strongly contracted and hardened, gradually regains its primitive state, and remains in repose, until, under the influence of the same stimulus, it is again thrown into action. The organic contractility, like all muscular power, is ex- pended by a prolonged exercise, and hence we can understand why the pains so often become at once more slow and feeble, or even cease altogether after a prolonged labor. Lastly, opiates have a marked influence over them; for by employing these preparations, we may suspend the uterine contraction nearly at will, for several hours during labor at term, and indefinitely, in a case of prema- ture delivery or abortion. This contractility may be excited by natural, accidental, or artificial stimuli: thus, all the causes of labor constitute the first; the second are those of abor- tion and premature labor; and the third comprise all irritations whatever of the neck or body of the womb; as electricity, ergot, and, in a word, all the means employed when it is desirable to deplete the organ. On the contrary, it may be weakened by an over-distension of the uterus, by prolonged contractions, or vivid moral impressions. An observation of 31. Brachet's might lead to the supposition that the organic contractility of the uterus would be weakened, or even totally destroyed, by lesions of the spinal marrow. It is, however, proved by numerous cases of para- plegia in females, as well as by experiments on animals, that labor is in no respect impeded by alterations of the cord, and that the want of action of the voluntary muscles is more than compensated for by the paralysis of those of the perineum, the slight resistance of which renders the last stage of the foetal expulsion both more easy and rapid. This result might indeed have been anticipated from the known absence of all nerves of animal life from the body of the uterus. The contractility of the uterus, like that of all the viscera of organic life, is OF SIMPLE UTERINE PREGNANCY. 121 retained for some time after death, and thus serves to explain the occasional ex- pulsion of a foetus several hours subsequent to the decease of the mother, as also the posthumous contraction of the uterus in Caesarean operations performed im- mediately after the mother has expired. The contractility of tissue exists chiefly in the fibres of the body. Dewees supposed it to be seated more especially in the circular ones that constitute the internal plane of the uterine muscular layer, and it is scarcely observable at the inferior parts, and in the neck. It was certainly a wise provision on the part of nature to place it in a region where the habitual attachment of the placenta causes a more considerable development of the vascular apparatus. This holds so true, that it is easy to detect the retracted fundus in the hypogastric region after delivery, as a hard, irregular tumor, whilst to the vaginal touch, the neck appears soft, flexible, and not the least contracted. Therefore, whenever the placenta is inserted on the neck, a hemorrhage is not only to be dreaded during labor, but also at the time of, and for a short period subsequent to, the delivery of the after-birth. In most females, the contractility of tissue accompanies the organic contractility, and these two properties are successively in action at the period of labor, and during the gradual depletion of the uterus. In fact, if after the contraction which has caused the expulsion of a certain part of the body en- closed in the uterine cavity, the walls of this organ did not retract promptly to fill up the void, it would constitute inertia of the womb. The contractility of the tissue, which is a true elasticity, should be carefully distinguished from the organic contractility, with which 31. Jacquemier was disposed to confound it. It has for its object the restoration of the uterus to its primitive size, through a shortening of its fibres and consequent expression of the fluids which had collected in its walls. The operation is a slow and con- tinuous one, and is prolonged throughout the period of the getting up. When it takes place in a regular manner, it is unaccompanied by pain, as we see in the cases of many primiparous women, in whom the retraction is accomplished with- out their being aware of it. The contractility of the tissue is not, however, always equal to this effect, at least during the first days after labor. Its insufficiency may perhaps be due to over-distension, or to a protracted, or too rapid labor, in which case the uterine fibre loses its elastic property, as Leroux expresses it, or else it may be, that the presence of a foreign body, whether solid or fluid, requires the intervention of a more active force. Here, then, the organic contractility is called into exercise, and the retraction of the uterus is effected by a true intermittent and painful contraction. This diminution of the contractility of the tissue is generally, however, of short duration, for after four or six days at the furthest, the organic contractility is no longer required, unless a new clot should happen to form in the uterus. The elasticity of the uterine fibres, assisted by the process of absorption, which goes on unceasingly, and also by the lochial discharge, are thenceforth sufficient to restore the organ to its normal condition. The contractility of the tissue is far from being equally powerful in all women, nor is it always easy to give a good reason for the difference. For example, it is much less active in multiparas than after a first labor, and this explains why 122 GENERATION. after-pains are much more common with the former than in the latter case, for the pains are a consequence of the exercise of the organic contractility, and the uterus returns more slowly to its habitual volume. Great over-distension of the womb, and a too rapid or too prolonged expulsion, also seem to diminish its action. Another circumstance which also destroys, or at least suspends its exercise, is acute or chronic inflammation of the uterus and its annexes. Whilst the in- flammation continues, the contraction of the womb appears to be suspended, and very often the organ begins to diminish in size only when the inflammation is overcome. Finally, even under the most favorable circumstances, the retraction of the womb is far from being uniformly regular, for, after having gradually decreased in size, it may remain stationary for several days, and then begin again its pro- cess of diminution. If it be indisputable that there are circumstances which diminish the elasticity of the uterine fibres, it is also fully proved that we possess certain agents capable of exciting its action. Thus, external or internal irritations acting on the neck and body (such as cold or frictions), and the administration of ergot, often have this happy effect. C. Relations—At term, the uterus is in relation—1. In front, with the vagina, the posterior face of the neck and body of the bladder, and superiorly, with the anterior abdominal wall. This last is not always immediate, for occasionally a portion of the intestinal mass slips between the uterus and the ventral parietes, as occurred in the woman upon whom 3L Dubois practised the Caesarean opera- tion in 1839; and, as the professor has remarked, the operator should be very prudent in making his incisions, from the possibility of encountering this anomaly. 2. Behind, with the rectum, sacro-vertebral angle, and vertebral column below, and with the mesentery and intestinal mass above. 3. On the right, with the corresponding side of the pelvis, the iliac vessels, psoas muscles, ccecum, and right abdominal wall. 4. On the left, with that part of the pelvis, the iliac vessels and aorta, the sigmoid flexure, the psoas muscles, and the whole body of intes- tines which separate it from the abdominal wall. ARTICLE II. CHANGES IN THE NEIGHBORING PARTS. We can readily imagine that the strange modifications just studied do not take place in the uterus without affecting the neighboring parts, and the changes in these will next engage our attention. 1. As the uterus gradually rises in the abdomen, its surrounding peritoneum is carried along with it; the folds, called the broad ligaments, then disappear, and consequently the Fallopian tubes and ovaries are drawn nearer to the body of the uterus, where they lie very nearly in a vertical direction; the fundus be- comes rounded, its angles diminish and finally disappear. The Fallopian tubes, which in the unimpregnated state are inserted at the apex of the angles, and on the same horizontal line with the fundus, are no longer implanted upon the highest part, but correspond to the upper fourth, or even to the middle of the total length OF SIMPLE UTERINE PREGNANCY. 123 of the organ. The round ligaments are then composed of short linear fibres, among which a great number of muscular ones, prolongations of those of the uterus, may be distinguished. 31. Velpeau asserts that he discovered and watched their contraction in three different females, during the efforts of the uterus to expel the after-birth. The greater development of the anterior than of the posterior wall of the uterus, removes the insertion of the round ligaments from the lateral position which they occupy in the unimpregnated organ, to a point so much farther in front, that they are implanted at about the union of the anterior fifth with the posterior four-fifths of the antero-posterior diameter. 2. As the womb and upper part of the vagina are intimately associated, the latter is necessarily shortened as the former enlarges in the early periods of preg- nancy, whilst the vagina becomes longer when the womb rises above the superior strait. The venous system in the vaginal walls is considerably developed, owing to the greater activity of their circulation. This dilatation of the veins is, doubt- less, the consequence of a greater vitality in the genital organs, but it is also due in part to the stasis of the blood, which is impeded in its course by the uterine development. The varicose state, and the nodosities frequently encountered by the finger on the vulva and vagina towards the end of pregnancy (described by 31. Deneux under the name of thrombus), which certainly predispose females to hemorrhagic accidents, may probably be attributed to the same cause; and this -congestion even affects the capillaries; for otherwise it would be difficult for me to explain the livid spots or discolorations, resembling wine-lees, presented by the vaginal mucous membrane, and to which attention has again been recently called as affording a sign of pregnancy.1 But unfortunately this sign can only be ser- viceable in a medico-legal case, because in private practice very few females would permit such explorations. In practising the " touch," the finger frequently detects some arterial pulsa- tions at the upper part of the vagina, though they are more frequently found on some point of the supra-vaginal portion of the uterus, and are evidently due to the great hypertrophy of the vaginal and uterine arteries. Doctor Osiander, of Gottingen, attaches great importance to this as a diagnostic sign, and has called it the vaginal pulse.2 It is not uncommon to find the mucous membrane of the vagina covered, about the seventh or eighth month, throughout its whole extent, with myriads of little pimples as large as a pin's head. These small granulations, which I have fre- quently met with, not only line the vagina, but also cover the neck on its exte- rior, and even on its interior surface. Now is this to be attributed to an abnor- mal development of the mucous follicles ? I am the more disposed to consider it 1 This discoloration is evidently owing to the greater activity of the circulation in the genital organs, and consequently it ought to be met with in all cases predisposing to a vascular congestion of the genito-urinary apparatus. Mr. Montgomery has detected it in a female at the menstrual period, and it is a well-known fact, that cattle-breeders ascer- tain whether an animal is in heat or not, by examining the orifice and internal surface of the vagina, which is almost as black as ink under such circumstances. a The hypertrophy of the vessels of the vagina and of the vulva sometimes renders wounds of these parts very dangerous. Profuse hemorrhage has been known to occur in consequence of it. 124 GENERATION. in this light, because their presence always coincides with a marked increase of the vaginal secretion. The vaginal mucosities are always secreted abundantly during pregnancy, but the time of their appearance is very uncertain. Usually, however, they are more copious in the advanced stages, and the women then say, " they are losing the milk;" an opinion unworthy of refutation. In some, this flow appears in the early months, then ceases, and again reappears several times; though perhaps not at all, or else only at a very late period. 3. The bladder is gradually pushed above the superior strait, the meatus urinarius is drawn out and elongated, and its orifice, from being so high up, is concealed behind the border of the symphysis pubis, thereby rendering the in- troduction of an instrument very difficult. The urethral canal is more curved than usual, and the curvature is sometimes so great that the male catheter can more readily be used; because the bladder being strongly.pushed forwards, and above the pubis, by the developed uterus, draws this canal upwards, and causes it to be applied against the posterior face of the pubic symphysis, thus producing a curvature of the urethra having its concavity in front. Lastly, as the upper part of this canal is compressed by the enlarged womb, the circulation in its inferior parts is impeded, and the whole tube becomes greatly tumefied. It is placed behind the osseous projection produced by the posterior part of the arti- cular surfaces of the pubis, and these two superposed eminences form a consi- derable tumor in the interior of the pelvis; I have frequently known students who were practising the touch, to be unable to explain the remarkable tumefac- tion encountered by the finger behind the symphysis. An annoying vesical tenesmus is often produced by the pressure exercised on the body and neck of the bladder, tormenting the female with frequent ineffec- tual desires to urinate; these demands are always very urgent, and are satisfied by the discharge of a few drops of urine, but are again reproduced with equal intensity some minutes after. Some persons, judging from this frequent mictu- rition, have thought the urinary secretion was augmented. In certain cases, the swelling of the urethral walls, and possibly also the com- pression they sustain, produces its complete obliteration and renders catheterism necessary. M. Velpeau avers, that he has frequently known the bladder, from the fact of its being more compressed above the fundus than below it during the last fort- night of pregnancy, to project into the upper part of the vagina so as to form a true vaginal cystocele. I think, however, that it is of rare occurrence during pregnancy, since I have met with but two instances of it. 4. The pressure of the uterus upon the vascular trunks, which go to or return from the inferior extremities, genital organs, and lower part of the rectum, inter- rupts the venous and lymphatic circulation in those parts; whence it frequently happens that a considerable oedema of the limbs and sexual organs is produced, as well as the development of some hemorrhoidal tumors. 5. Pregnant women are habitually costive; hence a voluminous tumor is formed at the lateral posterior part of the excavation by the rectum distended with fecal matters. The pressure of the uterus upon the entire mass of the in- testines, frequently gives rise to colic and disorders of digestion. OF SIMPLE UTERINE PREGNANCY. 125 6. The base of the thorax is enlarged and projects in front; the diaphragm is pressed upward by the uterus and intestinal mass, having its concavity increased in consequence; so much so, indeed, as to obstruct respiration, and the circula- tion in the heart and great vessels. 7. The skin of the abdomen is very much distended, and is marked, especially towards its inferior part, by some streaks of a brown or bluish color, which form parallel curved lines with the convexity towards the pubis and groins. These are very numerous in some women, but. in others they scarcely exist; they be- come paler, but do not disappear altogether after the delivery; sometimes they are continued even to the upper and internal part of the thighs. Besides these marks, a brownish line is observed upon the skin, extending from the pubis to the umbilicus, where it mostly stops, though it sometimes ex- tends beyond it in dark brunettes. This line may generally be regarded, espe- cially in a primiparous female, as a certain sign of pregnancy; it may, however, in some exceptional cases, exist in non-pregnant females or even in males. (Jose Cormack, Gaz. Med., 31arch, 1845.) The muscles and aponeuroses of the abdominal walls become thinner, the recti muscles are removed from each other, and the aponeurotic space which separates them, instead of being a narrow band, as usual, is at least four and a quarter inches wide, on a level with the navel. The umbilical depression, which in the two first months seems deeper, disappears gradually as gestation progresses; the ring becomes distended, and most generally the skin exhibits a protuberance in- stead of a pit in its place. The eminence is particularly well marked when the female exerts herself, owing to the engagement of a small piece of epiploon in it, constituting a temporary hernia. Not unfrequently an oblong tumor appears on the median line after delivery, produced by a projection of the bowels in consequence of the great separation of the aponeurotic fibres. The tumor is especially evident during any exertion; and increases in size with each succeeding pregnancy, until it finally becomes an infirmity, which obliges the woman to have recourse to a bandage. 8. The relaxation of the pelvic symphyses is a frequent occurrence; when existing to a great extent, it constitutes a disease that will be more fully detailed in the pathological history of pregnancy. 9. The mammoz, which must also be considered as an appendage to the genital organs, undergo, during gestation, some modifications preparatory to the accom- plishment of the great function to which they are destined after the accouche- ment; thus, in the very commencement, most women find their breasts to become tender and larger, and with some, this is so constant a sign that they do not hesi- tate to consider themselves enceinte as soon as it is perceptible. The enlarge- ment is frequently attended by certain pricking sensations or positive pains, sometimes even by engorgements of the axillary ganglia. It is by no means uncommon for the swelling to diminish towards the fourth or fifth month, but it reappears again near the end of pregnancy, and is then considerably larger than before. In some women it is accompanied by fever, analogous to the milk fever, and this may even be carried to the extent of producing an inflammatory en- gorgement of its substance, followed by an abscess. 31ore rarely, the breast, which was at first slightly enlarged, subsides, and remains flaccid and soft until 126 GENERATION. after delivery. In general, this is an unfortunate circumstance, because, from the observations of my friend, Dr.Donne, such women prove very poor nurses on account both of the bad quality and the small quantity of their milk. About the end of the second month, according to 3Ir. 3Iontgoniery, but in ^ny own opinion a little later, the nipple swells, and becomes more erectile, sensi- tive, and projecting; its color also is deeper. The surrounding skin becomes the seat of a larger afflux of liquid, and assumes an almost emphysematous ap- pearance. This skin is also discolored, exhibiting at first a light yellowish tint, but in the course of the two succeeding months the areola is completed, and the skin of the uiainma then presents the following characters: A circle around the nipple, the color of which varies in depth of shade according to the individual, being generally darker in persons who have black hair and eyes, and in brunettes, than in blondes, or iu feeble and delicate women. The circle is from three-quarters of an inch to one inch and a quarter in extent, but, like the intensity of the discoloration, it in- creases with the advancement of gestation. In the negress, the areola likewise becomes darker. At the centre of the areola, but more especially at that portion of it which surrounds the base of the nipple, a number of small glandules, varying from twelve to twenty, soon appear, and attain an elevation of one to two lines above the cutaneous surface. These little glands apparently have an excretory duct, because, by pressing upon them, a serous, or sero-lactescent liquid may be made to ooze out. Some small irregularly circular spots begin to show themselves about the fifth month, situated immediately around the areola just described, and resembling the stains created by the aspersion of a colored liquid, thus constituting another spotted and stained areola. This latter is much more limited in extent than the first, though not unfrequently it invades a great part of the skin covering the breast. About the same period a number of large venous trunks are seen distributed over the surface of the bosom, and sending numerous ramifications towards the areola, some of which, indeed, traverse it. Along the course of these vessels we may occasionally observe some shining silvery lines, closely resembling those found on the skin of the abdomen, though they are more marked in those females whose mammae were but slightly developed prior to conception, and had expe- rienced a sudden increase in size after it. than in others. These silvery streaks remain for a longer or shorter period after the accouchement. They are further serviceable in proving that the female has had a child, but they cease to be of any value as a diagnostic sign of her subsequent pregnancies. These modifications usually persist during lactation, though where the woman OF SIMPLE UTERINE PREGNANCY. 127 does not suckle her infant they diminish after the delivery, but do not wholly disappear. Consequently, they are more conclusive in primiparae than in others; and although we must not always anticipate their existence in pregnancy, yet, whenever they are found, they constitute an almost certain sign of that condition. ARTICLE III. DIAGNOSIS OF PREGNANCY. The signs of pregnancy are divided into the rational and the sensible. The first comprise all those characters pointed out by authors as existing in the earliest periods, by which they assert a conception may be justly suspected; then in the subsequent stages,—the suppression of the menses, the enlargement of the abdomen, the pouting of the navel, the phenomena just studied in the breasts, the symptoms, or rather the functional disturbances in the digestive organs, the condition of the pulse, the modifications in the urine, and lastly, certain changes that occur in the woman's habits, as well as in her moral and intellectual faculties. § 1. Rational Signs. According to Aristotle, there is some ground for believing the woman has con- ceived, if no fluid oozes out from the vagina after coition, and if the penis is unusually dry when withdrawn; and the opinion seems to be universally received by shepherds, that the retention of the semen is an evidence of impregnation. Agreeably to Hippocrates, the eyes become more sunken, more languishing, and are surrounded by a blueish circle, and spots of different sizes appear on the face. Again, since the days of Democritus, a swelling of the neck is also enumerated as a sign of conception. However, all these symptoms have but little, if any value, and I accord far greater importance to the more voluptuous sensation, the more general erethism experienced by some females during a prolific coition, by which a few of them can recognize with a degree of certainty that they have become pregnant. 1. Suppression of the Menses.—Females cease to be regular during pregnancy; and this is a law.of such general truth, that whenever it occurs in a healthy woman, without a known cause, and not attended with, or followed by any mor- bid symptom, it is justly regarded as a probable sign of gestation; but as this suppression might be produced by a number of other causes, whenever a physi- cian is consulted about it, he ought carefully to inquire into all the circumstances, past or present, which may have produced such an effect. It would be out of place now to enter into this diagnosis, but we may reiterate an observation, already made by several authors, and which our experience has frequently veri- fied, namely, that in some young married women, who had hitherto been quite regular, the menses become at once suppressed, and continue so for several months, without any known cause; and this suppression, resulting probably from the irritation or derangement produced in the genital organs by the first conjugal approaches, is frequently accompanied by an augmental volume of the abdomen, and a more exalted sensibility of the mammary glands; and, as the mind so 128 GENERATION. readily believes what it most ardently desires, nothing more than this is wanted to found a hope of a commencing pregnancy. Hence the physician must exer- cise great discretion in his diagnosis, when consulted on so delicate a subject. The menses may continue during pregnancy; thus they frequently appear in the earlier months, more rarely during the first five or six months, and what is still more unusual by far, they may exist during the whole period of gestation. Xumberless observations of this kind, recorded by authors, prove the truth of these assertions, and we also can bear testimony to the same point; thus, we saw some females in 1837-38, who were evidently pregnant, and in whom the menses flowed at the usual periods, and lasted for the same number of days; one of them assured us that she menstruated during the first five months, and that her courses appeared on the second of each month, and lasted for two days, just as she had them previously. Again, two females came under my observation at the Hotel Dieu, whose cases have already been published in my thesis, who were regular throughout the whole term of pregnancy. Haller and 31auriceau likewise cite similar cases; but notwithstanding all this, some accoucheurs still deny that women can be regular whilst pregnant. 31. 3Ioreau, who professes this belief, has, however, often known females to have sanguineous discharges at variable periods during gestation, but the irregu- larity of their appearance, the qualities of the blood itself, and the greatness or smallness of its amount, serve to distinguish these, in his estimation, from a true menstrual discharge. The remark of 31. 31oreau is certainly applicable to many cases, but the instances above cited, and numbers of others that might be quoted from various writers, do not permit me to entertain a doubt that a woman may menstruate during pregnancy. On the other hand, females may become pregnant without ever having had their menses ;* and the same is true of some others in whom they are suppressed either by accident, from the progress of age, or in consequence of nursing.2 1 A young woman presented all the signs of pregnancy, and although she had never menstruated previous to that period, her courses then appeared and continued during the whole of gestation. (Perfect, Cases of Midwifery, vol. ii, p. VI.) A lady, aged twenty-four years, during eight of which she had been married, was never regular except during pregnancy, and each appearance of her menses proved to be a cer- tain sign that she was enceinte. A woman, who married at twenty-one, had never been regular; two years afterwards she experienced some gastric distress, and the flow appeared. Nine months subsequently, she was delivered of a healthy child, notwithstanding the menses did not fail to appear every month. (Churchill, Observ. on the Diseases of Pregnancy, p. 36 ) 2 Dr. Flechner, of Vienna, relates that a young woman of twenty-two, had always been regular, but the menses never reappeared after the first accouchement, being replaced each month by an intense headache, accompanied with a feeling of oppression and heat in the forehead and parietal regions. During the succeeding thirteen years, she gave birth to six healthy children. (Gaz. Med., p. 91, 1841.) Dewees states, that a woman who had been married for several months, suffered some gastric distress. She had never been regular but three times, and for a number of years there was a complete suppression. He directed rhubarb pills, which purged her slightly, but did not relieve her; six months afterwards, the abdomen being somewhat enlarged, he was enabled to ascertain that she was six months advanced in pregnancy; and soon after the menses returned, and continued regularly until term. During lactation, which lasted a year, the courses did not appear ; she then weaned the child, and in a short period an-ain became regular, and this, like the former, was the announcement of a new pregnancy. OF SIMPLE UTERINE PREGNANCY. 129 All those anomalies will be understood without difficulty, if we do but recollect that, although the appearance of the menses is always connected with the ovarian evolution, the latter may take place without being accompanied by the menstrual flow. (See Menstruation.) Deventer, Baudelocque, and Chambon furnish accounts of women who were regular only during gestation; the case cited by Deventer is particularly curious, from the opportunity he had of observing this fact in four successive pregnancies of the same woman. Finally, Desormeaux believes from his observations, that in certain years, and often without any apparent cause, a greater number of women have their menses during gestation, even where they were completely sup- pressed during former pregnancies. Does this result, as he appears to think, from atmospheric influence, or is it pure chance ? For my part, I am unable to decide the question. Though it is important to be aware of these exceptional cases, it is equally necessary to guard against the general tendency to a belief of the marvellous. It should not be forgotten, that the continuance of the menses during pregnancy is of rare occurrence, and that although their suppression is of great value as a point of diagnosis, it may nevertheless be the result of a variety of causes. 2. Enlargement of the Abdomen.—An increase in the size of the abdomen may be produced by so many different causes that its slight value as a sign will be readily foreseen. There is, however, something peculiar in its shape and mode of development in gestation. Thus the abdomen swells somewhat in the first month, but this is owing to a collection of gas in the intestinal cavity, which, after remaining a few weeks, diminishes and disappears, whence the woman often seems smaller at the end of the second month than during the first; but when- ever this slight tympanitis is not manifested, the abdomen is flatter the first month than before, probably because the uterus settles down in the excavation. At the beginning of the third month, or at three months and a half, the hypo- gastric region evidently becomes more salient, and the enlargement is thenceforth regular and always increasing until term. Consequently, the tumefaction begins to show itself just above the symphysis pubis, being more considerable at first on the median line than elsewhere, while the sides appear flattened ; after the fourth month, the upper extremity of the uterine tumor may be clearly perceived through the abdominal wall, especially in thin subjects, by placing the woman on her back and the abdominal muscles in a state of relaxation; but if the parietes be thick and tense, palpation, practised in the manner hereafter described, will become necessary to ascertain this point. The modifications in the size of the abdomen, at different periods of gestation, have already been described; but its development is not always regular, being, for instance, much more rapid in twin pregnancies, and in dropsies of the amnios than in other cases. Besides, the relation between the volume of the abdomen and the stage of pregnancy, is not always maintained; thus, some women are no larger at seven or eight months than others are at five, owing either to their high stature, their breadth of pelvis, or the small degree of projection in the ver- tebral column and upper part of the sacrum. On the contrary, in small women, more especially in those having a contracted pelvis, and in whom the womb is therefore necessarily raised, during the early months, above the superior strait, 9 130 GENERATION. the abdominal protuberance is premature, if I may so express it, and is much better marked at quite an early period than ordinary. The umbilical depression at first appears deeper, its bottom seeming to be drawn downward and backward in consequence of a tension of the urachus, occa- sioned by the fundus of the bladder following the descent of the uterus in the excavation. The circumference of the ring becomes at the same time the seat of a distressing dragging sensation, and is more sensitive to pressure; and this sensibility is sometimes extended over a considerable portion of the abdominal wall. But about the end of the third month, that is, as soon as the uterus gets above the superior strait, the umbilicus resumes its nornial condition; at the fourth month, it is less hollow than before conception—then its bottom becomes more and more superficial during the fifth and the sixth, and the whole depres- sion is effaced, and is found on the same level as the skin by the seventh month, and in some cases, the umbilical ring is sufficiently dilated to receive the end of a finger; finally, in the last two months, the navel forms a protuberance. Not unfrequently, small portions of the epiploon become engaged in the ring during the exertions of the female and project externally. These changes in the umbilicus afford a rational sign of great value, because they are almost constant. I say almost, for in a case observed by M- Blot, there existed a depression three-eighths of an inch in depth, the woman being at term and of ordinary embonpoint. Though these alterations of the umbilical depres- sion may be produced by a pathological tumor of considerable size, or by an accumulation of fluid in the peritoneum, it is equally true, that they almost always exist in advanced pregnancy, and that their absence is, in a majority of cases, conclusive against the existence of a foetus of seven or eight months. 3. The presence of the streaks, and especially of the brown line, which ex- tends, as we have stated, between the pubis and umbilicus, are very important to the diagnosis, especially in a primiparous female. 4. The phenomena presented by the mammae afford, in the opinion of Mr. Montgomery, a certain sign of pregnancy. Smellie and Hunter also considered the changes in the areola as a positive evidence of this condition. The latter surgeon, indeed, did not hesitate on one occasion, when examining a dead body, to declare from this sole indication, the uterus to be enlarged by the product of conception ; as the examination proceeded the hymen was found intact, but even this did not change his opinion, and when the womb was opened its correctness was fully confirmed. This fact, with many others which might be cited, prove the value of these signs when they exist, which unfortunately is not always the case; any one of them, indeed, may be wanting, and sometimes they are totally absent. Thus, in 1837,1 saw a strong and vigorous young brunette at La Clinique, who had advanced to the end of gestation, without any of the indicated marks appearing around the nipple; and I have since made the same observation on several different occasions. Their absence is not therefore an absolute proof of the non-existence of pregnancy, so that their importance in this respect has been exaggerated by some English surgeons. These cases, however, are rare, and I should diagnosticate as almost certain the existence of pregnancy in a young woman who had never borne children, and whose breasts presented both a brownish-colored areola, the tubercles, and the freckled characters before de- OF SIMPLE UTERINE PREGNANCY. 131 scribed. But in those who have had children, it is very difficult to determine whether these signs result from the modifications of the breast in former preg- nancies, or from a new conception. In such cases we have only the testimony of the women themselves to rely on, and this more especially, if but a short time has elapsed between the last and the present gestation. 4. I have never been able to appreciate the reputed value of the signs founded on the state of the pulse of pregnant women, for although it has always seemed more developed, fuller, and harder, I could discover nothing further concerning it. The disorders of digestion, as well as of the moral and intellectual faculties, are of but secondary diagnostic importance; they can do little more than direct the attention to the possibility of a doubtful pregnancy, but as they belong more properly to the pathology of gestation, they will be studied hereafter. 6. Alterations of the Urine.—For several years past, the attention of a number of physicians has been directed to the peculiar phenomena exhibited by the urine of pregnant woman. Thus, 31. Nauche, and after him, 31essrs. Eguisier and Tanchou, in France, Dr. Letheby (London Med. Gazette, December, 1841), and 3Ir. Stark (The Edinburgh Med. and Surg. Journal, January, 1842), in Great Britain, and Dr. Elisha Kane, in America (Am. Journal of the Medical Sciences, July, 1842), have submitted the result of their observations to the public, after arriving at the conclusion that pregnancy may be detected by the inspection of the urine alone. This question, however, is not of such recent origin as many seem to believe, for several of the ancient authors, Avicenna in particular, had previously described the characteristics of this fluid in gestation, and their writings frequently exhibit a special attention to the subject. But we may add, that their observations were far less precise, and, in fact, had become altogether forgotten, when M. Nauche undertook his researches. We shall now present the principal results which have been recently obtained. If the urine of a pregnant woman be received in a wineglass, and then be per- mitted to settle in a light, airy place, the following peculiarities will be observed: When first excreted, the urine is acid, whitish, somewhat clouded, and of a nauseous odor; frequently little white corpuscles, readily distinguishable by a glass, are held in suspension, but, in a few moments, these subside in the form of cloudy flakes, either on the bottom or sides of the glass, the urine meanwhile becoming more limpid and transparent. Agreeably to the observations of Dr. Kane, this primary deposit does not always occur, nor is it peculiar to the preg- nant state, for it cannot be distinguished from the mucous deposits so often seen in the ordinary urine. No change is visible on the surface during this period, but, in the course of eighteen or twenty-four hours, a number of small, brilliant, crystalline granules, irregularly isolated, appear there, in numerous cases; and in some instances, these granulations unite so as to constitute a thin, transparent, and iridescent layer, which is only visible in certain positions. The urine remains in that state for several days, though it soon begins to ma- nifest the peculiar signs of gestation; thus, upon the second day, or during the course of the third, according to M. Eguisier, sometimes sooner, but rarely later, its transparency diminishes, the original clouded appearance returns with in- creased intensity, the odor becomes stronger, and a pellicle may be discerned forming, at first like a nebulous streak, but soon acquiring larger dimensions. 132 GENERATION. All of these characters are more evident on the third and fourth days, and some small debris fall from the pellicle to the bottom of the glass. By the fifth or sixth day the pellicle is almost entirely destroyed; its debris precipitate and form a white crust .upon the sediment. It is, however, replaced successively by new pellicles less white than the former, and studded with minute brilliant points having a crystalline lustre; a greenish tint also supplants the milky appearance. In the succeeding days, as the evaporation of the urine progresses, its turbidity and green color increase; putrefaction commences, and the second pellicle is destroyed to give way in its turn to a third, which resembles more or less that which putrefaction engenders upon ordinary urine. Dr. Kane, who has observed these changes almost hourly, furnishes the fol- lowing account of their progress :—The pellicle appears at a variable period; I have seen it sometimes at the end of thirty-six hours—at others, as late as the eighth day; it is scarcely perceptible at first, but soon a light cloud of a milky or bluish-white appearance is seen at the centre or sides of the glass; at the be- ginning, in some cases, it is uniformly deposited on the surface, constituting there a transparent layer, which becomes more and more distinct; at other times, it is not so well characterized in the early stages, presenting only a few striated, irre- gular circular lines, resembling a web, but these striae become condensed, and about the fifth day are resolved into a true pellicle. It now presents a creamy, opaline layer, of a light yellow color, which grows thicker and thicker; its exter- nal surface is rendered unequal and ragged by the presence of small granulations, which are whiter in color and crystalline. The pellicle then resembles the layer of fat that floats on the surface of cold broth, and it retains these characters for a long time. On the subsequent days, the sides of the glass are covered with small whitish streaks, varying from a line to a fourth of an inch in extent, which attest the descent of the pellicle during the evaporation. The pellicle, especially when thick, gives off a strong cheesy odor, according to Dr. Bird, and thus faci- litates the diagnosis; but Dr. Kane has verified this observation in only seven cases out of twenty-five, and he has not remarked that any relation exists between the thickness of the pellicle and the intensity of the odor. After standing for several days, the pellicle seems first to give way at the centre, and fissures extend, somewhat later, from this point toward the circum- ference. Gradually, small particles separate from the debris and fall to the bot- tom of the glass; the pellicle thus diminishes in thickness, but it seldom disap- pears altogether before the putrefaction of the liquid takes place; and the primary deposit at the bottom is thus increased by all the detached portions of pellicle, which gradually settle down. The substance forming the pellicle has been denominated kyesteine (from xwjois, sco?, gestation), by M. Nauche. The globules, held in suspension when the urine is excreted, gradually aggregate, mount to the surface, and constitute the pellicle above described. This pellicle rarely fails to develope itself in the urine of pregnant women; thus, for instance, in eighty-five cases examined by Dr. Kane, it appeared in sixty-eight with all its characteristics, in eleven it was not well-marked, and in six only it failed to appear. One of the last six had a mammary abscess, and was convalescent from typhoid fever • another was very much enfeebled by previous hemorrhages, and only four could be regarded as true exceptions to the rule. OF SIMPLE UTERINE PREGNANCY. 133 Without denying the existence of the modification which we are studying, I cannot accept the opinion of the American accoucheur in regard to the fre- quency of its occurrence. With the view of determining this point, I have examined the urine of a great number of pregnant females, and I can certify, that although it did present the characters indicated in a certain number of cases, yet very frequently, and especially in the later months, nothing of the kind was discoverable. I confess, also, that were I to depend upon the result of my latest investiga- tions, I should be inclined to regard the existence of this pellicle as altogether exceptional in the last six weeks of gestation; for I have examined (September and October, 1849) the urine of fifteen women without observing it. I do not, however, forget that I have, in former years, proved the correctness of the ob- servations of my predecessors, and I am unable to explain this difference in the result of experiments performed in absolutely the same manner. Can it be due, as 31. Regnauld supposes, to the preservation of its acidity much longer than usual, instead of becoming alkaline within two, three, or four days, as is cus- tomary ? I acknowledge that my attention was not directed to this point. The urine of healthy women who are not pregnant, exhibits nothing similar to this, and if at any time it furnishes a pellicle, it has not the distinctive charac- ters of kyesteine. Some years ago, it was my custom to examine comparatively the urine of non-pregnant females, which I placed in the same kind of vessels, and under the same conditions of temperature and atmospheric exposure; and every time that I met with kyesteine in the urine of pregnancy, that of the other woman presented nothing similar. In certain pathological conditions, the urine is sometimes covered with a pel- licle which might prove a source of error, though some authors have pretended to be able to distinguish it from that which is due to pregnancy. For instance, the pellicle which occasionally forms on the urine of persons laboring under phthisis, articular diseases, vesical catarrh, or a metastatic abscess, does not ap- pear before the fifth or sixth day, that is, at about the period when putrefaction begins, and having once commenced, its development is completed in the course of a few hours; whereas, the true kyesteine appears on the second day, is then developed but very slowly, and apparently quite independent of putrefaction. Again, this latter has a greater specific gravity than that produced by any patho- logical state whatever. According to the views of 31. Regnauld, which we shall give shortly, it will be seen, that inasmuch as it is due to the same cause, the pathological pellicle ought to present the same characters, and that writers have been deceived as to the value of the differential signs just mentioned. The chemical characters of kyesteine will serve to distinguish it from all the mucous or albuminous matters found in the urine. These properties, agreeably to 31. Eguisier, are nearly all negative; thus, it is neutral, insoluble in alcohol, ether, water, and ammonia, and, unlike albumen, it is not soluble in alkaline fluids, nor, like mucus, in a mixture of soap and ammonia, neither in boiling alcohol and ether like fat. Further, the urine containing it will not coagulate by boiling, as albuminous urine does, but deposits a copious white powder on cooling; nor will it coagulate by the addition of nitric acid. 134 GENERATION. Kyesteine has, however, many of the properties of these substances; for, being evidently of an organic nature, it is precipitated by the deuto-chloride of mer- cury, by most strong acids, and the astringent solutions. Finally, in the present state of our knowledge, it must be regarded as a new substance, which is con- sidered by 3131. Bonastre and Nauche as gelatino-albuminous. (Eguisier.) We shall find further on, that the researches of 31. Regnauld tend to establish the contrary. Although writers on the subject agree very nearly as to the physical and chemical properties of kyesteine, they differ widely in regard to its microscopical characters. Thus, 3131. Eguisier, Golding Bird, Kane, and Donne disagree as to the size, form, and number of the globules 31. Simon, who has very fre- quently subjected the pellicle to microscopic examination, gives the following as the result of his researches. It is found to contain the following elements: 1, an amorphous matter, formed of small opaque points; 2, numerous vibriones in active motion; 3, crystals of ammoniaco-magnesian phosphate; 4, if the exa- mination be made at a still later period, it will contain an abundance of monads. The most difficult point of the subject to determine is the following: To what is the presence of kyesteine in the urine of pregnant females to be attributed ? After having endeavored to prove that it could not result from a particular action in the kidney, from the functional derangement of the respiratory appa- ratus, from any modification whatever in the digestive action, or from the new functions of the mammary glands, M. Eguisier concluded that it must be owing to the passage of the amniotic liquor, or a part of its elements, into the urine, and he thought that the two following propositions (which are more fully detailed in his memoir) proved the correctness of his conclusions in a satisfactory man- ner, namely: A. There is a continual exhalation and absorption going on upon the external face of the amnios, the products of which are removed from the organism through the urinary passages. B. The admixture of a certain quantity of the liquor amnii with the urine of a healthy person, not pregnant, confers upon it many of the properties of kyes- teinic urine. The truth of this proposition being admitted, it readily explains, he says, 1, why the urine only begins to be charged with it at a period when the amniotic liquor is abundant enough for us to suppose that its passage into the urine would be appreciable; 2, why the kyesteinic characters are not so evident at the end of gestation, a period when the liquor amnii is less abundant, or less charged with animal matters; and* 3, why they suddenly disappear after the evacuation of the waters. But Dr. Kane does not admit this explanation, plausible as it seems; for he believes that the kyesteine is intimately associated with the lacteal secretion, and appears to attribute it to an admixture of milk with the urine. "In fact," he continues, " I have frequently proved the presence of kyesteine in the urine, at different periods of lactation, notwithstanding the formal proposition of M. Egui- sier; for in forty-four suckling women, out of ninety-four, the perfect kyesteinic pellicle was developed, with all the characters it exhibits during gestation; and it was nearly always in those cases where the flow of milk is limited, or rendered OF SIMPLE UTERINE PREGNANCY. 135 difficult by some particular circumstance, and in which the breasts were conse- quently more or less engorged, that kyesteine appeared in the urine, but it was found much more rarely whenever the mother nursed her infant, and her breasts were properly drawn. In a word," says Dr. Kane, "the existence of kyesteine during pregnancy, and even after the accouchement, up to the establishment of the mammary secretion; its rare existence during lactation, and its reappear- ance, when the latter is suspended or impeded, at the time of weaning, for in- stance, establish an intimate relation between the functions of the mammae and the kyesteinic urine." Golding Bird, Simon, and Lehmann entertain nearly similar views. An attentive study of the facts pertaining to this subject has led my colleague and friend, 31. Regnauld, to the following opinion : Normal urine holds in solution a certain amount of azotized matter, originating, probably, in an incomplete combustion of albuminous substances, which in the blood are transformed into uric acid, or, by a higher degree of oxygenation, into urea. Now we may readily assure ourselves, that during pregnancy there is a hyper- secretion by the kidney of an analogous, if not of an identical matter; and it is to the action of the air upon this azotized matter in its abnormal proportions, that the several phenomena before described appear to be due. The first cloudiness of the fluid is due to the separation of carbonate of lime, formed by the reciprocal reaction of the carbonate of ammonia, resulting from the decomposition of the urea, and of the phosphate of lime, which already existed in the urine. In proportion as the decomposition giving rise to ammonia progresses, the fluid loses its acidity, until the brilliant crystals of ammoniaco- magnesian phosphate, which are so readily recognized by microscopic examina- tion, begin to appear upon its surface. It is singular, that whilst these reactions are going on, such a multitude of microscopic animalcules (vibriones) should be developed in the urine as to cause the whitish layer, when examined with a proper magnifying power, to seem composed entirely of them, in connection with crystals of ammoniaco-magnesian phosphate. In order to prove that the formation of the pellicle of which we are speaking is really due to the action of the oxygen of the air upon one of the elements of the urine, it will only be necessary to observe what takes place in two equal quantities of the same urine, one of which is exposed to the air, whilst the other is removed from its influence by being placed in an atmosphere of hydrogen, of carbonic oxide, &c. The first will present the characters described, whilst the other will exhibit no such phenomena. M. Regnauld does not regard these properties of the urine as due to a special matter contained in it, but as a consequence of the presence of an over-proportion of an element which is common to all urine; whence it seems reasonable to sup- pose, that this excess of azotized matter might exist under other circumstances, and then give rise to the same phenomena. The period at which the kyesteine appears in the urine of pregnant women, is stated by writers to be exceedingly variable. M. Eguisier says that the charac- ters which we have described usually begin to show themselves in the course of 136 GENERATION. the second month, and acquire their greatest development from the third to the sixth month; after the seventh, they generally decline until the end of gestation, so that in the course of the ninth, and sometimes even of the eighth month, they are hardly more marked than in the second. 31. Tanchou has observed them iu women who had missed their courses but once. Dr. Kane saw them on one occasion before the fourth week, once before the fifth week, and often before the end of the third month. (Dr. Elisha Kane, American Journal of the Med. Sciences, July, 1842.) I think that the facts which I have observed, and the details which I have given, justify the following conclusions : 1. That the pellicle described by Nauche is not composed of a matter of new formation. 2. That it is due to an oversecretion of azotized matter which exists in small quantity in normal urine, and to the action of the atmospheric oxygen upon it. 3. That it is far from being always present at any period of the pregnancy, and that it is very rare in the latter months. 4. That it may appear in certain pathological conditions, and then differs iu no respect from that which is observed during pregnancy. 5. That although the views of certain authors who regard it as a certain diag- nostic sign cannot be sustained, its presence in the urine of an otherwise healthy woman is nevertheless an important rational sign. Finally, it will be perceived that no one of the rational signs whose diagnostic value has just been discussed is conclusive, when taken singly; excepting, how- ever, the changes undergone by the breasts, which, if well marked in a prinii- parous female, may of themselves remove all doubts as to pregnancy. But although, singly, these various signs may only give rise to doubts, their union furnishes a sum of probabilities nearly equivalent to certainty, a certainty which, however, could never be complete until after a determination of the sen- sible signs, which we shall next proceed to examine. § 2. Sensible Signs. All the sensible signs of pregnancy are derived either from auscultation or the touch. Hence, we must carefully study these two means of exploration, as well as the results which they furnish. A. Of the Touch.—The touch, considered in an obstetrical sense, is the art of ascertaining the condition of the various hard and soft parts in the female, which contribute to the great act of reproduction; and it consists in the exploration of those parts by aid of the finger and hand applied to the vulva, vagina, and rec- tum, or upon the abdomen. The touch is practised under various circumstances, for the purpose of ascer- taining the existence and stage of the gestation; the imminence of an approach- ing accouchement; the progress of the travail; the presentation and position of the foetus; the nature and energy, or the feebleness of the contractions ; and the character, volume, and situation of obstacles presented by the hard or soft parts, which might prevent the spontaneous termination of labor, and demand the re- sources of art. The fact that any moment in the life of the accoucheur may call for its exercise, is of itself an evidence of its great importance, and of the neces- OF SIMPLE UTERINE PREGNANCY. 137 sity for practising it. With some experience, any one, whatever be the shape or size of his finger, may acquire such a degree of skill in the touch as will bear him through the most difficult cases in practice. Let no student, therefore, be disheartened by the difficulties met at the com- mencement, or by the groundless fears of too short a finger, for this becomes longer by exercising the touch; and those pedants are unworthy of credence, who seize a hand, and after examining it gravely, reject it with disdain, exclaim- ing, " You will never be an accoucheur with such a hand as that." Women, generally, have shorter fingers than ourselves, yet they become very perfect in the touch; and I repeat, that, unless there is a malformation of the hand or fingers, anybody may learn by practice to touch, and to touch well. The touch comprises the exploration of the vagina and of the rectum, as also palpation of the abdomen. 1. Vaginal Touch.—The index finger is usually employed for this purpose; after being extended, it is entered horizontally in the fissure between the nates. until arrested by the soft parts, and the index is then drawn forwards, as far as the opening of the vulva. I prefer this method to the one in which the finger is carried from before backwards, in such a manner as to pass over the clitoris and the meatus urinarius, because friction against these parts should always be avoided with the greatest care. In bringing the finger from behind forwards, it would not be possible, except through gross negligence, to confound the anal orifice with the vaginal opening, and this being once found, the index is first pressed almost directly backwards, until one-third of it has penetrated into the vagina, and then by strongly depressing the wrist, the operator gives his finger a nearly vertical direction, so that the thumb may be applied against the anterior face of the symphysis, the radial border of the index be directed in front, and its cubital border be placed against the anterior perineal commissure, which it serves to push backwards. The other three fingers vary in position, according to the case, and more especially to the object in view; for example, if desirable to ex- plore the parts situated on the posterior plane of the excavation with the index, it is better, in my opinion, to extend them on the perineum, pressing the latter up by the radial border of the medius; but if, on the other hand, we wish to perform the ballottement, or to explore the parts on the anterior plane, it will be more convenient to flex the thumb and the other three fingers into the palm, the index alone being extended, with its palmar portion directed in front. Stein directs the medius to be joined with the forefinger, but this is generally useless, and often inconvenient, for although the two fingers may possibly penetrate a little deeper; the sensation is not so clear as that obtained by one. Physicians should accustom themselves to touching with both hands, for there are some diseases of women, and some positions of the foetus, which compel the accoucheur to use the left hand. Or, it may also happen that a wound upon the right will necessarily require the left to be substituted, though, for all ordinary purposes, the right is sufficient. The woman should be placed either in the erect, or the recumbent position during the examination, according to circumstances. In the commencement of pregnancy, it is better, as a general rule, to have her lying down; because, in this position, the head being propped up, and the inferior extremities flexed and 138 GENERATION. separated, the abdominal muscles are thrown into a state of relaxation, and thus the development of the uterus can more easily be determined. Again, such diseases as prevent the female from standing erect, may also require the same posture. But at a more advanced period, either position may be used indiffer- ently, though most frequently the ballottement can be accomplished better while the woman is standing. In this latter case, her loins should lean against a wall or some piece of furniture; a chair must be placed at each side for her hands to rest upon, and the upper part of her body is to be slightly flexed forward. Where any difficulties are encountered in the exploration, it is advisable to touch in both positions. Before operating, the accoucheur should anoint his finger with some unctuous substance, fat, butter, oil, mucilage, &c, for the double object of rendering the introduction easier and less painful to the woman, and to protect himself from the contagion of any diseases she may be affected with. When the female is standing, he should place himself before her, resting on one knee—in my opinion, it is not wholly immaterial which—for, as a general rule, the knee opposite to the operating hand is preferable, because the other one will then furnish a point of support for the elbow to lean upon; though, if the woman be very short, it would be better to flex the right knee, if the right hand is used. When the patient is recumbent, the accoucheur places himself at her side, the right one, if he intends using the right hand, and on the left, if the other is to be employed. One hand is then placed upon the abdomen, while the other is engaged in the vaginal exploration; and this precaution is especially advisable, when the ballottement is practised, in order to fix the fundus uteri, and keep it steady. In passing the finger over the perineum, and before entering the vagina, we ascertain the presence or absence of the fourchette, or the inequalities that supply its place after a labor; and as the index enters the vagina, it should ex- amine the condition of the external labia, the length and width of the vagina, its mucous membrane, whether smooth or rugous, the various diseases, tumors, or degenerations that may exist on the surface or in the substance of its walls, and the condition of the rectum, whether full or otherwise. Hereafter, we shall have occasion to speak of this process as a means of diagnosis in the various vices of conformation. All these explorations being made, the next step is to examine the neck of the uterus, and learn its modifications in form, consistence, situation, direction, and in the dimensions of its cavity; all which have been carefully described. (See page 105, et seq.) The finger may detect the development of the body of the uterus, by ascertaining the spreading out of its inferior part. Until toward the third month, the organ is almost wholly within the excavation, it having at that early period increased so much in size as to occupy almost all the true pelvis. Its mobility is, however, very slight, in consequence of its restrained position, whilst in the ordinary unimpregnated state, it may be carried to the right or left, forward or backward, by simply pressing with the finger on the side of the neck. The restraint of the body during pregnancy renders the neck immovable, so that it becomes impossible, or at least very difficult, to produce such motions; the uterus will also be found much heavier if an attempt be made to raise it. OF SIMPLE UTERINE PREGNANCY. 139 2. Palpation of the Abdomen.—An exploration of the abdomen, says Schmitt, is of great importance in diagnosis, and should always be resorted to when it is desirable to ascertain whether pregnancy exists. It is often, indeed, more in- structive, and furnishes surer results, than the internal examination. Some obstacles are, however, met with in this mode of research. Thus: 1, the walls of the abdomen maybe too thick; 2, its muscles maybe very tense; 3, the bladder may be greatly distended with urine, and the intestines with gas or fecal matter; 4, lastly, a fixed pain in the hypogastric region, rendering any pressure there often insupportable to the patient. The too great thickness of the walls of the abdomen is the only one of these difficulties which is permanent, but which, nevertheless, frequently renders the palpation of the abdomen entirely fruitless; for as the tension and sensibility of the walls are but temporary, the exploration may be deferred to a more favorable opportunity, and the bladder and rectum may always be evacuated beforehand. These obstacles are of rare occurrence, the examination being generally quite easy, owing to the flexibility of the walls of the abdomen. In order to practise it, the female must lie down in such a way that her hips shall be elevated, the head flexed on the chest, and the thighs on the abdomen; in a word, so as to relax the abdominal muscles completely. Whilst in this posi- tion, the abdomen should be first examined with both hands, so as to ascertain its form, size, tension, resistance, and hardness, especially in the sub-umbilical region. In the earlier months of gestation, if the parietes are not too thick, a round tumor, of fleshy consistence, can be detected rising out of the pelvis, some- times in the middle, and at others a little towards the right or the left side; during the first two months it seems to rise higher above the pubis than in the course of the third, which fact is readily accounted for by the sinking down of the organ, occasioned by its increasing weight and volume. This tumor, which is the womb, rises gradually toward the epigastrium as gestation progresses, and it often becomes necessary, in order to form some idea of the time at which labor will probably occur, to ascertain the exact amount of its elevation. The following is, I think, the best mode of accomplishing this object: Place the ends of the eight fingers immediately above the symphysis, and then continue to ascend gradually, so long as they feel any resistance, for when the fundus uteri is gained, the resistance suddenly ceases, and the fingers sink deeper as they glide over the convexity, which is thus recognized without difficulty. The uterine tumor, which is at first quite resisting, becomes less so as gestation advances; sometimes, however, it is so soft as to be barely distinguishable. An attentive examination will enable us to detect the following characters: 1. It always remains circumscribed and retains its oval form; 2. It presents a certain amount of elasticity, similar to that of a cyst filled with serum; 3. If this manual exploration be continued in the same direction, the examiner will detect greater and lesser parts of a single irregular mass, which are movable and easily dis- placed like bodies suspended in water. Often, indeed, these movable parts may be recognized as belonging to the foetus. As a part of the abdominal exploration should also be reckoned the sign fur- nished by percussion, namely, a dull sound over every part of the abdomen occu- pied by the developed uterus, instead of the resonance perceived at other points. 140 GENERATION. Some care is necessary in percussing, during the first four or five months, not to be misled by the dulness which a distended bladder, or a pathological tumor of considerable size might produce. It should also be borne in mind, that although the uterus may have risen to near the umbilicus, a clear sound will be yielded on percussion throughout the greater part of the sub-umbilical region, provided a few folds of intestine be interposed between the walls of the abdomen and the womb. Sometimes the uterus is above the superior strait in the earliest months. I had an opportunity of observing a case of the kind at the Clinic, with Professor Dubois, in a woman who was advanced six weeks or two months; the uterus was so elevated, being found in the right iliac fossa, that at first we doubted the existence of pregnancy, which however was real, as was proved more positively several weeks after, and fully justified by the event of the case. The palpation of the abdomen and the vaginal touch are in most cases prac- tised simultaneously; we shall, therefore, point out the signs which this joint investigation furnishes at the different periods of pregnancy. 1. In the first three or four months, the uterus either remains wholly within the lesser pelvis, or else its fundus projects somewhat above the superior strait. In the first case, it will be easily discovered by the vaginal touch that the entire excavation is occupied by a slightly movable tumor, with a smooth and regular external surface. In the second case, the lower half of the lesser pelvis is empty, but the examination of the abdomen, conducted according to the rules above mentioned, discovers the tumor formed by the womb in the hypogastrium. The first point to be ascertained is the exact size of the uterus, and this can only be determined by the double exploration spoken of: the finger, having been intro- duced into the vagina, is applied directly on the neck, or, still better, against the anterior or posterior portion of the inferior segment of the uterus, while the other hand, placed above the pubis, presses down the muscular walls, and searches for the tumor formed by the fundus uteri; the womb is thus included between the finger in the vagina and the hand on the hypogastrium. and, of course, the volume of the organ may be thus ascertained, and a comparison made between it and the unimpregnated uterus. 3Ioreover, its displacement in mass can be very easily recognized in this position. To accomplish this, the finger should remain applied as above stated, and when the hand slightly depresses the fundus, the finger in the vagina recognizes the depression; and the counter-proof may be made by endeavoring to raise the uterus from below, by pressing strongly on the inferior part, which is found deep in the excavation. But the tumor which is felt in the lesser pelvis, or in the hypogastric region, may be either formed by the uterus, or developed in the adjacent parts. In the latter case, the womb will generally be found to be displaced, and pressed by the tumor against one of the sides of the pelvis; and if the neck be traced from be- low upwards, the finger will detect a line of demarcation between the wall of the uterus and the pathological tumor; sometimes, it can even be insinuated between them. The motions to which the neck is subjected are not usually communi- cated to the tumor, and vice versa. Finally, the neck will exhibit none of the changes peculiar to pregnancy. Hitherto we have only demonstrated that the uterus is developed; but the OF SIMPLE UTERINE PREGNANCY. 141 question arises, what is the cause of that development ? The solution is nearly always difficult; we may state, however, that when the womb is enlarged by a product of conception, its walls are generally more flexible than if the enlarge- ment were dependent upon some chronic disease; and that, after a little practice, this suppleness can be detected by carrying the finger to the posterior surface of the body, which may be done in consequence of the depression and retroversion of the fundus. The uterine wall then offers about the same resistance as an cedematous limb, or perhaps still nearer, that of caoutchouc when slightly softened in hot water. The tumor detected either by the vaginal touch, or by depressing the ventral parietes, is rounded and smooth throughout, and does not present any of those irregularities observed in cancerous or fibrous degenerations of its walls; and this fact, together with the preceding observation, will serve to distinguish a morbid state from a true gestation. It certainly will not prove quite so easy to determine whether the enlargement is caused by a foetus, or the presence of a mole in the cavity; in fact, I do not believe this diagnosis is possible, except at a very advanced stage, and then the absence of the foetal inequalities, the non-appearance of its movements, auscul- tation, &c, might suffice to remove the doubts on the subject. In some women, the womb becomes congested and considerably tumefied at the menstrual periods. Now this state may readily be confounded with a com- mencing pregnancy, the more particularly, because at those epochs the neck usually becomes softer and dilates a little; and I know no way of escaping this error, if the woman insists that she is pregnant, and experiences the various rational signs of that condition. In two cases of the kind I have met with, I only succeeded in detecting the falsity of my diagnosis by examining the woman a second time, two or three weeks after; for these females, who were used as subjects for practising the touch at the Clinique, wished to be considered preg- nant ; but, unhappily for them, the fortune which aided in the first examination, deserted them at the second; for, being ignorant of the cause of my mistake, they returned at a time still more distant from their menstrual period. On the whole, then, there is no certain sign of pregnancy during the first three or four months; yet it becomes almost certain, when the sensible signs above indicated coincide with the presence of the rational ones, in a healthy woman who can have no intention of deceiving us as to her condition; still, in a medico-legal case, the physician should express his doubts, and demand a new examination at a more advanced period. But if it is not always possible at the beginning of a gestation to prove that it does exist, we can, at least in the great majority of cases, satisfy ourselves positively that it does not; for, most frequently the unimpregnated state of the organ can be readily made out. 2. The existence of pregnancy is announced during the last five months by certain signs that are far more reliable than any of those hitherto mentioned, and which are revealed by the double exploration just described; these are the foetal movements, which have improperly been called the active and passive, but better designated by 31. Stoltz as the movements proper and the communicated ones. Active Movements.—The woman generally perceives the foetal movements at about four months and a half, although the muscles of the infant had contracted 142 GENERATION. long ere this, unconsciously to her; for every accoucheur must have detected these motions by placing his hand upon the abdomen, at a time when the mother herself still doubted her own pregnancy. Now these movements are excessively feeble at first, and produce a kind of tickling, or rather a sensation analogous to that of the crawling of a spider; they gradually become more characteristic, and may then be classified in two species. One of these is produced by the move- ments of the whole trunk, or some of its parts, the first of which are recognized by a quivering that is perceptible to the female, while the partial motions give rise to quite large projections, which are even visible through the abdominal walls; the other, on the contrary, are blows, certain small, short strokes, which at times are violent enough to elicit cries from the sufferer, and these shocks are evidently produced by the action of the thoracic or inferior extremities of the child. Such movements, so distinct and clear to the mother, would seem to be an infallible sign of gestation, and yet such is by no means the case, since it is not at all uncommon to find women, whose veracity is beyond question, asserting that they have felt them for a long period, and sometimes the motions have even been perceived by the husband or other persons, yet without their being pregnant. The history of one of the English queens is well known, who, believing she had felt the motions of a child, dispatched couriers with the happy news to all the foreign courts, but proved to be only the commencement of a dropsy ! Such errors are frequent, and there are but few accoucheurs who have not met with many of them in practice. Consequently, the physician should not rely in this matter upon the statement of the woman, but should perceive them for himself before hazarding an opinion. It would seem, indeed, that in some cases, the intestinal movements, the rapid passage of gas in the intestines, certain partial and irregular contractions of the abdominal muscles, and the pulsation of a large artery, especially when situated behind any tumor which it raises at every beat, have often deceived not only the patient, but even her medical attendant. Some females, from the desire of simulating pregnancy, have acquired the power of contracting their abdominal muscles in so singular a manner, that many able accoucheurs have been deceived, and believing that they felt the foetal move- ments, have consequently pronounced them pregnant. (3Iontgomery, p. 84.) These motions may be detected by the vaginal touch in certain positions of the breech, or even of the trunk, but we must rely chiefly on the abdominal palpa- tion for their detection. In general, it is only necessary to place the hand flat on the abdomen, or to make use of slight pressure, to perceive them; though if they are feeble and infrequent, it is better to dip the hand in some very cold liquid, and then place it suddenly upon the skin. This rapid change in the tem- perature of the abdomen probably reacts upon the infant, for it generally moves convulsively. I believe, with Dr. Tyler Smith, that the sudden impression of cold is more likely to produce a rapid contraction of the abdominal muscles or uterus, than to act directly upon the foetus, and that its use might readily deceive as to the nature of the motions which it occasions. I prefer placing a hand upon one of the sides of the abdomen, and striking with the other on a point opposite; for the foetus then rarely fails to move briskly as though to resist the impulse. As before stated, the movements begin to be felt about the end of the fourth OF SIMPLE UTERINE. PREGNANCY. 143 month. To this law, however, there are numerous exceptions; thus, some women perceive them as early as the latter half of the third month, others not before the fifth, sixth, seventh, or eighth months of gestation. One woman, who had advanced to the latter period, was brought to the Clinique, in consequence of a fall in the street, and she assured us that she had never felt the movement prior to the accident. We have already alluded to the person, seen by us at La Charite, under the care of Professor Fouquier, who was delivered at term of a very healthy child, but the motions of which were neither perceptible to the mother nor ourselves. Mauriceau, Delamotte, and many others, bring forward similar cases. But the most remarkable of all is the one reported by Campbell. I knew a lady, he says, the mother of nine children, who, excepting in her first pregnancy, never perceived any motions of the foetus; but she was herself very inanimate and pas- sive, and what was still more singular, the children were equally nonchalant with herself. Whenever an ascites complicates the pregnancy, these motions are very indistinct, thus affording an evidence that it is the abdominal walls, and not the uterus, which perceive the impulse. After the movements have been distinctly felt, they sometimes diminish with- out any appreciable cause, both in frequency and intensity, and then altogether disappear, which circumstance demands the most serious attention of the accou- cheur, as it is in general an unfortunate symptom. I believe this spontaneous cessation of the active movements may usually be referred to a plethoric state of the mother, which reacts on the child's health. But whatever may be the value of this opinion, it is quite certain that bleeding, under such circumstances, has always produced a favorable result; for when not delayed too long, the movements reappear soon after, and hence I cannot re- commend the measure too highly. The Passive Movements, or Ballottement.—This, according to most authors, is a sensation analogous to that produced by placing a ball of marble in a bladder full of water, and then striking the bladder with the finger just under the spot where the ball rests, when the latter is thrown up, and falls back from its own weight upon the finger which displaced it. This comparison, however, only holds good at a certain period of gestation, and we shall again take occasion to refer more particularly to this point. To perform the ballottement, M. Velpeau directs the index finger of one hand to be placed under the cervix, and the palmar face of the other hand over the fundus uteri; then, by a sudden movement of the finger in the vagina, the uterus is to be pushed upwards; being movable, free, and the only solid body in the amniotic liquid, the foetus ascends, strikes the point diametrically opposite, and falls back upon the finger which gave it the impulse. But as this mode will not, I believe, afford any satisfactory results in the ma- jority of cases, I recommend students to pursue the following plan in performing the operation; the vaginal finger should not be placed under the cervix, because it will then be separated from the foetus by the whole length of the neck, and of course the finger cannot recognize so clearly the descent of the displaced body; but rather in front of, or behind the neck (according to the woman's position), upon the walls of the body itself, for then the index is only removed from the 144 GENERATION. substance to be examined by the very thin walls at the inferior region of the uterus, and it detects very readily the least motion of the-enclosed foetus. If the woman is standing, the index should be introduced in a vertical posi- tion, with its palmar face turned forward, and the other three fingers flexed into the palm, and as the symphysis pubis scarcely exceeds an inch and a half in length, the digital extremity of the forefinger easily passes its superior part, and reaches the body of the organ, where it almost always encounters a hard globular tumor formed by the head of the foetus; then a light, quick blow is to be given by it, after which the finger must remain immovable on the part struck. This shock should be made in a direction from below upwards and from behind for- wards by suddenly flexing the first phalanx. This last recommendation I deem very important; for in the great majority of eases, the uterus is inclined forwards, its long diameter, like that of the foetus, corresponding very nearly to the axis of the superior strait. Now, if under these circumstances, the shock be communi- cated to the presenting part of the child from below upwards, and from before backwards, as generally done, it is evident that the motion given to it will, at furthest, be but a slight movement of displacement or jolting, but never one of ascension, which in fact would be impossible, because by the direction of the blow the foetus is pushed against the posterior uterine wall, and not along the axis of its cavity. The ballottement may also be effected when the woman is recumbent, by acting in the manner I have just indicated, but it is then generally necessary to place the finger upon a point somewhat nearer to the neck, sometimes before, but at others behind it. The erect position, however, is usually the more favorable for the perception of the ballottement, and therefore preferable. It sometimes happens, about the fifth month of gestation, that if the woman be standing, the vaginal touch does not afford the sensation of ballottement; but if she be directed to lie down, and the vaginal finger be applied upon the uterine wall, whilst the body of the womb is forcibly depressed by the other hand placed near the umbilicus, the vaginal finger is struck by some part or other of the foetus, which is displaced by the external pressure. At an early period of pregnancy, it is sometimes possible to perceive the bal- lottement by simply feeling the abdomen. If the woman be placed on her side, in a horizontal position, the foetus, in obedieuce to gravity, descends to the lowest points. If the hand be then glided beneath the side of the abdomen which touches the bed, some part of the foetus will be distinguished and may be readily displaced, but soon returns to its original situation. This sign usually becomes valuable about the fourth month, for before that period the foetus is generally too small, and, possibly, the uterine walls are too thick. Again, it varies much after that time: for instance, our search is not always successful in the fifth month, the small size of the child permitting it to change position very easily; on one day it is found without difficulty, and on the following it defies all efforts at detection. Towards the seventh month, the ballottement is in general the most clearly recognized, since it is at this period, especially, that the finger perceives the solid mass, enclosed and swimming in a liquid, to rise up and shortly afterwards to fall back upon it; but the sensation is no longer perceptible at the end of the eighth OF SIMPLE UTERINE PREGNANCY. 145 or the beginning of the ninth month, unless there happens to be an unusual amount of water, for then the foetus has become too large. The finger can in- deed raise it, but the friction against the walls of the uterus almost destroys the tendency to ascend. The mobility of the tumor is readily detected, but it now leaves the finger which impels it; it is a displacement in mass rather than bal- lottement. Finally, in the latter periods of gestation, the head pushing the uterine wall before it, engages in the superior strait, sometimes even gets low down in the excavation, thus becoming jammed in, as it were, and of course the ballottement is then altogether impossible. Writers declare this sign to be a certain indication of pregnancy; but the pro- position is, perhaps, somewhat too absolute : for example, it is possible for a stone resting in the bas-fond of the bladder to lead to an error, and I once met with a case which might readily cause a mistake of this kind. During the time I acted at the obstetrical clinic, as chef de clinique, a woman was subjected to the touch, who declared herself pregnant, and advanced three or four months; at first, I examined her in the recumbent position, and found all the negative signs of ges- tation, but one of my advanced pupils then performed the same manipulation in the standing posture, and declared that he perceived the ballottement, when I re-examined her, and found the following condition of things: The neck was strongly pushed backwards and a little to the left, it was slightly softened, and sufficiently patulous to admit the extremity of the finger. (This woman after- wards acknowledged she was delivered only four months previously.) As the finger left the cervix, and advanced just behind the symphysis pubis, it encoun- tered a large resisting surface, which was evidently the body of the organ, and then, by giving a slight blow, a movable body was felt there, which immediately fell back upon the finger, exactly as the foetus would in the fourth month. I confess that at first I believed her enceinte, and re-touching her in the recum- bent state, I once more remarked the negative signs, but my finger could not now detect the substance that had been so easily moved when she was standing. At the third examination, I discovered an anteversion of the womb, so complete that its anterior face had become inferior or horizontal, and it was over nearly the whole extent of this face the finger had passed in examining; and further, I found that the fundus uteri, situated behind the symphysis pubis, was the light movable body which had produced the sensation of ballottement. If a similar case should occur again, it might give rise to uncertainty in diag- nosis, and on that account I concluded to make it public through this work. There are also some particular positions of the foetus in which the ballottement would be of little service: for instance, in those of the breech it is generally very difficult, and nearly impossible in those of the trunk. In two cases, however, I succeeded in detecting a small part, which, from its diminished size, must have been an elbow, wrist, or heel; and this, together with the other signs, satisfied me that it was a position of the trunk. 31. Hatin, who attended one of these women in her accouchement, found a presentation of the left shoulder; the other was delivered at the Clinique, and like the first, verified my diagnosis. 3. The Anal Examination.—The accoucheur is very seldom obliged to intro- duce his finger into the rectum, but still a partial obliteration of the vagina may render such an exploration necessary; it might also be useful where there were 10 116 GENERATION. reasons for supposing a young girl to be pregnant who insisted upon her virginity. For the necessity of sparing the hymen, which may possibly be intact, renders the vaginal touch very difficult. In cases where a tumor exists at the posterior part of the vagina, it is sometimes difficult to decide whether the enlargement is located in the recto-vaginal septum, or is attached to the bony structure. Here the diagnosis is very important, for the course to be pursued in the two cases would be widely different, and all doubt may be removed at once by introducing the index into the rectum, and the thumb into the vagina. I can recall but few other circumstances where an accoucheur would feel obliged to resort to the anal examination, although I am well aware that it is frequently recommended for certain cases of doubtful diagnosis in the earlier months; but most women are so shocked by this mode of examination, that, in truth, they are unwilling to submit to it, unless from motives of strong interest or necessity. B. Of Auscultation as applied to Pregnancy.—31. 31ayor, of Geneva, first detected the pulsations of the foetal heart by auscultation; but this discovery, originally published by him in 1818, had been entirely forgotten, when M. de Kergaradec announced, in 1S23, that if the abdomen of a woman who has passed the first half of her pregnancy be carefully auscultated, two sounds, which are perfectly distinct in character, will be recognized : one of them, consisting of double pulsations, or rather of redoubled ones, according to the expression of 31. Stoltz, is evidently produced by the movements of the fcetal heart, and has been compared, with some reason to the ticking of a watch enveloped in a napkin; the other is a kind of rustling, unattended by shocks, and consequently without beating, being characterized by simple pulsations, accompanied by the souffle, which have been successively compared to the sibilant murmur, or to the sound of an erectile tumor, or varicose aneurism ; this is called the bellows sound (bruit de souffle).'1 1. Sound of the Heart.—The pulsations of the heart generally become per- ceptible in the course of the fourth or fifth month, though more frequently during the latter, and often then at an elevated part of the abdomen near the umbilical region; in one case, however, I thought I heard them a little before the fourth month, but, unfortunately, I could not re-examine the female until six weeks afterwards. 31. Depaul declares that he has heard them at the end of the third month and in the eleventh week. These pulsations are far more frequent than those of the mother's heart; ranging, as they do, from one hundred and thirty to one hundred and sixty per minute; and, moreover, they are very often accelerated or diminished, without our being able to detect the cause of the changes. Like most observers, I have several times remarked that, if the foetus exhibited any violent movements during the examination, the pulsation increased and be- came very difficult to count; but they are not influenced by any variations in the mother's pulse, whatever may be their cause. 1 The nature of this work will not allow me to enter into the historical details having reference to this important subject; I cannot too strongly recommend all who wish to make themselves acquainted with what has been published relative to it, to consult the excellent monograph recently put forth by M. Depaul. (Traite de l'Auscultation Obst£tricale, 1847.) OF SIMPLE UTERINE PREGNANCY. 147 The dorsal region of the child seems to transmit the double pulsations most easily, and consequently they are more clearly perceived at that part of the abdomen which corresponds to it. This circumstance likewise explains why the pulsations change position so easily prior to the seventh month; in fact, it is only during the last three months, that extensive movements on the part of the child become difficult, and its position nearly fixed. They may be heard most frequently on the anterior inferior portion of the abdominal wall, just above the iliac fossa, or still more rarely on the median line, and not merely at a very limited spot, but over a radius of two or three inches. In some cases they may even be heard over more than half of the abdomen; but it is always easy to perceive that they are stronger and clearer at one point than elsewhere, and from this point as a centre, they become weaker and weaker as the distance increases. The intensity of pulsation is of course less marked as the child is younger, although, in some instances, they exhibit as much force in the sixth month as at term, but this is very unusual. As regards the number of pulsations, the statement made by many observers that it is much more considerable at an early period than at term, is not abso- lutely true, for the foetal heart always beats with the same quickness, saving some accidental variations, at whatever period it may be examined. Labor produces no modification of the foetal pulsations up to the moment of rupturing the mem- branes; but this rule fails after the amniotic liquid has escaped, because they are then generally louder and clearer, and may be heard over a more considerable extent of surface, which can readily be explained by the fact that the ear or in- strument is then nearer the fcetus. When the contractions become more energetic, the pulsations are not so regu- lar, and they are more feeble and slower while the contraction lasts. In those cases where the labor is of moderate duration, the indistinctness of the sound of the heart may be referred, I believe, to the difficulty of ausculting during the pain; but if the foetus has been too long subjected to uterine pressure —as where the labor has been unusually prolonged—the number, force, and regularity of the pulsations sensibly decrease. 3Iost observers have asserted that the sounds are not always perceptible, and M. Stoltz even declares that they cannot be heard whenever the dorsal region is directed backwards, unless some part of the thorax be in contact with a portion of the uterine walls which may be explored. For my own part, I have not failed, for several years past, to hear them in examinations made after the sixth month, in all cases where the children were living; and as my researches have now ex- tended to at least seven or eight hundred women, I feel convinced that we can always distinguish them after that period, in any position of the foetus whatever. 31. Dubois was the first to point out the fact, that the sound of the foetal heart has sometimes a peculiar resonance, resembling the metallic tinkling, a singu- larity which I have twice had the opportunity of observing at the Clinique. This remarkable sonoriety is most frequently met with in women in whom the uterus is distended by a great quantity of fluid. There are also some circum- stances which render the pulsation a little obscure and somewhat difficult to hear ; thus, for instance, a lumbo-posterior position of the foetus, a large quantity of water, by which the uterine walls are greatly distended, and a sufficient de- 148 GENERATION. pression of them by the stethoscope to approach the child prevented; the inter- position of several folds of intestines between the abdominal walls and the uterus, and the existence of borborygmi, are all so many circumstances calculated to render the perception of the pulsations more difficult, although not absolutely impossible. The beatings of the fcetal heart are composed of two distinct sounds, the sec- ond being stronger and more sonorous than the first; but, in a great majority of eases, both of them may be heard quite distinctly. 31. Naegele, however, appears to think that only a single sound is heard under certain circumstances, and I have sometimes made the same observation ; but it has always seemed to me that the perception of only one sound might either be referred to bad manipulation on my part, or else to some one of those circum- stances just described having prevented the application of the stethoscope over a point near enough to the back of the foetus. Thus, though I have frequently heard but a single sound at first, after changing the instrument, others became clearly perceptible. I am happy to extract the following paragraph from the thesis of 31. Carriere, a pupil of 31. Stoltz, which fully confirms my opinion. He says: "I have remarked that the single character of the foetal pulsations here described, is most likely to be observed when the point examined approaches the fundus of the uterus." Like all useful discoveries, obstetrical auscultation has had its opponents as well as its partisans; and though the former are daily diminishing in number, the latter certainly have injured their cause by exaggerating its importance ; we shall, however, carefully endeavor to ascertain its practical utility. a. It has been stated that a perception of the pulsations of the fcetal heart was a certain sign of pregnancy, as also that the absence of this sound, positively determined by several examinations made after intervals of some hours, subse- quent to the sixth month, announces with certainty the death of the foetus; sup- posing, of course, we have a satisfactory assurance of the previous existence of gestation. There is, notwithstanding, one circumstance which might lead to a suspicion of pregnancy even when the uterus was really empty; it is this: in certain females the pulsation of the heart is felt and heard as low down as the sub-umbilical region, and we can imagine that if, in such persons, under the emotions naturally produced by an unjust suspicion of gestation, or, from the influence of any febrile movement, the circulation be accelerated, the pulsations, from their number and rapidity, might be mistaken for those of a fcetus; but in such cases, all errors of diagnosis may be easily avoided by observing : 1st. The perfect isochronism between the pulse at the wrist and the abdominal beatings; and 2d. That the intensity of pulsation constantly increases as the precordial region is approached; which two peculiarities are never presented by the sound of the fcetal heart. b. Can a twin pregnancy always be recognized by auscultation ? It is said that, in most cases, the existence of two children in the uterine cavity may be known by the following sounds : 1st. The sound of the heart will be heard at two distant parts of the abdomen; and 2d. The want of isochronism which may sometimes be detected between these two series of pulsations. These characters are advanced by some writers as indicating a double preg- OF SIMPLE UTERINE PREGNANCY. 149 nancy with certainty, but we shall point out several sources of error on this point: thus, it frequently happens that the pulsations of a single heart resound in very distant parts. Now can this be referred, as 31. Dubois thinks, to deficient thoracic development, to the unusual comparative size of the heart's cavities, to the density of the lungs, or, lastly, to the position of the fcetus itself, the head and extremities of which, being applied against the thorax, and there receiving the impulses from the heart's contractions, serve to transmit them to a greater distance ? I should be inclined to adopt this view; for, whatever be the expla- nation, the fact is certain, and the following appears to me the best method of resolving the difficulty: Whenever the pulsations are heard at two distant points, the line between these should be carefully followed with the instrument; for if they are produced by the presence of two foetuses, the pulsations will become feeble, or almost disappear, towards the centre of this line; but if, on the con- trary, they are due to a single child, they will be just as strong at its middle part as at either extremity. Again, the absence of isochronism in the pulsation does not positively prove the existence of two children; for one series may be owing to the foetal heart, and the other belong to the same organ in the mother, the resonance being trans- mitted to the abdominal cavity., Hence, it is evident that the unusual distinct- ness of the mother's pulsations coinciding with the presence of a single fcetus may lead to the belief of a double pregnancy which does not exist, and a com- parative examination of the pulse then becomes necessary. A double gestation may be easily recognized, if the precautions just indicated are observed, because, the twins being habitually placed one on the right the other at the left part of the abdomen, distinct beatings will be clearly heard, if the stethoscope be successively applied to each side. But this happy state of affairs does not always exist, for sometimes one foetus is situated directly before the other; and then it is nearly impossible, even with the greatest attention, to hear the heart of the posterior child; and, consequently, when the other signs of a twin pregnancy are present, the results derived from auscultation would not prove its non-existence. Is it necessary to add, that equal care should be taken to abstain from hasty decisions in those cases in which there is reason to believe that one of the children is dead ? c. Auscultation has also been applied to the diagnosis of the fcetal positions, but the results derivable from this method of exploration have certainly been exaggerated. 31y own experience, however, justifies me in regarding the follow- ing deductions as certain : 1st. When the pulsations are heard low down, on the left, and in front, the fcetus is in the first position of the vertex (left occipito- iliac); if heard below, in front, and to the right, the fcetus is in the second posi- tion (right occipito-iliac); but it is often very difficult, not to say impossible, to distinguish an occipitoanterior from an occipito-posterior one, by this method. In general, however, I have thought the pulsations were more sonorous, and less apparent in the flanks, in the first case than the second. 2d. A presentation of the breech may be suspected, when the sounds are heard on a level with or above the umbilicus, the point where they are most distinct, indicating the relation of the posterior plane of the fcetus; and our suspicions will almost amount to a certainty when this sign shall be further strengthened by those derived from the touch. 150 GENERATION. As to recognizing a position of the trunk, in the way described by 31. Depaul, it seems to me to be wholly impossible.1 d. Can we appreciate the state of the child's health or disease, of its debility or vigor, during labor, by means of auscultation? This question, which was brought before the Academy by a memoir of 31. Bodson, and which gave rise to a remarkable report by 31. P. Dubois, is certainly one of the most curious and interesting subjects of study; for if we could pos- sibly judge from the signs furnished by auscultation, of the integrity of the foetal life, no uncertainty could arise with regard to the course to be pursued when the labor is too long delayed, after the rupture of the membranes; for the fee- bleness and relaxation, or the excessive frequency of the fcetal pulsations; the intermission and irregularity of their rhythm ; the absence of the second stroke; or the complete cessation of this phenomenon during the uterine contraction, and the slowness of its return after the pain has ceased, would sufficiently au- thorize a prompt termination; whilst the opposite phenomena would justify delay. These signs, and more especially the irregularity of the pulsations, which ap- pears the most important of all, indicate in the clearest manner that the fcetus is in a state of suffering; and hence they should serve as a formal indication to the accoucheur to remove the infant promptly from the danger which threatens it, by an artificial termination of the labor. But, as M. Dubois has very judiciously remarked, there is not then a sufficient integrity of circulation to establish the extra-uterine life; for, although the foetal pulsations may be still regular and sonorous at the moment of birth, yet the child has suffered so much from the long pressure of labor, that the respiration cannot be established; and hence, in this respect, the accoucheur should not rely upon auscultation alone for judging of the opportune moment for the intervention of art, because other considerations quite as important should influence his decision; still, however, this is a method of diagnosis that is never to be neglected. 1 " When one of the regions of the trunk is presenting," says M. Depaul, fi it is possible, provided the dorsal one be in front, to ascertain in which iliac fossa the head is situated, and thence to announce which shoulder tends to engage in the excavation. The typical sound will be discovered in the left inferior quarter, in the left cephalo-iliac positions of the right or left shoulder; and it will be found in the right inferior quarter, in the right cephalo-iliac positions of the left or right shoulder. In some cases, however, it will be less easy to determine which plane of the fcetus corresponds to the anterior portion of the abdo- men; though, in reality, the precise information is of little importance; the knowledge of the relations of the head is. on the contrary, of the greatest interest." I have quoted this passage literally, because it is rather obscure; though I think we may infer from it that M. Depaul believes it possible to discover the positions of the trunk by auscultation. I have frequently endeavored to arrive at the same results, but am, after all, obliged to con- fess that it has always seemed to me to be impracticable. (For further details, see the excellent thesis of M. Depaul.) The latest results obtained by M. Hohl, tend to confirm the opinion which I entertain of the slight confidence to be reposed in auscultation as a means of diagnosis in trunk pre- sentations. Thus, in seven first positions of the right shoulder, the sound of the heart was heard five times a little to the left, and twice a little to the right. In three presentations of the left shoulder, the head was once to the left and the back in front; here the heart was heard beating to the left. In the two other cases, the head being to the right and the back in front, the pulsations were heard in the middle. OF SIMPLE UTERINE PREGNANCY. 151 31. Naegele, junior, has recently described a bellows murmur, which he attri- butes to the pulsations of the umbilical cord, and compares it with the sound produced by the beating of the carotids in chlorosis, and the murmur consists, he states, of a simple pulsation, which is not synchronous with the one pre- sently to be described. It is caused, as he thinks, by the winding of the cord around the neck of the fcetus, or by its compression between the child's back and the uterine walls; the sound increases after the escape of the liquor amnii, and its force is greater in proportion as the arteries of the cord are the more developed, and are more twisted on each other. In the positions of the head, it is situated below the umbilicus, but higher up in those of the breech, and it seems to descend during the expulsion of the fcetus. Sometimes a bellows murmur is heard accompanying the cardiac pulsa- tions, especially at the first sound, but it appears difficult to reconcile this cir- cumstance with the interruption in the circulation caused by any pressure on the cord. Since 31. Naegele, junior, pointed out this peculiarity, several others have noticed it, and I also have met with it at different times, where nothing would indicate even a slight compression of the cord, or any winding around the neck. Does this belong to the fcetal heart, as 31. Dubois and 31. Depaul believe? Indeed, the latter states that he has detected this sound, which he had previously heard during the intra-uterine life, by ausculting the infant immediately after birth. But nine other cases, he says, turned out differently, and oblige me to state the facts as they occurred. The foetal murmur occupied a part of the uterus entirely removed from that where the beating of the heart was detected; the latter being pure, and unmixed with any murmur. Five of these children were born with one or several turns of the cord about the neck, whilst in the sixth, it surrounded the lower part of the thorax. The remaining three were free from anything of the kind. All were born living, and on none of them was it pos- sible to detect a souffle in the cardiac region immediately after birth. The question must therefore be decided by new observations; for, although the sound may be produced by the compression of the cord, the compression often exists without the abnormal murmur. Lastly, 31. Stoltz has described a rustling sound, which is only observed after the death of the fcetus, and is attributed by him to the decomposition of the amniotic liquid. "In searching for the signs furnished by ascultation," he says, " I have noticed a dull, irregular murmuring like the sound of fermentation, in many women who were carrying dead children, which I did not confound either with the buzzing heard when the ear is applied to any body whatever, nor with the rumbling or displacements of the intestines, and I therefore attributed it to a decomposition of the liquor amnii and of the fcetal fluids." This phenomenon would not therefore be constant, because the decomposition does not always take place, especially at the commencement of gestation, for the silence of death generally reigns in the womb at that stage. The sound is syn- chronous with the pulse of the mother, and consequently varies in frequency like it; it is not accompanied by either impulse or blow, and seems as though it took place in parts which were much more sonorous. I confess that though I have had several opportunities of ausculting females whose foetuses had ceased to exist 152 GENERATION. for eight or twelve days, or even two weeks, I have never yet heard anything resembling the sound described by the learned Professor of Strasbourg. 2. Bellows Murmur.— Numerous denominations, each of which is founded on its supposed nature, have been applied to this sound; for instance, M. Kergaradec thought it was produced in the utero-placental circulation, and hence gave it the name of the placental murmur; on the other hand, 31. Bouillaud, and many others, have subsequently assigned its seat (which, to say the least, is very pro- bable) to the large arterial trunks placed on the posterior abdominal plane, where they are subjected to considerable pressure from the developed uterus, and they have denominated it on this account the abdominal souffle; and still more re- cently, 31. Paul Dubois has endeavored to prove that it originates in the vessels which ramify in the substance of the uterine wall itself, whence he has called it the uterine sovffle. But as we shall take occasion hereafter to discuss these three opinions, which embrace all our present knowledge on the subject, we will pass them over here. In general, the bellows murmur may be heard as soon as the uterus, by rising above the superior strait, becomes accessible to the stethoscope—that is, a little earlier than the sound of the foetal heart; in fact, 31. Delens asserts he has de- tected it at the third month, and Dr. Kennedy towards the tenth, eleventh, or the twelfth week. 31. Depaul has also made the same observation; but as there is a very great difficulty in approaching the uterus at so early a period, these facts are certainly exceptionable. The murmur undergoes some very singular modifications during the course of pregnancy : thus, we do not hear it in every instance ; again, it is not at all un- usual for it to escape detection for a long time after having once been heard, and then to reappear somewhat later; sometimes even we may auscult for several minutes in vain, when it suddenly appears directly under the ear, augments, becomes quite loud and distinct, lasts for a few moments, then diminishes, and finally ceases altogether. In other cases, two or three pulsations, attended by blowing, are heard during profound silence, but nothing more after that; and on the other hand, very fre- quent opportunities are afforded us of observing the promptitude with which the sound changes its locality ; for it seems to pass suddenly from one point to an opposite one, being sometimes immediately beneath the ear, at others very dis- tant : only covering a single spot in the majority of cases, but occasionally extend- ing to two remote regions, and, what is very remarkable, with equal force and clearness at both those points ; further, the extent over which the sound is heard is usually quite limited, but in some instances it becomes perceptible over a very large surface, trespassing upon nearly the whole anterior abdominal region. On several occasions my pupils have had opportunities of studying all these varieties, which indeed are almost inexplicable, whatever opinion may be adopted as to the cause of the sound. The murmur is modified during labor; for at the very instant when the pains begin, and even before the patient herself is aware of them, it becomes at once louder, more sonorous, and more distinct, and at times exhibits some strange modifications : thus, at one time the sound heard resembles, partially at least the tone of a reed, or of a tense cord thrown into vibration, though as soon as the OF SIMPLE UTERINE PREGNANCY. 153 contraction becomes stronger and more general, it seems to grow weaker, appear- ing at longer intervals, and finally becoming imperceptible ; but when the pain ceases, the sound returns, at first with the intensity it manifested at the begin- ning of the contraction, and gradually regains the same sonorousness it had during the gestation. Such is the order presented when the contractions are regular and energetic; but if they are false or irregular, the souffle is not modified, or at least is not any stronger, except it be for a few instants only. It may likewise be perceived after the expulsion of the foetus, and even of the after-birth : for example, 31. Carriere says he heard it twenty-four hours sub- sequent to the delivery of the placenta. Generally, it extends towards the inferior lateral part of the abdomen; more rarely, it is heard near the fundus uteri. The following is the result of 295 observations, made by M. Depaul, of women who had passed the fifth month of gestation; it will be seen that it accords with my own experience. It was heard very distinctly 182 times on each side of the uterus, at a short distance from the crural arch; in 27 cases, it appeared on one side only; in 43, towards the fundus of the organ; and in 18, it was spread over the entire surface of the uterus. Finally, 31. Depaul states, that in 12 cases, it was present in three distinct situations, namely, the fundus of the womb and the parts above the crural arches. During the first half of the pregnancy, it was oftenest observed when the stethoscope was placed upon the median line a little above the pubis. 31. Hohl locates the murmur at a point corresponding to the insertion of the placenta, and bases his opinion upon the following reasons: 1. In 21 cases in which he removed the placenta with his hand, he found it adhering where the souffle was first heard; 2. In 15 cases where it was inserted upon the orifice, the murmur was heard very low down; 3. In 10 others the autopsy revealed the after-birth where the souffle had been distinguished ; 4. In 8 cases of version the same fact was discovered directly; 5. In 12 cases of twin pregnancy, one murmur only was heard when but a single placenta was present, and two distinct ones, when the after-births were separate; 6. Lastly, in a great number of cases the intensity of the souud appeared to be in direct relation with the bulk and extent of the placenta. I unite with 31. Depaul in the belief, that the place where the murmur is heard, is independent of the placental insertion. The character of the sound heard varies greatly ; sometimes it is short, abrupt, and separated from the succeeding one by a longer or shorter interval of com- plete silence, which is dependent upon the frequency of the pulse; sometimes it is a prolonged roaring, a true " bruit de diable," which has its period of begin- ning, of increase, and termination, the latter blending with the next succession. In short, it presents all the variations of rhythm which have been attributed to the chlorotic murmurs. Though generally simple and intermittent, it is some- times continous and double (bruit de diable); finally, it may be both continuous and simple. I have not yet met with the typical, double intermittent sound. Like the murmur in the carotids, the rhythm may change in a few moments so as to present in a very short time several of the varieties just mentioned. The quality of the sound also varies greatly; and this not only in different 154 GENERATION. women, but even in the same woman, and sometimes whilst the exploration is going on. Occasionally it is whistling, and resembles much the sound of the wind blowing through a badly-closed doorway; again it becomes roaring, so as to imitate the vibrations of a bass cord; at other times it is plaintive, suggesting the cooings of a turtle-dove. The seat and mode of production of this sound is a question that has given rise to much controversy, though, as the sound is synchronous with the mother's pulse, it must be evidently connected with the maternal vascular system. Thus far all agree, but diversities of opinion immediately spring up when a more pre- cise location of it is attempted; for the murmur is produced outside of the uterus, exclaims one party; not so, it is seated in the uterine or the placental vessels, say the others. 1. The Murmur is Produced in Parts distinct from the Uterus.—Whenever a tumor is developed over the course of a large arterial trunk, the compression exercised by it on the vessel produces a souffle, and it is not at all unusual, when- ever a pathological tumor is developed in the abdomen, to hear a murmur in such cases, very nearly resembling that of pregnancy; now, the uterus developed by a product of conception constitutes a considerable tumor, one which must neces- sarily compress the vessels and produce the effect described. This view is advo- cated by numerous partisans, who contend that the murmur does not begin to appear until the uterus really compresses the iliac vessels by being elevated above the superior strait; that it is usually heard at the inferior lateral part of the abdomen, and more frequently on the right side, because the uterus is habitually inclined to the right; and lastly, that if, according to the plan of my friend, Dr. Jacquemier (which I have since often practised myself), the female, after having been ausculted in the supine position, be made to kneel down, with the body bent forward nearly horizontally, and the elbows resting on the ground, in a word, in such a position as to throw the whole weight of the uterus upon the anterior abdominal wall, the murmur will no longer be heard, although distinctly audible before. 2. The Murmur is Produced in the Uterus.—Those who locate the sound in the uterine circulation, differ essentially as to its precise seat and the mode of its production. Thus, 31. de Kergaradec attributes it to the placental circulation; whilst M. Hohl, who also believes it is perceived at the point where the placenta is inserted, differs from him, by supposing that the sound results from the pas- sage of the arterial blood into the venous sinuses of the placenta; but, to refute this latter opinion, it is only necessary to bear in mind the great variety in the seat of the murmur during pregnancy, and that in some cases it is still percep- tible after the delivery of the after-birth. The views of 31. Dubois still claim a notice; for whenever, says this Pro- fessor, the disposition of the uterine apparatus is carefully studied, the freest communication will be found to exist between the arteries and veins, the uterine walls appearing to be transformed into an erectile tissue, or one of varicose aneu- risms; and the column of blood brought by the arteries, and divided through their branches, mingles, whilst passing directly into the veins, with the slower and less compressed columns contained in the canals of the latter. This circum- stance is incontestably the cause of the murmur and souffle that is so remarkable OF SIMPLE UTERINE PREGNANCY. 155 in varicose aneurisms and the accidental erectile tissues, and it is very likely that the same cause produces it in the uterine walls. Hence we can comprehend why it is only heard at that period when the vascular modifications of the organ are the most marked; why it is most frequently audible over the spot corresponding to the placental insertion, because the development of the uterine vascular system is the most considerable there; and finally, why this sound may still be heard in some women after delivery, when the retreat of the uterus is not yet complete, and the circulation in its walls has not been reduced to its condition in the non- gravid state. No one, since the researches of M. Dubois, has been able to rediscover the large and free communications between the uterine arteries and veins; it is in fact certain, that they communicate directly in no other way than through their terminal and capillary ramifications. It is plain, that when a supposed anato- mical fact is proved to have no existence, the theory which is founded upon it can no longer be maintained. There are still some other points concerning the uterine circulation, which have recently been advanced: thus, Dr. Corrigan thought the passage of the blood from the uterine arteries into the sinuses, was the cause of the souffle; and M. Carriere, who admitted this opinion, added, that the circulation being much more active at the point corresponding to the placental insertion, the sound should be most audible on a level with that insertion. M. Depaul has quite recently re-promulgated the views of Corrigan, adding thereto the compressions produced both within and without by some portion of the fcetal ovoid, and he attributes an important influence to these compressions, which, however, had previously been brought forward by 31. de Kergaradec, in explanation of the frequent variations of the souffle in its seat and intensity. The cause of the sound, says 31. de la Harpe de Lausanne, neither rests on a particular condition of the blood, nor on a modification of its course, nor yet in any peculiar state of the vessels, but simply on the multiplicity of the vessels concentrating at the same point; which multiplicity, by increasing the currents a hundred fold, increases the sounds in the same ratio; thus rendering those audible by multiplication, which, taken singly, were imperceptible to the human ear. Perhaps a comparison will serve to illustrate this idea: if a person place himself, on a mild day, under a tree that has been closely pruned, deprived of its leaves, and only Leaving some large branches left, he will hear no sound or rust. ling of the air; now let him pass from this tree to another one better furnished with branches, though still deprived of leaves, and he will perceive, if the same air be stirring, a commencing sound, produced by the branches that are agitated in the wind; again, the intensity of sound will become much greater, if he once more changes to a fir-tree; for notwithstanding the leaves of this latter are rigid and immovable, yet they are innumerable; and just such is the case with the placental murmur. In fact, a liquid cannot circulate in a tube without producing a certain amount of sound by the friction of its molecules against the walls of the tube; only the sound is not detected by the ear when the vascular canal is isolated, but the contrary results, when thousands of little canals are found at the same point. Which theory, therefore, is to be received as the true one? To so many con- 156 GENERATION. Aiding views, shall I be permitted to add another? It appears to me most pro- bable, that the sound in question has its origin in the arteries distributed in the posterior plane in the abdomen, sometimes in the aorta, but most frequently in the iliac vessels. I think, however, that the causes are numerous, and not due simply to the pressure of the uterus upon these large vessels. This compression is doubtless one of the most active causes of the murmur, and the reasons why it should be so, above stated, seem to me convincing; the contrary opinions of my colleague, M. Depaul, notwithstanding. I am, however, also convinced that the abdominal souffle is, like that of chlorosis, partly due to the alterations which the blood undergoes during pregnancy. Whatever theory be embraced respecting the mechanism of these abnormal vascular sounds in chlorosis, whether they be attributed to the diminution of the corpuscles, as 31. Andral supposes, or to hydraemia, according to 31. Beau, and, we may add in passing, this latter theory seems to me to be the only admissible one, the great analogy between the blood of chlorosis and that of pregnancy cannot be ignored. It is equally difficult not to recognize the entire resemblance between the souffle of pregnaut women and that of chlorotic patients. They exhibit the same varieties of rhythm, as also of tone and sonorousness; both are sometimes mixed or composed simply of buzzing, rasping, or whistling sounds, which seem to be alike peculiar to the early stages of the affection. Both present, if I may so ex- press it, the same mobility of duration, rhythm, and intensity, and appear to be similarly affected by the greater or less pressure of the instrument, as also by changes in the circulation of the female as a consequence of disturbances of tem- per, violent movements, &c. Is it not, therefore, natural to conclude, that since pregnancy and chlorosis produce the same changes in the blood, the souffle, which is exactly alike in both cases, is also due to the same cause ? But, it will be replied, in chlorosis the murmur is heard more especially in the cervical region; why, therefore, during pregnancy should it, if due to the same cause, fix itself particularly in the abdomen ? I would reply, in the first place, that in some cases the cardiac and carotid murmurs have been observed in preg- nant women; still I admit that, most generally, they are not heard even when the abdominal souffle is present. The latter circumstance can be readily explained, for it is in fact rarely that the alteration of the blood is carried to the same extent as in ordinary chlorosis; the proportion of globules rarely descends below one hun- dred, and the amount of water is far from equalling the enormous proportion which it reaches in chlorosis. Now, if it be true, as 31. Andral supposes, that the production of abnormal sounds is an indication of a more advanced alteration, we can comprehend why they should not be perceptible in the carotids, where only poverty of the blood could produce them. The conditions are not the same in the abdominal vessels, for there to a com- mencing hydraemia, is superadded a considerable diminution of the calibre of the vessels, which diminution is a result of the compression of the uterine tumor • and these two circumstances united are capable of producing a souffle which they would be unable to determine singly. The compression of the arteries thus "ives rise to a sort of insufficiency, which renders still more sensible the slight increase which the total amount of the blood has undergone. OF SIMPLE UTERINE PREGNANCY. 157 These two circumstances appear to me to afford a sufficient explanation of the abdominal souffle. Those accoucheurs who have made a special study of this question, committed an error, in which I myself shared for a long time, in not having reflected sufficiently upon the physiological conditions of pregnancy, which, indeed, were badly understood, until, at least, within a few years past. In endeavoring to discover the cause of these abnormal sounds in a special ar- rangement of the vascular apparatus, of the uterus, they wandered farther and farther from the truth. In order to render their theory more acceptable, they made distinctions between the abdominal souffle and the carotid murmur, which have no real existence. Thus, say they, the latter is accompanied by a sensation as of a blow, and of pulsation, which is always wanting in the former. But it is now satisfactorily proved that the sound of a blow, analogous to those of the healthy heart, is ordinarily nothing but the simple reverberation of the first sound of the heart, which is capable of extending into the arteries situated near that organ, but which is very rarely propagated into the. abdominal aorta, and the iliac and femoral arteries. These arterial trunks, says M. Beau, present only a considerable pulsation, or elevation, which is very rarely accompanied by a true murmur. It should also be observed, that the souffle in the cervical region is itself frequently independent of anything like the sound of a blow. It has been stated that we have several times known the sound to disappear when the woman was placed on all fours, but that in other instances it still re- mained. 31. Depaul recollects having repeated this experiment, with the effect of continuing to hear the uterine murmur, without the slightest variation. This last remark, made by such observers as 3IM. Depaul and Carriere, deserves fur- ther attention on our part. As M. Beau has pointed out, it is much more diffi- cult than would be supposed, and sometimes even impossible, to cause the woman to assume such a position that the large arteries shall escape all compression by the uterus. The abdominal walls of young primiparous women are too resisting to yield under the momentary weight of the uterus, and whatever position be assumed, they retain the organ strongly applied against the posterior plane of the abdomen. M. Beau has also proved that this persistence of the abdominal souffle is not peculiar to pregnancy, but that in the case of a woman affected with a cyst of the ovary, shown to be such at the autopsy, it was impossible to give the tumor any position in which it ceased to compress the arteries of the pelvis, and conse- quently to put an end to the murmur. I would add, that whilst admitting, as I endeavor to prove, that compression is not the sole cause of the murmur, but that the serous plethora of pregnancy also contributes to its production, it might readily be supposed that if the latter reach a certain degree, it might of itself give rise to the abnormal sound, even should the position of the female entirely relieve the abdominal vessels from pressure. The same remarks will apply to the variable results which are sometimes ob- tained, when, after having heard the sounds on one side of the abdomen, the woman is made to reverse her position. Sometimes, we have said, it ceases to be heard ; at others it persists, although the inclination of the uterus had re- moved the pressure from the vessels on the point opposite the side upon which 158 GENERATION. the woman lies. In the first case, the plethora was too slight to maintain a sound, the production of which was partly due to the compression of the vascular tube; in the second, either the inclination of the uterus had not removed the pressure, or else the alteration of the blood was alone sufficient to produce the abnormal sound. Although 3131. Barth and Roger are disposed to attribute the abdominal murmur to pressure, they nevertheless find some objections which prevent their adopting the opinion in its full extent. Why, say they, is not the sound in- creased when the uterus is pressed upon with the stethoscope, and why does it sometimes disappear when the pressure is made rather stronger ? It is, replies 31. Beau, because the murmurs are the result of a certain degree of pressure. which if increased or diminished, the sounds are altered or lessened. The effect is the same as that which is frequently observed in the carotid murmurs, which do not increase, and which even disappear, when a little too much pressure is made upon the artery; and as these latter sounds are sometimes found to have their intensity somewhat increased by a slight pressure, so the abdominal mur- murs are occasionally notably increased when the uterus is a little pressed upon. Finally, how happens it, say 3131. Barth and Roger, that in certain cases in which no souffle was heard upon auscultation of the abdomen, it could, through the assistance of the metroscope of 31. Nauche, be perceived upon the neck of the uterus, which is situated in the centre of the pelvic cavity, and therefore re- moved from the vessels? We may suppose, again replies 31. Beau, that in the cases in question the murmur had its origin in the hypogastric arteries. Now the neck of the uterus is nearer these arteries, than that part of the body of the organ which is in rela- tion with the abdominal parietes. Besides, is it not possible that certain organs which are poor conductors of sound, s*ich as a mass of intestine or of omentum, might have been interposed between the surface of the uterus and the walls of the abdomen, and thus have prevented the transmission of the vibrations to the ear? In short, I agree with M. Bouillaud, and with the views advocated by 31. Beau, in his excellent memoir upon arterial murmurs, in regarding the abdo- minal souffle of pregnancy as due, in part, to the compression of the vessels situated on the posterior wall of the abdomen; but I also think that the altered state of the blood assists, as it does in chlorosis, in the production of the pheno- menon. Since the researches of Hope and of 31. Aran, some physicians have regarded the veins as the seat of the continuous souffle, which is sometimes heard in the cervical region of chlorotic patients. For a long time, I entertained this opinion myself, but it was so thoroughly shaken by the experiments of M. Beau, that I now regard the arterial system as the seat of all the abnormal sounds. I should, however, remark, for the benefit of those who still hold to the theory of Hope| that this does not invalidate the explanation which I suggest of the nature and point of departure of the abdominal souffle, for beside the iliac veins, there are large venous trunks destitute of valves proceeding from the uterus,' which are equal to the production of certain sounds, which are sometimes heard during pregnancy. OF SIMPLE UTERINE PREGNANCY. 159 The abdominal souffle is not of great practical importance; its value, as a sign, is limited to rendering the existence of pregnancy probable. It may exist inde- pendently of pregnancy, and does not always accompany it; it is not influenced by the life or death of the fcetus, nor is it modified in any degree by a state of suffering of the child; it cannot, in any case, enable us to determine certainly either the place of insertion of the placenta, nor its form, size, nor the changes which it may undergo. The observations of 3131. Depaul and Naegele, jun., prove, in opposition to the conclusions of Hohl, that the diagnosis of double or triple pregnancies, is incapable of assistance from the souffle, presenting as it does in these cases no modifications which are not also observed in simple preg- nancies. Summary.—It is now well understood that, in ausculting the abdomen of a pregnant woman, we may hear both the pulsations of the foetal heart and the bruit de souffle. The first is a certain sign of pregnancy; but the second, being also produced by other causes, only becomes of importance when we have pre- viously ascertained that the female has no other disease. The sound of the heart may aid in ascertaining the position of the foetus ; the souffle can communicate no information as to the place of insertion of the placenta, and indicates nothing as regards the child's position; while any feebleness, and more especially any irregularity or intermittence of the heart's pulsations, furnish strong presumptive reasons for believing that the foetus is suffering, and that its life is compromised. When desirable to auscult a female who is supposed to be pregnant, we must request her to lie down on her back; at the commencement of gestation this precaution is indispensable; but towards the last it becomes less so, and she may then be examined standing. In fact, whatever be her position in the latter months, this exploration is quite easy, on account of the dimensions of the uterus and the volume of the foetus, but at first it is nearly always necessary to flex the thighs upon the belly, so as to completely relax the abdominal muscles, and of course this could only be done in the horizontal position. The dorsal or lateral decubitus is requisite to explore thoroughly the fundus or sides of the womb, and also to cause the fcetus to fall from either side; the thighs should also be flexed, or extended, according to the region examined. The unaided ear will answer, but the stethoscope should generally be employed; for, by using it, the sounds detected can be more readily limited, and the abdominal parietes more easily depressed so as to approach nearer to the fcetus; besides, many females object to the accoucheur thus applying his head flat on the abdomen. Experience has likewise convinced me that, when the unassisted ear is used, the clearness of the sensations is singularly diminished by the frictions which the respiratory move- ments of the abdomen make against the ear. When used, the enlarged extre- mity of the instrument should be deprived of its mouth-piece, and its whole cir- cumference be exactly placed over the region to be ausculted. It is also advisable that the woman lie on a bed of sufficient height, other- wise the accoucheur is obliged to stoop too much, and this inconvenient position is attended by such a degree of congestion as to render it impossible to hear anything. And further, to avoid all unnecessary searching, it is best to place the stethoscope at first directly over the part where the pulsations of the heart are most commonly heard, that is, in front, below, and a little to the left side. 160 FENERATION. It is equally desirable to ascertain from the female where she generally per- ceives the foetal movements, for most frequently the pulsations of the heart will be found on the opposite side, because the superior and inferior extremities being always folded on the abdominal plane, the back, in other woids, the part of the fcetus which most easily transmits the sounds, will evidently be turned towards the left, if the right side is the habitual seat of the active motions. Before the fifth month, the pulsations are usually perceived in the lower part of the abdomen on the median line, about half way between the pubis and um- bilicus ; consequently, the instrument should be first applied there. The instrument proposed by Nauche, under the name of metroscope, the ex- tremity of which is intended to be introduced into the vagina and applied to the neck or inferior part of the womb, ought not to be used. A Table exhibiting the Signs of Pregnancy at various Periods RATIONAL SIGNS. SENSIBLE SIGNS. First and Second Months. 1 1. Suppression of the menses (numerous ex- ceptions). 2. Nausea—vomiting. 3. Slight flatness of the hypogastric region. 4. Depression of the umbilical ring. 5. Tumefaction of the breasts, accompanied with sensations of pricking and tender- ness. Augmentation in the size and weight of the uterus. 2. Descent of the organ. 3. The womb is less movable. 4. Its walls have the consistence of caout- chouc. 5. The neck is directed downwards, for- wards, and to the left. 6. The orifice of the os tincae is rounded in primiparae, but more patulous in others who have had children. 1. A slight softening in the mucous mem- brane covering the lips, and this mem- brane appears cedematous. Third and Fourth Months. 1. Suppression of the menses (a few excep- tions). 2. Frequently, the appearance or the con- tinuance of the vomitings. 3. A small protuberance in the hypogastric 3 region. 4. Less depression of the umbilical cicatrix. 4 5. Augmented swelling of the breasts, pro- minence of the nipple, and slight disco- loration in the areola. 1. The fundus uteri rises to the level of the superior strait towards the end of the third month, and is perceived at the close of the fourth about the middle of the space between the umbilicus and pubis. 2. A perceptible flatness on percussion in the hypogastric region. 3. A rounded tumor, as large as a child's head of a year old, may be detected by the abdominal palpation. By resorting to this process and the va- ginal touch jointly, the displacement en masse, and the volume of the uterus may easily be ascertained. 5. The neck has the same situation and di- rection during the third month as in the preceding ones; at the fourth it is ele- vated and directed backwards and to the left side. OF SIMPLE UTERINE PREGNANCY. 161 RATIONAL SIGNS. 6. Kyesteine in the urine. SENSIBLE SIGNS. . The softening of the periphery of the ori- fice is much better marked. The latter is more open in multiparce, even admitting the extremity of the finger; but is closed and always rounded in primiparae. Fifth and Sixth Months. 1. Suppression of the menses (some rare exceptions). 2. The disturbances in the digestive organs generally disappear. 3. Considerable development of the whole sub-umbilical region. 4. A convex, fluctuating, rounded abdomi- nal tumor, salient, particularly on the middle line, and sometimes exhibiting the foetal inequalities. 5. The umbilical depression is almost com- pletely effaced. 6. The discoloration deeper; glandiform spotted. 7. Kyesteine in the urine a. the areola is tubercles; areola 1. The fundus uteri is one finger's breadth below the umbilicus at the end of the fifth month; and the same distance above it at the expiration of the sixth. 2. Fcetal irregularities, and active move- ments, which are very perceptible. 3. The sound of the heart and abdominal souffle are now perceptible. 4. Ballottement. 5. A tumor is felt at the anterior superior part of the vagina, which is sometimes soft and fluctuating, at others rounded, hard, and resisting. 6. The inferior half of the intra-vaginal por- tion of the cervix uteri is softened. 7. The whole ungual part of the first pha- langeal bone can penetrate the cavity of the neck in multiparce. The latter is soft- ened to the same extent in primiparae, but the orifice is closed. Seventh and Eighth Months. , Suppression of the menses (the excep- tions are very rare). Disorders of the stomach (rather rare). 3. The abdominal tumor has the same cha- racters, except that it is more voluminous. 4. A complete effacement of the umbilical depression, the dilatation of the ring, and sometimes a pouting of the navel. 5. Numerous discolorations on the skin of the abdomen. 6. Sometimes a varicose and oedematous condition of the vulva and inferior extre- mities. 7. Vaginal granulations—abundant leucor- rhoeal discharge. 1. Increased size of the abdomen. 2. The fundus uteri is four fingers' breadth above the umbilicus at the seventh month, and five or six at the eighth. 3. The organ is nearly always inclined to the right. 4. More violent active movements of the fcetus. 5. Sounds of the heart and abdominal souffle. 6. Ballottement is very evident during the seventh month, but more obscure in the eighth. 7. The softening extends along the neck, above the vaginal insertion. In primiparas, the cervix is ovoid, and seems to have di- minished in length ; in others it is conoi- dal, the base being below, and sufficiently 11 162 GENERATION. RATIONAL SIGNS. SENSIBLE SIGNS. patulous to admit all the first phalanx. The neck at its superior fourth is still hard and shut up. 8. Deeper discoloration of the central areola, and an extension of the spotted areola. Sometimes there are numerous stains on the breasts; flow of milk; complete deve- lopment of the glandiform tubercles. 9. Persistence of kyesteine in the urine. First Fortnight of the Ninth Month. 1. The vomitings frequently reappear 2. The abdominal tumor has increased; the skin is much stretched, and very tense. 3. Difficulty of respiration. 4. All the other symptoms persist, and are increased in intensity. ]. The fundus uteri reaches the epigastric region and gains the border of the false ribs on the right side. 2. Active movements. Sounds of the heart and abdominal souffle. 3. Often there is no proper ballottement, but merely a kind of rising of the tumor formed by the head. 4. The neck is softened throughout its whole length, excepting the circumference of the internal orifice, which still remains closed and resisting. In women who have pre- viously borne children, the finger may be introdnced into the cervix to the extent of a phalanx and a half, and in fact is only arrested by the internal orifice, which is closed and wrinkled,though, in some cases^ already beginning to open. In primiparae, the softening is equally extensive, and the neck is swollen in the middle in an ovoidal form; but the external orifice, although partially opened, does not permit the in- troduction of a finger. Last Fortnight of the Ninth Month. 1. The vomitings often cease. 2. The abdomen is fallen. 3. The respiration less oppressed. 4. More difficulty in walking. 1. The fundus uteri has sunk lower than in the first fortnight. 2. Active movements; bruits du cceur and de souffle. 3. Ballottement often imperceptible. 4. The head more or less engaged in the ex- cavation. 5. Frequent and ineffectual desires to urinate. 5. In multiparce, the internal orifice softens and dilates; the finger can then penetrate through a cylinder, as it were, an inch and a half in length, and come into contact with the naked membranes, lnprimiparce, the internal orifice experiences the same modification, but the external remains closed. During the last week, in conse- quence of the spreading out at the inter- nal orifice the whole cavity of the neck becomes confounded with that of the body, and the finger, in reaching the DEVELOPMENT OF THE HUMAN OVUM. 163 RATIONAL SIGNS. SENSIBLE SIGNS. membranes, only traverses a thin orifice in primiparae, but a rounded collar in the others of a variable thickness. 6. Hemorrhoids; augmentation of the cedema and varicose state of the lower extremities. 7. Pains in the loins, and colics. BOOK III. OF THE HUMAN OVUM AFTFR FECUNDATION. The human ovule, prior to fecundation and at its full maturity, is composed, as previously stated (page 69), 1st. Of the vitelline membrane, or the envelope. 2d. Of a granular liquid contained in this membrane, and called the vitellus (yolk). 3d. Of a little vesicle enclosed in the first, and situated in the midst of the granular liquid. This is the germinal vesicle, originally discovered by Pur- kinje, in the eggs of birds, and subsequently proved by M. Coste to exist in those of mammalia. 4th, and lastly. Of the germinal or proligerous spot (macula germinativa), which is detached from the clear contents of the germi- nal vesicle, and is held in suspension in the fluid which the latter contains. If the ovule be examined several weeks after the fecundation has taken place, it will be found to have undergone some very remarkable transformations; for it is then composed of such different parts, that if comparative anatomy had not furnished us opportunities of observing, step by step, and hour by hour, the divers modifications it passes through before the organization is fully completed, we could not believe it to be one and the same product. Thus, at the end of the second or third week after fecundation, it exhibits some very different elements to the observer: for example, we encounter, in passing from without inwards, Tst. The chorion, a thick exterior membrane, studded with numerous villosities. 2d. A much thinner membrane, situated more internally, and designated as the amnios. 3d. A more or less considerable space between these two envelopes, that is filled by an albuminous liquid, in the midst of which a little vesicle (the um- bilical vesicle) is situated. And 4th. A liquid fills the cavity of the amnios, the quantity varying with the period of pregnancy, and in this fluid is the embryo. Finally, let us add that the ovule is enveloped nearly throughout by a double membrane, which at first is entirely foreign to, but subsequently contracts inti- mate relations with it; this is the deciduous membrane. But before studying the constituent parts of the ovum at an advanced period of its development, let us see what is their proper commencement, and how they can arise out of the simple elements that form the ovule prior to conception. 164 GENERATION. CHAPTER I. DEVELOPMENT OF THE HUMAN OVUM. When the ovule has attained its full maturity, the vesicle in which it is en- closed becomes the seat of an excitation which determines there a considerable ... afflux of fluid, and causes its progressive distension. This hypertrophy may, as we have seen, be either spontaneous, or produced by coition or other venereal excitement. As a consequence of the distension, the vessels on that portion of the vesicle which projects the furthest from the surface of the ovary become atrophied, their walls grow thinner, and soon give way, thereby permitting the ovule to escape, which, in passing out, draws along with it a part of its granular cumulus. The ovum then engages in the tube, whose enlarged extremity had been applied to the ovary. It must not be supposed that the period for the ovule's arrival in the tube is invariable in the same species of animals, and it probably varies in the human race also, though nothing positive is known on that point. Pending its stay in the ovary, the ovum underwent no appreciable modi- fication ; but as soon as it enters the oviduct, the beginning of those changes it must necessarily pass through, in order to give birth to a new being, is observed; and hence, to study these modifications in due course, we must first examine those manifested in the tube, and then such as do not appear until after its arrival in the uterine cavity. ARTICLE I. CHANGES OF THE OVUM IN THE TUBE.1 After the ovum is once deposited in the oviduct, it is no longer possible to find either the vesicle or the germinal spot; and this disappearance of the vesicle, and of the accumulation of granules at its centre, constitute the first modification which the ovum undergoes subsequent to its departure from the ovary. In the first half of the tubal canal the ovum is environed by a layer of granu- lations, of variable thickness, which constituted the proligerous disc while it re- mained in the ovary. The vitelline membrane is somewhat thickened, but it is still the only one that can be observed around the vitellus; when the ovum reaches the second half of the tube, it is no longer imbedded in the granulations 1 It has heretofore been always impossible to study these changes in the human egg, and the description we are about to give is the result of observations made on the eggs of mam- malia, especially of the dog and rabbit; but analogy favors the belief that similar pheno- mena take place in the human species ; indeed, the strongest resemblance exists between the ovum of the latter and the unfecundated egg of a bitch ; besides, the youngest ova that have been studied in the female, exactly resemble those which have arrived at a certain degree of development in animals. It is, therefore, extremely probable that if they are en- dowed with the same organization before conception, and still exhibit a perfect resemblance after the fecundation, they must have passed through similar successive transformations. DEVELOPMENT OF THE HUMAN OVUM. 165 of the disc, since they have disappeared, though a layer of a perfectly transparent gelatinous substance may be distinguished around the vitelline membrane. During the first part of this course the yolk has its consistence increased (Bis- choff), and forms a more compact mass ; it therefore does not exactly fill up the vitelline membrane, a small quantity of clear, transparent liquid being interposed between the internal face of the latter and its own proper surface. This conden- sation of the yolk is sufficiently marked, even after the envelope has been incised, to constitute a solid body, which may be separated by a very fine needle into two, four, or six parts. In the second half and inferior third of the tube, the surrounding layer of albumen augments, as well as the thickness of the vitelline membrane. But, Fig. 35. Fig. 36. Fig. 37. A. The layer of albumen, v. The vitelline membrane. according to the statement of Barry and Bischoff, the yolk undergoes the most remarkable changes of all, for, instead of'form- ing, as hitherto, a compact, homogeneous mass, it is divided first into two rounded portions (Fig. 35), the number doubling successively, in proportion as the ovum approaches the womb— their diameter of course diminishing at the same time ; consequently, in tracing the vitellus along the duct, the whole yolk will be observed to divide in two regular rounded halves, then into four (Fig. 36), afterwards into eight little spheres, and finally, each of the last subdivides again; so that, by reason of these successive subdivisions, the vitelline spheres become smaller and smaller, and ultimately terminate by causing the whole mass of the yolk to resemble a mul- berry in appearance. The yolk is in course of dissolution at the period when the ovum arrives in the womb. . . The time necessary for the ovum to traverse this passage is very variable in different animals, and even sometimes in the same species; thus, according to M. Coste, the ovum of rabbits does not reach the uterus before the third or the fourth day, whilst in the bitch, it has been found in the tubes as late as the tenth, twelfth, or even fifteenth day; and we have formerly stated that, in the human species,' no one case has ever proved its existence in the womb prior to the twelfth The Fecundated Ovum at a more advanced stage. 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. 166 GENERATION. day. However, it is well to remark, that as a general rule, the passage is very rapid through the external half of the tube, whilst its progress through the second half and especially through the last third is exceedingly slow, in conse- quence perhaps of the extreme narrowness of this portion of it. Finally, the ovum augments somewhat in volume during its course, being pro- bably nourished at first at the expense of the granulations which accompany it, and subsequently by absorbing the albuminous liquid secreted in the oviduct itself.1 AKTICLE II. MODIFICATIONS OF THE OVULE FROM ITS FIRST ARRIVAL IN THE WOMB UNTIL AFTER THE DEVELOPMENT OF THE ALLANTOIS. Fig. 38. When the ovum approaches the uterine cavity, it consists of the vitellus, to- gether with any granulations that may remain from the decomposition of the mulberry-like body, of the thickened vitelline membrane, and a very thin layer of albumen that surrounds it. Shortly after, the vitelline granulations wholly disappear, and they are replaced by a perfectly limpid and transparent liquid. These granulations seem to be condensed on the internal wall of the vesicle, and by their adherence to each other, to constitute there a second vesicle, enclosed by and lining the first. This second membrane is not easily recognized; but, if the example of M. Coste be followed, and the ovule be placed in water, it will be- come quite apparent. In fact, a very curious endosmotic phenomenon then takes place; the water passing through the vitelline mem- brane detaches the second vesicle in such a manner that the latter, being completely isolated, as also puckered and corrugated in every direction, floats or hangs suspended in the new liquid which dis- tends the vitelline membrane; and to this M. Coste has given the title of the blastodermic membrane, But while this blastodermic vesicle, or membrane, is being developed, the layer of albumen which sur- rounds the ovum on its first arrival in the uterus, disappears, and consequently the vitelline vesicle loses much of its thickness. Hitherto, the ovum still remained free and without any adhesion to the uterine walls; but period to contract more intimate relations with the latter, and hence can no longer be displaced by blowing upon it. Towards the sixteenth or seventeenth day after the fecundation, a rounded whitish spot begins to appear on some point of the blastodermic vesicle, which seems to 1 This layer of albumen which surrounds the ovum of the rabit and of the roebuck whilst it remains in the tube, does not exist around the ovum of the bitch and of the sow. On account of these differences, it will remain uncertain whether it envelopes the human ovum until observations which, as yet, it has been impossible to make, shall settle the question. The ovule shortly after its arrival in the womb. a. The diminished albuminous layer, v. The vitelline membrane, b. The blastodermic membrane. it commences about this DEVELOPMENT OF THE HUMAN OVUM. 167 be detached, or to stand in relief; this has been called the tache embryonnaire (the embryonic spot), by M. Coste, and it, like the blastodermic vesicle, is com- posed of cellular granulations, excepting that these latter are more contracted; and are aggregated in a larger quantity at this point. (Figs. 39 and 40.) At Fig. 39. Fig. 40. Fig. 39. The blastoderm, with the embryonic spot seen in front, v. The vitelline membrane, b. The ex- ternal layer of the blastoderm, f. The embryonic spot. Fig. 40. The same figure in profile, to show the two layers of the blastoderm, v. The vitelline mem- brane, e. The external; and I, the internal orintestinal layer of the blastoderm. the same time, a minute examination is all that is necessary to convince us that the vesicle, as also the embryonic spot, is composed of two laminae, lying in contact with each other, but which may be separated by a couple of fine needles. To render this doubling of the blastoderm more evident, we present two theoretical figures, exhibiting it at the same stage of development. In the first, which is a front view of the ovum, the blastoderm with the rounded embryonic spot is seen. The same figure, in profile, shows the two blastodermic laminae, both presenting a swelling near the embryonic spot. One has been called the external, or serous layer, and the other is denominated the internal, mucous, or the vegetative one. Shortly after this period, the embryonic spot enlarges by the further addition of granules, but more in one of its diameters than in the others, so as to exchange its rounded for an elongated form. A considerable projection above the external face of the blastoderm may be simultaneously noticed, which exhibits a convexity towards the vitelline mem- brane, and a concavity looking to the central part of the ovum (Fig. 41); and thenceforth the cavity of the blastodermic vesicle is divided into two distinct portions, the one embryonic, the other forming the umbilical vesicle. A line of greater obscurity may soon be recognized at the centre of this spot, being the first trace of the embryo. The margins of this spot fold inwards, as do also the extremities, thereby giving rise to an elongated body, with the ends swollen, in consequence of their doubling up, and a cavity of some depth at its centre. The body of the embryo is then readily distinguished, and resembles tolerably well in shape the body of a guitar. The extremity that is most swollen is called the cephalic, and the other, or less voluminous one. the caudal extremity; about that time the serous lamina of the blastoderm can be traced as continuous with the most external layers of the embryonic body, whilst the mucous one forms its internal plane. In proportion as the embryonic spot loses its distinctive characters, numerous little elevations, irregularly scattered over the external surface of the ovum, are seen to develop 168 GENERATION. Fig. 41. A section of a more deve- loped ovum, in which the two portions, the embryonic and the umbilical vesicle, begin to appear, o. The umbilical vesicle. I. The internal layer of the blastoderm, b. The ex- ternal layer, v. The vitelline membrane. Fig. 42. themselves, being, in fact, the commencement of those villosities which sub- sequently stud the exterior surface of the chorion. During the progress of these phenomena, the exter- nal, or serous layer of the blastoderm (Fig. 4U) is raised in folds around its central portion, which has been de- veloped into the embryo, and more especially so at the caudal and cephalic extremities. The fold gradually enlarges above, below, and on the sides, in such a man- ner as to form a true hood over the head and caudal termination; hence named from this resemblance the cephalic and caudal hoods. These folds elongate rapidly, passing along the dorsal regions of the embryo, and ultimately come into contact with each other on the median line. (Fig. 43.) The internal lamina of this fold is continuous with the embryo, along the whole circumference of its large ventral opening; and hence this first lamina, which is originally applied almost directly to the embryo, but soon after is separated from it by a certain quantity of liquid, thus becomes its im- mediate envelope, and has received the name of the amnios, and the interposed fluid, that of the amniotic liquor. As to the external layer of the fold, it is mani- festly continuous with the serous lamina of the blastoderm, and although primarily applied to the preceding, it is speedily separated therefrom by the interposition of a liquid whifih removes them fur- ther and further from each other, until at last its exterior face is brought into contact with the vitel- line vesicle. According to some authors, these two become confounded, and by uniting form the outer membrane of the ovum; but others teach that the vitelline vesicle will be gradually absorb- ed (as we have endeavored to represent in the plates Figs. 44, 45, and 46), while the external lamina of the blastoderm is being developed, and the latter alone will then constitute the enveloping membrane. We embrace the former opinion the more willingly, because we have a proof that the exochorion is the primary membrane of the ovum, from its exhibiting some small irregular elevations on its exterior surface, prior to the formation of the amnios, which are the rudiments of the chorial villosities. At the point of junction, the cephalic and caudal hoods constitute, by their union, a kind of membranous bridge, which there joins the amnios to the chorion. This bridge is gradually absorbed, and the two membranes become completely isolated. (See Figs. 45 and 46.) Such is the view most generally received on the mode of formation of the A section, showing the origin and first traces of the amnios, o. The umbilical vesicle. I. The intestinal; and e, the external layer of the blas- toderm, v. The vitelline membrane. c c. Origin of the cephalic and cau- dal amniotic hoods. DEVELOPMENT OF THE HUMAN OVUM. 169 Fig. 43. The amniotic hoods more developed. o. The umbilical vesicle, i. The inter- nal or intestinal; and e, the external layer of the blastoderm, e'. A portion of the external layer converted into the amnios, e". The embryo, c. The limit of the amniotic hoods, v. The vitelline membrane. amnios. We must mention, however, one other, which, without being new, has latterly acquired considerable importance by the discussions which it has created at the Academy of Sciences. We have just seen that the amnios is directly continuous at the umbilicus with the abdominal walls of the embryo, which is in fact so mani- fest, that no just ground of belief is afforded that the latter was ever independent of the amnios, as some have recently supposed. Messrs. Oken, Pockels, Serres, and Breschet have en- deavored, notwithstanding, to prove that the amnios once existed as an independent vesicle, distended by a fluid; and that afterwards the fcetus, by coming into contact with it, caused its depression, and became enveloped by it, like a double night-cap, but having no other relation with it than that of simple apposition; or, in other words, that the amnios had the same con- nection with the embryo as the serous membranes with the viscera they cover. Messrs. Coste, Velpeau, and Bischoff have combated this view successfully, in my estimation, by contending for the exist- ence, at all periods, of the continuity we have just described, and they cannot possibly admit an opinion which is founded solely on pathological alterations. For my own part, after examining the preparations of M. Coste, I can have no doubt as to the little value of such assertions. Immediately after the amnios is formed, the margins of the embryonic spot, and especially its two extremities, become more and more turned inwards, thereby aug- menting the concavity which it previously exhibited; and, at the bottom of the groove thus constituted, the mucous lamina of the blastoderm is observed to concur in forming the intestinal canal, which is represented at this early period by an elongated gutter, com- municating freely with the interior cavity of the blastoderm. But, in proportion as this constantly increasing inversion of the lateral walls, and of the extremities of the embryo, progresses, this communication becomes more and more contracted, so that in a short time the intestinal cavity only connects with the blastodermic vesicle by a contracted pedicle; and thenceforth, this latter receives the name of the umbilical vesicle, and the vessels which are distributed to its vascular layer, consisting of two veins Fig. 44. This figure shows the amnios almost completed, and likewise the origin of the allantois. o. The umbilical vesicle. I. The intestines, e. The amnios, e . The ex- ternal 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. 170 GENERATION. that enter, and an artery that emerges from the embryo, are called the omphalo- mesenteric vessels. (Fig. 44.) As the contraction of the ventral opening in the embryo, and the circumscrip- tion of the umbilical vesicle goes on, we may observe at the inferior part of the intestinal canal, just in the region where the bladder and rectum, during the earlier days of embryonic life, are confounded under the name of cloaca; we observe, I repeat, the intestinal parietes to form there a slight elevation. Now, this little tumor (Fig. 41) gradually elon- gates, so as to constitute a minute vesicle, which communicates by its narrow pe- dicle with the intestinal cavity; this is the allantois, which has been known for a long time to exist in mammalia, but which M. Coste was one of the first to detect in the human ovum. The allan- tois is scarcely formed before it is pro- vided both with venous and arterial vessels, consisting of the two umbilical arteries and one umbilical vein; the former arising from the primitive iliacs, the latter going to the liver, as may be seen somewhat later. This little vesicle passes through the umbilicus at first alongside of the pedicle belonging to the umbilical vesicle, and soon undergoes a rapid development. The growth of the allantois and its ves- sels is so rapid that it soon comes into contact with the external membrane of the ovum. In some animals, the allan- tois comes into juxtaposition by its base with only one point of the chorion, and becomes attached there; and then the terminal extremities of the umbilical ves- sels not only reach this membrane, but even extend for the most part to the vil- losities developed on its external surface, and acquire there a considerable growth. In others (see Figs. 45 and 46), the allantois spreads out like an umbrella around the embryo and umbilical vesicle, and applies itself to the whole external face of the amnios, as well as to the internal one of the chorion, then the two laminae are fused into each other in such a way as to leave no trace of the allan- tois (Fig. 46); though when this view is more critically examined, it cannot be regarded as altogether exact, says Bischoff, as regards the human species, for: 1. No one has ever observed the least trace of the allantois, either on the internal face of the chorion, or on the external one of the amnios; and as both these are perfectly simple membranes, surely some ovum would have been found in which the fusion had not become so perfect. 2. The amnios never has vessels, and the chorion is equally devoid of them, except at the point where the allantois is attached, and the contrary should exist, as in the runii- Fig. 45. This figure shows the rapid progress of the allantois, and how it spreads over the foetus, the umbilical vesicle, and the amnios. This latter begins to ensheath the pedicle of the umbilical vesicle, and that of the allantois in such a way as to form a commencement of the cord. Ac- cording to some writers, the vitelline membrane disappears more and more. o. The umbilical vesicle, e'. The amnios, e". The external layer of the blastoderm, c. The point where the two hoods come into contact, v. The vitel- line membrane almost entirely atrophied, a. The aUantois. DEVELOPMENT OF THE HUMAN OVUM. 171 nantia and carnivora, if the allantois of women observed the same law as it does in those animals; it is therefore pro- bable that its base only is brought into contact with a circumscribed portion of the chorion. It is very difficult to decide upon this question; but the cases in which the point of insertion of the placenta is very distant from that at which the cord is attached to the chorion, would seem to prove, that, in some cases at least, the allantois spreads around the entire cir- cumference of the ovum. Whichever opinion we adopt, the views relative to the vascular relations which become established between the chorion and the allantois, remain unchanged. The development of the allantois com- pletes the essential parts of the ovum, although by reference to Fig. 55, Plate III, it will now be found to consist: 1, of the embryo; 2, of a variable quantity of liquid in which it swims; 3, of the amnios, already considerably distended, and forming a sheath to the parts that pass through the ventral aperture; 4, of the umbilical vesicle situated between the amnios and chorion, whose delicate pedicle, with the omphalo-mesenteric vessels appertaining to it, however, still communicate with the intestinal cavity; 5, the pedicle of the allantois vesicle still charged with the umbilical vessels; 6, the space between the amnios and chorion, partly occupied by the umbilical vesicle, but principally filled with a liquid called by M. Velpeau the reticulated or the vitriform body, according to the degree of its consistence; and 7, of the outer envelope, or the chorion. The phenomena yet to be studied have special reference to the enlargement of the ovum, and the development of the embryo; but before engaging with them, it is indispensably necessary to detail the changes that occur during the first fortnight of gestation on the internal surface of the womb. 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 amnios, c. The point where the two hoods are fused into each other, and form but a single membrane. e". The external layer of the blastoderm, a. The allantois. v. The vitelline membrane. 172 GENERATION. CHAPTER II. OF THE DECIDUA. In the second edition of this work, after having stated the opinions which have been successively advanced, respecting the origin, nature, and mode of develop- ment of the decidua, I said, " I have examined, with M. Coste, several of the pre- parations on which he relies for the support of his view, that the decidua is nothiugelse than the uterine mucous membrane itself, which is hypertrophied by the progress of gestation; unfortunately the ovum in all of them had advanced to the third month at least, and it seems to me that the question can only be determined when an opportunity shall be afforded of examining an ovum of not more than five or six weeks. ,1 am, therefore, far from having a settled convic- tion, though I am willing to confess that the last uterus examined by us together, has singularly shaken my belief on this point of ovology; and this, conjoined with the descriptions given by Weber and Sharpey, restrains me from speaking with the same degree of confidence as formerly. I therefore think it a question requiring further examination." (Page 176, trans, of 2d edition.) My desires expressed in 1844 have been realized; and, thanks to the kindness of M. Coste, I have had the opportunity of examining an admirable collection of specimens of all ages, which, I take the opportunity of acknowledging, have not left the remotest doubt in my mind, at least as regards the principal fact. I therefore reject the more or less ingenious hypotheses proposed hitherto,—hypo- theses which, it is true, were rendered very probable by the examination of a large number of ova expelled by abortion,—and with the sincerest conviction of its truth adopt the opinion, that the decidua is nothing else than the hypertrophied mucous membrane. For the benefit of those who may not have the good fortune to see the beautiful preparations of the learned Professor of the College of France, I think it proper to give further on the description and the figure borrowed from the magnificent atlas which he is publishing. But, before stating what I believe to be proved in reference to this interesting point, it will be necessary to give a brief exposition of the theory which has been generally received until of latter time, as also to endeavor to discover the cause of the error of almost all who have investigated this subject. If an ovum which has been expelled intact, in consequence of an abortion within the first two months, be examined, there will be found to exist, outside of the chorion, a sort of pouch with which the ovum lies in contact by nearly four- fifths of its external surface, whilst the villi of the chorion are free and floating in the other fifth. This pouch, which is pyriform in shape, like the uterine cavity upon which it seems to be moulded, generally presents but a single opening, situated at the apex of the cone, which it represents, and evidently corresponding to the orifice of the neck of the uterus; sometimes, however, I have found it perforated on at least one side at the point corresponding to the opening of the Fallopian tubes. The walls of this pouch are formed by a membrane known to embryologists as the decidua. It has two surfaces, one external and the other internal? The OF THE DECIDUA. 173 internal surface is smooth, covered with epithelium, and when examined with a lens, presents small elevations, in form not unlike the circumvolutions of the cerebrum, and each furnished with several oval openings. The cavity limited by this surface sometimes contains a muco-albuminous fluid, and in certain patholo- gical cases, fluid or coagulated blood, though ordinarily they do not exist in it. The external surface of the decidua may be divided into two portions, the smaller of which is in contact with the ovum, and surrounds the greater part of its external surface; the other, and by far the largest portion, is entirely free, and must, when the ovum was still within the uterus, have been applied to the internal surface of the womb. This external surface is very irregular, and thickly studded with small and slender filaments. The portion of this membrane in contact with the ovum, was at first termed the ovular decidua, and afterwards, as suggestive of the way in which it was supposed to be formed, the decidua reflexa ; the other was called the uterine or parietal decidua, on account of its ^' relation with the wall of the uterus. Now, what is the nature of this membrane ? What is the mode of its formation ? At what period is it deve- loped ? To furnish replies to these questions the following theory was imagined, which theoretically furnishes quite a good solution of all the difficulties of the case. As previously stated, the uterus, like all the other geni- A section &f tne womb tal organs, becomes the seat of a more active vitality imme- exhibiting the decidua in diately after a fruitful coition; inconsequence of which J^0^T *eT*™^ the blood flows there in increased quantity, occasioning a of the neck, b b. Orifices congestion and turgescence of tissue, not far removed from <>f the Fa>u°Pian *»*><»• c. ° ° ' The decidua. d. The cav- inflammation. This abnormal excitement is always accom- ity of the deciduous mem- panied by the secretion of coagulable lymph, a sero-albu- orane. minous fluid, which soon fills up the uterine cavity. In the course of a few days the fluid thickens, and its exterior particles, by becoming more consistent, form a soft pulpy membrane, which lines the whole internal surface of the womb; thereby constituting a true sac, that is in contact externally with the mucous membrane throughout, and is filled by the uncoagulated portion of the fluid. From its position, this pouch must evidently assume the shape of the uterine cavity upon which indeed it seems to be moulded (Fig. 47). The fecundated ovule does not reach the cavity of the womb until after the lapse of eight, ten, or even twelve days, from the time of fecundation, but the membrane just spoken of begins to form much earlier. The consequence is, that after the ovule has traversed the tube, it finds the internal orifice closed by the decidua, and evidently can only pass between it and the uterus by pushing the membrane before it. From this time, the decidua presents two distinct layers, the most extensive of which lines the internal surface of the uterus, except at the point occupied by the ovum; it is called the external or uterine decidua. The other, which is pressed inward by the ovule, and is therefore in contact with a greater or less extent of its external surface, is termed the internal or reflexed decidua, the ovular decidua, and the epichorion of Chaussier. These two layers are at first widely separated from each other; but as the 174 GENERATION. Fie. 48. The decidua after the arrival of the ovum. c. The external, or ute- rine decidua. b. e. The internal or reflected layer, d. The cavity of the decidua. f. The chorion, o. The amnion. The other references the same as in the preceding figure. ovum increases in size, the extent of the reflected decidua is necessarily aug- mented and the cavity diminished, so that by the fourth month the latter has disappeared, and the parietal and ovular layers come in contact. The ovum is in immediate contact with the uterine mucous membrane by a small part of its chorial villosities only; all the rest of its external surface being separated from it by the reflexed layer, the cavity, and the parietal layer of the decidua. All the villi of the chorion which are covered by the decidua, after a time become atro- phied and disappear; but those which are in immediate contact with the mucous membrane become greatly developed, and contract more or less intimate connections with the vascular villi belonging to the latter membrane, at the point where subsequently the placenta will be developed. We see that thus far this hypothesis coincides very ingeniously with the appearances presented by ova which have been ex- pelled uninjured by abortion. It enables us to understand perfectly how that, notwithstanding the complete integrity of the decidua, the ovum is yet covered by it in but a part of its extent. Subsequently, however, at the autopsies of women who died in the third or fourth months of gestation, a membrane was discovered upon the external sur- face of the placenta, resembling precisely the parietal decidua, and continuous with it, without there being any discoverable line of demarcation between it and this inter-utero-placental membrane; so that this uterine decidua, which in aborted ova was in contact with but a portion of the surface of the ovum, was found to surround it completely, as the shell encloses the egg of a bird, when opportunity offered for examining it in situ in the uterus.1 This apparent con- tradiction with the theory was accounted for by the following hypothesis. The arrival of the ovule does not at once suspend the former secretion in the uterus; and it continues to go on, more particularly from the surface that is directly in relation with the ovum, in consequence of the greater vitality which the latter maintains; and the secreted matter, being precisely similar to that which formed the primitive decidua, thickens in turn, thereby constituting a layer of plastic material, precisely like the first, between the ovum and the womb, which bathes both the chorial and the uterine villosities; and when this deposit finally coagulates, it contributes to the formation of the placental mass, the external surface of which is in this manner necessarily covered by an albuminous layer. This lamina has been called the secondary, or the inter-utero-placental decidua 1 In 1851,1 exhibited to the Academy of Medicine, and afterwards presented to M. Coste, who has had it engraved in his great Atlas, an aborted ovum, presenting a perfect decidua, Burrounding the ovum as the shell surrounds the egg of a bird. The examination of this ovum revealed an arrangement entirely similar to what will be described hereafter from specimens observed in the uterus. This is, I believe, the first perfect aborted ovum which has ever been studied. OF THE DECIDUA. 175 (decidua serotina). Although limited at first to the external surface of the placenta, it soon unites so intimately with the uterine layer of the primitive decidua, that their separation becomes quite difficult at a more advanced period. According to this view, the decidua serotina and the primitive decidua have a common origin and texture, and only differ as regards the time of their for- mation. In adding, finally, that the decidua was by some supposed to be destitute of vessels (anhistous membrane of Velpeau), whilst others considered it to be per- forated and traversed by arteries and veins in considerable number, we shall have briefly reviewed the most generally-received opinions upon the subject. With the exception of some disagreement in regard to unimportant details, all authors were unanimous as respects this capital fact, namely, that the decidua is a newly-formed membrane superadded to the uterine mucous membrane, from which, however, it is entirely distinct. So evident, indeed, did this fact appear, that for the past ten years, no one, notwithstanding the old assertions of Saba- tier, Mayer, Seiler, and Weber, could bring himself to admit that the decidua was only a development of the lining membrane of the uterus. And even at the present time, notwithstanding the numerous preparations of M. Coste (1842), who was the first to sustain the truth of this proposition in France, many honest minds still hold to the theory of Hunter, which I myself supported so long. The evidence of anatomical demonstration is not, however, to be resisted, and I doubt not that all who, like myself, shall have studied the beautiful pre- parations at the College of France, will be convinced of the error of their views Theory of the Decidua.—The history of the decidua is, at the present time, merely a continuation of the account of those modifications of the uterine mu- cous membrane, the study of which was begun whilst treating of menstruation. They are, in fact, so intimately connected, that in order to understand what remains to be said on the subject, it is necessary to recall the condition of the mucous membrane of the uterus at the menstrual period. Whilst the evolution of the ovarian vesicle is going on in the ovary, the vascu- larity of the uterine mucous membrane is, as we have stated (p. 73), greatly in- creased, and the highly-congested vessels are discoverable beneath the epithelium. The utricular glands also become visibly enlarged. By this development of its principal elements, the mucous membrane is so thickened, that in consequence of its restriction to the small cavity of the uterus, it is thrown into folds and cir- cumvolutions of variable depth, which are especially well marked at the angles, and give forth secondary ramifications from the sides, so as to occasion some uniformity of appearance. This state of turgescence, and the violet hue which often accompanies it, is maintained in a greater or less degree, until the ovule is discharged; it diminishes during the last days of the menstrual epoch, and dis- appears almost entirely some time after the catamenia have ceased. But, if the ovule, before leaving the ovarian vesicle, or during its passage through the tube towards the cavity of the womb, receive the vivifying influence of the spermatic fluid, the fecundation will maintain and increase the abnormal excitement of the genital organs, produced by the simple development of the Graafian vesicle. Then, instead of subsiding, the uterine mucous membrane 176 GENERATION. becomes still more turgescent, and of a deeper violet color, and the folds and wrinkles increase so as to more than fill the cavity of the organ. Its vessels are engorged and distended to such a degree as to cause small effusions, which are perceptible beneath the epithelium, and also to produce ccchymosis, which give to the internal surface of the uterus a striking marbled appearance. Notwithstanding this great turgescence, the internal surface of the mucous membrane is smooth and polished, and never presents the villous projections described by Baer, neither is there any fluid secreted, nor any trace of a newly- formed false membrane. The orifices of the glandular tubes, which are much more visible than in the unimpregnated condition, are alone seen upon the surface. For a short time after it has entered the womb, the ovule is free from all ad- hesions, but soon becomes permanently fixed at the point where it was arrested at the outset. Before studying the means by which at a later period it becomes adherent to a circumscribed portion of the uterine parietes, let us examine the facts, and see what can be learned respecting the youngest ovules which it has been possible to observe up to the present moment. In the beautiful Atlas of M. Coste, is figured and described the uterus of a young primiparous woman, who committed suicide about the twentieth or twenty- first day of her pregnancy, aud whose body was opened at the Morgue of Paris. The size of the organ was nearly double that of the normal condition. A longi- tudinal incision was made through its posterior wall, after which it was opened and spread out, so as to exhibit the whole extent of the cavity. The latter was free as in the unimpregnated condition, and contained no fluid. The mucous membrane was, however, much thickened and tumefied, presented numerous irre- gular folds, and was furnished throughout with a rich network of vessels. Not- withstanding the general hypertrophy of the mucous membrane, a sort of soft tumor was discoverable, situated on the anterior surface of the uterus between the two Fallopian tubes, as though the membrane were thicker there than else- where. (See Plate II, Fig. 47.) Upon incising this elevated portion, the ovum was recognized by the villi of its chorion. The internal orifices of the tubes and of the neck were free and permeable as usual. Another woman was examined at the Morgue, who had committed suicide about the fortieth day of her pregnancy. The uterus, which was much larger than in the preceding case, was incised longitudinally on its anterior surface, and so disposed as to exhibit the greatest possible extent of the internal surface. As in the foregoing specimen, the mucous membrane, which was very vascular throughout and greatly hypertrophied, was in some points still more puffed up, and furrowed with folds and wrinkles. The upper two-thirds of the cavity were occupied by a soft, fluctuating tumor, situated upon the posterior surface between the two Fallopian tubes. Exter- nally, this tumor presented altogether the appearance and organization of the mucous membrane lining the remainder of the womb. The lower third of the cavity was free, so that the cavity of the neck could be entered without any ob- stacle presenting. The openings of the tubes were also permeable. An incision upon the most prominent part of the tumor revealed a cavity enclosing an ovum. The most superficial examination of these two pieces convinced us : 1. That the internal surface of the uterus is lined by a thick, soft membrane, which pre- OF THE DECIDUA. 177 sents numerous wrinkles and folds at several points. 2. That the ovum was situated in the upper part of the womb, and apparently lodged in a cavity per- fectly distinct from that of the remainder of the organ. Now, in order to solve the problem which we are investigating, we shall have to ascertain, first, the nature of the membrane which lines the cavity of the uterus, as also of those forming the walls of the pouch which encloses the ovule. 1. The Membrane lining the Uterus is simply the Mucous Membrane in a state of Hypertrophy.—When these uteri are compared with the description given (page 73) of the changes which the organ undergoes at the menstrual period, it will be readily perceived that the internal layers of the uterus present in both cases the same physical properties, the former being, however, more tumefied, vascular, and folded. It will also be seen, especially after the uterus has been immersed in spirits and water, that the numerous small openings are merely the glandular apertures enlarged, which are observable upon the mucous membrane in the unimpregnated condition (Page 60). Finally, the demonstration is com- pleted by the researches of M. Robin, showing that this membrane, like that of the unimpregnated uterus, is composed of the same anatomical elements, that is to say: 1, of fibro-plastic elements; 2, of cellular tissue fibres; 3, of nucleated fibres in small proportion; 4, of an amorphous matter serving as a connecting medium; 5, of tubular glands; 6, of capillary vessels; 7, that it is covered with the same kind of cylinder-epithelium. Therefore, it can be none other than the same membrane in a hypertrophied condition. 2. The ovum is enclosed in a distinct cavity, separated from that of the uterus by a membranous partition, which has to be incised in order to expose it. This is the membrane hitherto described as the decidua reflexa; now what is it? It presents, throughout, the characters of the uterine mucous membrane; it has the same physiognomy, the same arrangement, the same vascularity, and the same glandular orifices; only there is upon its most prominent portion a small circular space, around which the vessels disappear. This space, which is whiter, or of a lighter rose color than the remainder, is the largest in the most advanced ovum. The membrane is distinctly continuous with the uterine mucous membrane at its base, and the vessels traversing it are absolutely the same with those which ramify in the latter. Finally, microscopic investigations leave no doubt that the structure of the two membranes is identical. With the same physical qualities, continuity of tissue, and identity of structure, the membrane surrounding the ovum, the decidua reflexa of authors, can be nothing else than a portion of the mucous membrane of the uterus. If the ovum be removed from the cavity which enclosed it, the bottom of the latter is found to be lined by a membrane which is thickly sown with anfractuosi- ties or irregular lacunae of various sizes, in which those villi of the chorion were engaged which subsequently form the placenta. It is the portion of the mucous membrane to which the fecundated ovule adhered at the outset, and fs conse- quently continuous with that covering the parietes. Therefore, the ovule, which upon entering the womb lies free in the cavity, becomes, after the lapse of a period as yet unascertained^ enveloped by and lodged in a sort of fold of the mucous membrane. The manner in which this inclusion of the ovule is effected is a subject of 12 178 GENERATION. hypothesis; for, although the ovule has been observed when free, at the outset, as also when completely enveloped after the third week of gestation, observations are wanting for the intermediate period. Therefore, in the absence of direct in- formation, we give the explanation proposed by M. Coste, and, indeed, it is diffi- cult to conceive how the phenomenon could take place otherwise. After traversing the Fallopian tube, the ovum escapes from its internal orifice, and falls into the cavity of the uterus. On account of the swelling of the mucous membrane, this cavity is almost obliterated, and the ovule is consequently sup- ported between two opposite points of the hypertrophied and softened membrane. Therefore, it rarely progresses very far, and usually becomes fixed upon the fundus near the middle of the interval between the orifices of the two tubes. Now, notwithstanding its minuteness, it is impossible that the ovum should not depress the softened tissues with which it is in contact, and it soon excavates, so to speak, a cell in their substance. As the ovule increases in size, the swelling of the mucous membrane also pro- gresses, especially at the point where the former is arrested. As a consequence of this simultaneous development, the depression produced by the ovule in the substance of the mucous membrane becomes deeper, and it is gradually buried, first one quarter of it, then one-half, until at last it is almost completely hidden and enclosed. (Richard, Extract from the Lessons of M. Coste.) In proportion as it becomes more deeply buried, the edges of the cavity excavated by it seem to grow up around it, at first to the level of the most projecting portion, and then approach each other, so as gradually to contract the opening by which a com- munication is maintained with the remainder of the uterine cavity. The borders of the opening draw still nearer, and finally circumscribe a minute orifice, the trace of which remains for a short time only, in the form of a central depression or umbilicus. The umbilicus itself at last disappears, and from this time the ovum is completely imprisoned in a sort of cyst, whose walls are composed exclu- sively of the mucous membrane. Whatever may be thought of this theory, we find in the uterus, five or six weeks after conception, an entirely free space, the ovum occupying but a portion of the cavity, and a greatly hypertrophied mucous membrane, which at the point where the ovum is fixed, seems to fold upon itself in order to embrace the latter. We have now to ascertain what becomes of the uterine mucous membrane during gestation, as also of the two layers produced by its folding. One of these layers is situated between the ovum and the. uterus, at the point where the placenta will subsequently be developed; the other covers the entire non-adherent portion of the ovum. The first, the intermediate or utcro-epichorial membrane, replaces the decidua serotina or secondary decidua, the inter-utero- placental tissue of authors; the other, or epichorial membrane, was called, accord- ing to the old theory, the decidua reflexa or ovular decidua.1 1 Examine Plate II, engraved upon copper, for the details to follow. The fineness of the parts to be represented would be very imperfectly figured by plates or wood-cuts, distri- buted in the text. The three engravings are borrowed from the splendid Atlas accompany- ing M. Coste's History of the Development of Organized Bodies. PI II Fig ±9 H 50. ?i£. 51. A hsj.VtL '.u.riairs lili Phil" OF THE DECIDUA. 179 EXPLANATION OF PLATE II. Fig. 49. Uterus at the twentieth or twenty-fifth day of gestation. Half the natural size. c, c. Mucous membrane of the uterus, with its rich vascularization. c/. The portion of mucous membrane which covers the ovum. x. The small circular space around which the vessels disappear, and whose centre presents the appearance of a recently-closed umbilicus. u, u. Muscular structure of the uterus, exhibiting, upon the cut surface, a multitude of venous sinuses in various degrees of development. m, m. Muscular portion of the neck, distinguished from that of the body by the ab- sence of venous sinuses. I. Vaginal portion of the neck. V. A gland of Naboth, greatly distended. a, a. The ovaries. On the one to the right is a highly-developed corpus luteum, #; its surface is very vascular, and on its apex is perceived g/, the cicatrix of the opening through which the ovule escaped. t, t. Fallopian tubes. p, p. Fimbriated extremities of the tubes. Fig. 50. Is the same specimen as the preceding, except that a circular incision has been made in the portion of mucous membrane upon which the ovum is situated, and the flap turned back, so as to exhibit its deep or ovular surface. h. Section of the mucous membrane covering the ovum, exhibiting its thickness relatively to that which lines the remaining portion of the womb. c//. Internal surface of the flap of the uterine mucous membrane (decidua reflexa) which covered the ovum. ce. The ovum, with its surface thickly set with short but considerably-branched villi, which come into direct contact with the maternal blood. Fig. 51. The uterine mucous membrane of the specimen represented by Fig. 49, divided on a level with the neck, and seen separately. The blood which distended its vessels having escaped, in consequence of its immersion in spirits and water, the vas- cular network which it exhibited has disappeared, and permits us to see that its entire surface is perforated with minute openings, which are the glandular apparatus, observ- able upon the mucous membrane of the uterus in the unimpregnated condition. The portion of mucous membrane beneath which the ovum was situated, is incised as in the preceding figure, but the ovum is here removed, so as to exhibit completely the walls of the cavity which contained it. f. The cell or cavity which contained the ovum, strewn with anfractuosities and irregular lacunae, in which the villi of the chorion were inserted. c//. Internal surface of the flap of mucous membrane which covered the ovum. The same lacunae are observable in it as on the opposite surface f, but they are smaller, less numerous, and less pronounced. s. Sections of the venous sinuses of the mucous membrane of the uterus. V, V. Internal orifice of the Fallopian tubes, rendered visible in the preparation by the greater unfolding of the mucous membrane. There is no indication of their ever having been obliterated, A. The Intermediate or Utero-epichorial Membrane.—If, after the removal of the ovum, the cavity which it occupied be examined during the first month, or the first half of the second, a multitude of irregular grooves or lacunae, of variable size and depth, in which the villi of the chorion were engaged (see PI. II, Fig. 51), will be perceived upon the mucous membrane which forms its bottom. These lacunae, into which smaller ones enter, and which are so numerous as to 180 GENERATION. give to this portion of the membrane the appearance of an areolar, erectile tissue, are supposed by M. Coste to be produced by the wearing away, or corrosion of the vessels, which are more hypertrophied at this point than elsewhere, by the in- vading growth of the chorion ; so that the lacunae, by communicating directly in this way with the subjacent uterine sinuses, permit the maternal blood to flow into the cavity occupied by the ovum, and come into direct contact with the villi of the chorion.1 The presence of the ovum determines at this point a considerable hypertrophy of all the elements of the mucous membrane. The corresponding villi of the chorion also become greatly developed, and all together constitute at a rather later period the mass of the placenta. (See Placenta.) B. The epichorial membrane presents very different appearances according to the period at which it is examined. Shortly after its formation is completed, that is to say, after the umbilicus is obliterated, it differs in no respect from the parietal mucous membrane: its uterine surface has the same color, the same thickness, the same profuse supply of vessels, and is perforated in like manner with numerous glandular orifices. Its ovular surface presents at the same period irregular cavities or lacunae of variable depth, resembling precisely those described as belonging to the inter-utero-placental layer, and which are penetrated in like manner by the villi of the portion of the chorion covering the ovum. (See PI. II, Figs. 51 and 52.) But, as the ovum enlarges, it elevates and extends it, until about the end of the first month, when commencing atrophy is observed at its centre, in consequence of which its vessels and glands disappear, and the whole of this portion of the membrane gradually loses its thickness. (See PI. II, Fig 49.) The result is, that either in consequence of the distension which it undergoes, or of the pressure exerted upon its most prominent portion through the growth of the ovum, a small but gradually enlarging circular space, deprived of vessels, appears in its centre, whilst the remainder of the surface presents the same vas- cularity as the parietal mucous membrane. This central portion becomes very thin, even at periods when the circumference of the membrane preserves a con- siderable thickness. The obliteration of the vessels and the atrophy of the glandules progress from the centre towards the circumference, so that by the third month, the epi- 1 M. Coste has several times witnessed the ovum swimming, as it were, in a pool of fluid blood. New researches are needed to show whether this be a normal condition, or the result of an accidental hemorrhage. When we consider that the entire ovular surface of the epichorion presented the same irre- gular lacunae, they may be supposed to have been produced by the development of the villi of the chorion, which penetrate the substance of the mucous membrane, as do the roots of a tree into the earth, and leave the place which they occupied empty, after the ovum is ex- tracted. That this areolar appearance is better marked upon the inter-utero-placental mucous membrane, is due to the much greater development of the villous tufts of the chorion there than elsewhere, and which occupy a larger space in consequence. There would be, therefore, no eroded maternal vessels; as regards the blood surrounding the ovum, I am better satisfied with supposing that, if the condition be a normal one the congested state of the uterine vessels is greatest at the point of attachment of the ovule, and may be carried to the extent of producing an exhalation of blood, which does not take place from the remainder of the parietal mucous membrane. OF THE DECIDUA. 181 chorial membrane differs so materially from the parietal mucous membrane that, except at the parts adjacent to the points where the two become continuous, the glandular orifices and vessels are no longer discoverable. The lacunae described as existing upon the ovular surface, are still further effaced by the atrophy, and as the villi of the chorion, which were inserted into them, can no longer derive thence the means of nutrition, they become useless and atrophied in like manner. As the development of the ovum progresses, it tends naturally to encroach upon the cavity of the womb, and consequently to bring the epichorion and the uterine mucous membrane nearer together, until, at the end of the third month, the two are in contact. At a rather later period, they become so adherent as to be sepa- rated with difficulty. It is hardly necessary to state, that when thus deprived of its vascular elements, the ovular portion of the membrane can no longer accommodate itself to the dis- tension produced by the ovum, otherwise than by a progressive thinning of the membrane, and that its extreme delicacy in advanced ovums, or at maturity, is to be thus accounted for. It is found, however, even after labor, adhering either to the chorion or to the parietal mucous membrane. C. The uterine mucous membrane retains the characters already described until towards the end of the second month; but from this time it begins to grow thinner, and its numerous and deep folds are gradually effaced. This first period of degeneration progresses, however, very slowly, for at the third month, the state of the membrane is very nearly the same as at the menstrual periods. (Richard. Thesis.) From the fourth month, it begins to lose the marks of energetic vitality which had characterized it hitherto, and its external appearance (perforation and vas- cularity) is altered; it becomes atrophied to such an extent, as to be reduced by the seventh month to the one-twenty-fifth of an inch in thickness, and is still thinner at the termination of pregnancy. Though inseparable at the outset from the subjacent tissue, it is now, in a measure, an independent membrane, and may be isolated and detached in strips of considerable size. This ready separation is due, according to M. Robin, to the commencing development between it and the muscular tissue of a new membrane, which is at first soft, downy, and homo- geneous, the first trace, in fact, of the mucous membrane which is to replace the decidua that falls after labor. It thickens gradually during the latter half of gestation, and lines the internal surface of the uterus, whose muscular fibres are not therefore left exposed by the complete decollation and expulsion of the uterine decidua, which takes place after labor. New researches are required to substan- tiate this opinion of M. Robin. After the birth of the child, the decidua, which is thrown off in connection with the chorion, may still be divided into two layers (uterine decidua and decidua reflexa). It has a reddish-gray and areolar appearance, and an irregular surface: it is, besides, quite soft and easily torn, and although the vessels which traversed it whilst attached to the uterus are for the most part obliterated and atrophied, some of them are occasionally found still filled with blood. The villi of the chorion become fibrous and non-vascular, are found inserted in its tissue, being especially numerous in the vicinity of the placenta. 182 GENERATION. The inter-utero-placental mucous membrane is detached and expelled with the placenta, of which it forms a part (maternal placenta). It is about one-eighth of an inch thick on the external surface of the cotyledons, though the prolonga- tions which it sends in between them are much thinner. At the circumference of the placenta, it is evidently continuous with the ovular and uterine deciduas. This sort of maternal placenta is traversed by numerous vessels, which accom- pany the prolongations sent in by it between the cotyledons (remains of the utero-placental vessels). (See Placenta.) From the details into which we have entered, it is evident, 1. That excepting the membranes proper of the ovum, the amnion and chorion, the uterus contains none other than its own mucous membrane; 2. That at the moment when the ovule enters the cavity of the uterus, this membrane has throughout a thickness equal to, if not greater than, that which it possesses at the menstrual period; 3. That this abnormal thickness is wholly due to the hypertrophy of its con- stituent elements, and especially of the fibro-plastic element, as proved by M. Robin; 4. That immediately after the arrival of the ovule, the vitality of the uterus seems to be concentrated, in a great measure, at that point of the mucous mem- brane where the ovule is arrested; 5. That as a consequence of this concentration of the vital forces, the point mentioned of the mucous membrane becomes thickened, grows up around the ovule, investing it with a circular ring, which soon encloses it completely; 6. That from this moment the ovule is separated from the uterine tissue by the utero-epichorial mucous membrane, and from the remainder of the uterine cavity by the epichorial mucous membrane; 7. That, after the first month, the epichorial mucous membrane becomes atro- phied from the centre towards the circumference, loses its vascularity and glan- dular openings, and then alone merits the title of anhistous membrane, given by M. Velpeau to the entire decidua; 8. That this atrophy involves that of the corresponding villi of the chorion, whilst those which are in relation with the utero-epichorial mucous membrane become, like the latter, considerably developed, and subsequently form the placenta; 9. That, from the fourth month, the parietal mucous membrane begins to degenerate, growing gradually thinner, in consequence of the diminution of the fibro-plastic tissue, and of the obliteration by atrophy of its vessels and glands • 10. Finally, that a new mucous membrane is formed, by which the old one is removed farther and farther from the muscular tissue to which it adhered so closely at the outset, and that after labor it is completely detached and expelled with the ovum. This exfoliation of the mucous membrane of the uterus after parturition is explained, to a certain extent, by the formation of a new mucous membrane • but it is much more difficult to understand how it should occur in abortions during the early months, when the adhesion between the mucous and muscular tissues is so very firm. It is true, that the exfoliated decidua is much thinner than that which may be observed still adhering to the uterus at the same period, and that MODIFICATIONS OF THE HUMAN OVUM. 183 we may suppose a part only of the parietal membrane to have been detached. But does this supposition render the fact any more intelligible? especially, does it explain why the utero-epichorial mucous membrane, with which the villi of the chorion have already contracted such intimate connections, is almost never thrown off with the ovum in abortions ? These difficult points evidently require that new researches should be instituted for their elucidation. CHAPTER III. MODIFICATIONS OF THE HUMAN OVUM. (from the development op the allantois until the end of gestation.) By the details already given, we have shown that the human ovum, after the allantois has been developed, consists of the embryo, the two vesicles which emanate from it, and the enveloping membranes, that are destined to protect it, and to establish with the mother the relations necessary to its existence. The modifications these different parts undergo, from the early weeks of intra-uterine life down to the end of gestation, still claim our attention; and we shall com- mence the description by examining the appendages of the foetus. ARTICLE I. OF THE F03TAL APPENDAGES. These comprise the allantois, the umbilical vesicle, the amnion, and the chorion. § 1. Of the Allantoid Vesicle. The little pyriform vesicle we have denominated the allantois, is observed, about the tenth day, to spring from the inferior part of the intestinal canal, and taking on a rapid growth it soon becomes applied by its base to the internal sur- face of the chorion. The terminal branches of the two umbilical arteries and vein, as previously stated, ramify on the walls of this vesicle; and hence the urachus, which is nothing else than the pedicle of the allantois, is accompanied in its course by three bloodvessels (see Fig. 59, PI. III.), two of which (i i) are arterial, coming from the iliacs, and called the umbilical arteries. They run to the chorion, where they ramify, and ultimately reach the villi that form the foetal placenta. The third trunk is venous, and is known as the umbilical vein. The umbilical vein j leaves the right auricle of the heart at the point f, and soon after receives the contents of the vena cava inferior k; it then traverses the under surface of the liver m, to which it sends a copious vascular supply, and, before passing this organ, receives the omphalo-mesenteric vein at the point o; then, after leaving the liver, it gains the left side of the abdomen between the 184 generation. walls of this cavity and the intestinal fold e; next, by turning abruptly towards the umbilical cord, it gets to the left side of the urachus, and accompanies the latter to the chorion, where it follows the umbilical arteries into the villosities. After the earliest periods of development are over, there is but a single umbi- lical vein left, although, during the first part of the embryonic existence two are met with, one upon each side of the urachus (and consequently one for each umbilical artery). That on the right side becomes effaced, but its traces may still be found at the thirtieth or even the fortieth day; indeed, some such existed and were perceptible on the embryo I am now describing. When the umbilical vein has actually passed the liver, it gives off no branches whatever, in its course along the urachus, nor does it divide and subdivide until it reaches the chorion. But, in the earlier periods of gestation, when the two exist, they are observed to spread over the walls of the chest and abdomen in the form of a large vascular plexus, extending as far as the vertebral column; however, this new apparatus soon vanishes and leaves no vestige of its former existence. The body of the allantoid vesicle disappears very rapidly, and scarcely a trace of it can possibly be found after the lapse of a few days from its first appearance. In fact, nothing more is seen than a cord of variable length, extending from the embryo to the chorion, and having the umbilical vessels enclosed within it. This likewise becomes gradually atrophied in such a way as to disappear altogether in the substance of the umbilical cord; nevertheless, a portion of it still persists in the abdominal cavity of the embryo, forming there the cord subsequently known as the urachus; and just as this latter terminates in the rectum, it exhibits a small swelling which is afterwards converted into the urinary bladder. We may remark, in anticipation, that this rudimentary bladder communicates with the rectum, and constitutes there that transitory cloaca, whose existence in the human species may be positively verified by direct observation. It is this early disappearance of the allantois which has induced some ovologists to doubt its existence in the human race. It is exclusively destined to bring the embryonic vessels into contact with the external membrane of the ovum, whence they are soon placed in their proper relation with the internal surface of the womb. § 2. Of the Umbilical Vesicle. This vesicle is formed exclusively by the internal or mucous layer of the blasto- derm ; at first, it is very voluminous, occupying nearly the whole cavity of the ovum, and communicating so freely with the intestinal cavity as to form with it apparently but a single vesicle. But the gradual contraction of the ventral opening serves to separate the two, as we have already demonstrated, leaving only a pellicle of variable thickness, according to the size of this aperture. The umbilical vesicle contains a yellowish-white liquid, in which numerous granules and some few globules are seen floating. It seems to be formed of two laminae, one being an external or vascular, and the other an internal or mucous layer. As the amnion becomes developed, the vesicle is crowded by this mem- brane, and is then found placed between the external face of the latter and the internal surface of the chorion. In consequence of the development of the allantois, the umbilical vesicle loses MODIFICATIONS of the HUMAN OVUM. 185 much of its importance in the human species, as it so soon becomes an organ of little value either to the growth of the ovum or the embryo: and furthermore, it dwindles away speedily; thus, during the first three weeks, it is as large as an ordinary pea, but after the fourth, it begins to collapse and diminish in size, and at six weeks subsequent to the conception, it does not exceed a coriander seed in bulk; then it remains stationary for a time, not disappearing altogether until towards the fourth month. I have observed it several times of latter years on ova of three to three and a half months, in which it generally still retained the volume and shape of a small lentil, being of a yellowish color, and having its surface wrinkled. However, I may remark, that its size appeared very variable in several ova of the same age. In proportion as the umbilical vesicle becomes atrophied, it is removed further and further from the trunk of the embryo, in consequence of the development of the amnion, and its pedicle is also elongated in a marked manner; thus, the latter is from two to six lines in length, being continuous at one end with the intestine, and at the other with the vesicle by a kind of an infundibuliform expansion. The pedicle is apparently separated into two portions by the amnios, before the abdominal walls are completely closed up; one part lying between the spine, or rather the intestine, and the spot afterwards occupied by the umbilicus, while the other remains exterior to the abdomen. This pedicle is traversed by a small canal for the first five or six weeks of its existence, and through it the fluid in the vesicle may be pressed back into the intestine, but it is obliterated after that period. About the same time, also, it becomes more and more delicate, and often ruptures from its great elongation; and its umbilical portion being lost in the cord, can no longer be traced into the abdomen. When broken, the vesicle may be found more or less removed from the root of the cord, and lying between the chorion and amnion. The umbilical vesicle has a rich vascular apparatus, the blood of which is carried to and from the embryo by the intervention of two trunks, one venous, the other arterial; both, however, accompany the pedicle, and form a constituent part of it. The first, N (see Fig. 59, PI. Ill), called-the omphalo-mesenteric vein, enters the abdomen, winds around the duodenum, and then opens into the umbilical vein at the point o, just as the latter is emerging 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 which furnishes the branches just described, persists in the adult under the name of the ventral or hepatic-portal vein, whilst all the rest will disappear with 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 intes- tine itself; then it reaches the pedicle, and follows the latter to the umbilical vesicle, upon which 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 vascular system of the umbilical vesicle re- presents the primitive circulation in the embryo, corresponding in it to the san- guiferous apparatus of the yolk of fowls. Of course, these vessels will become atrophied with the organ to which they belong. 186 GENERATION. The umbilical vesicle seems to be intended to serve as a reservoir for the fluid designed to nourish the foetus during the first weeks of intra-uterine existence. § 3. Of the Amnion. The most internal membrane of the ovum, or the amnion, is formed by the inner lamina of the fold, or the cephalic and caudal hoods which constituted the external serous layer of the blastoderm surrounding the embryo. Being con- tinuous, as we have shown, with the margins of the ventral opening, it seems at first to be attached by its middle part to the skin on the dorsal region. The internal amniotic surface subsequently exhales a liquid into its cavity, in which the embryo swims freely; hence the amnios constitutes a little sac around the foetus, having smooth and transparent walls. Its inner surface is bathed by the liquid enclosed in the cavity, whilst its external one is separated from the chorion by a space of variable size, which is likewise filled with a fluid. Originally, this membrane was not concentric with the chorion; but in pro- portion as the development advances it presses back the exterior liquid more and more, thereby condensing it, and finally comes in contact with the external enve- lope of the ovum. Now, since it adheres to the periphery of the umbilical open- ing, it must furnish, by such an extension, a sort of membranous sheath to the pedicles of the allantoid and the umbilical vesicles, as well as to their accom- panying vessels, surrounding them throughout their course from the umbilicus to the chorion; and all the parts thus enclosed constitute what is called the umbilical cord; whence it follows that the abdominal cavity itself must be in connection with the canal represented by this cord, and consequently that the foetal appendages may communicate with it through the route thus opened to them. It is thus that the pedicle of the umbilical vesicle becomes united to the ileo-ccecal fold of intestine, whilst the allantois connects with the rectum by the intervention of the urachus. As we have just stated, the amnios is separated from the chorion during the earlier weeks by a space filled with fluid, which space is larger in proportion as the ovum is the more recent. This extra-amniotic liquid forms a gelatinous or albuminous mass, of a weblike arrangement, and having the umbilical vesicle in its midst. The mass becomes more and more compact by pressure of the amnion, which has a constant tendency to approach the chorion, thus acquiring the aspect of a membrane (the membrana media of Bischoff), which is situated between the chorion and the amnion, where, says this author, it may be readily distin- guished towards the end of pregnancy, as a gelatinous, though continuous mem- brane. Wagner, on the other hand, describes this mass as resembling the inter- muscular cellular tissue; and M. Velpeau has given it the name of the vitriform or reticulated body; but he is certainly wrong in considering it as analogous with the allantois. The amnion undergoes no important change during the ulterior development of the ovum, nor does its texture. Of course, it would be more firm and con- sistent, acquiring by time a greater resemblance to the serous membranes, although it neither encloses nor possesses vessels at any period. Nevertheless, says Duges, it probably has some openings, which permit the waters, exhaled by the uterine capillaries, and received by the vessels of the decidua and the villi MODIFICATIONS OF THE HUMAN OVUM. 187 of the chorion, to be diffused around the foetus; but this perspiration of the liquids secreted by the internal uterine surface, may very possibly be a simple phenomenon of endosmosis. § 4. Waters of the Amnion. The amniotic cavity is filled with a liquid, in which the fcetus is immersed. At the commencement of pregnancy, this fluid is of slight density, and more or less transparent and limpid, but towards term it becomes viscid, unctuous, and more consistent than pure water; sometimes it is as clear as serum; at others, is of a light yellow or greenish color. It frequently becomes lactescent, turbid, and interspersed with yellowish-gray, or even black albuminous flakes; again, in cer-< tain cases, it is strongly tinged with yellow, when the membranes are ruptured, from the admixture of a quantity of meconium; it exhales a disagreeable odor, analogous to that of the spermatic fluid, and its taste is slightly saline. The quantity of the amniotic fluid varies greatly; thus, in the early months it is, relatively to the foetus, more abundant, in proportion as the embryo is younger. Riolan found four ounces in an ovum containing a fcetus of the size of an ant. The weight of the foetus and that of the fluid at the middle of ges- tation, are very nearly equal. Again, dating from this period, the difference is generally in favor of the foetus, and the weight of the latter at term is four or five times greater than the waters, which seldom exceed a pound or a pound and a quarter; consequently, if the assertion is true, that the waters augment in their absolute quantity until term, it is equally so to say they increase relatively to the fcetus in the first, and diminish in the second half of pregnancy. In fact, the variations in this respect are infinite, even at the time of the accouchement. According to the analysis of Vauquelin, 100 parts of amniotic liquor consist: of water 98-8; of albumen, hydrochlorate of soda, phosphate of lime, and lime, 1-2. The interesting question now arises, What is the source of the amniotic fluid ? Some assert that it comes from the mother ; others, that it is produced by the foetus. Chaussier, Meckel, and Beclard, adopting an intermediate opinion, suppose that its secretion takes place simultaneously from the female and her product. Everything proves, says M. Velpeau, that the liquor amnii is the result of a transudation or of a simple exhalation, like the serum of the pleura, pericardium, &c, and that this process requires no particular canals for its accomplishment, being a phenomenon of pure vital imbibition. According to Burdach, the amniotic waters cannot be secreted by the foetus, because they exist prior to its formation,1 and therefore they must be exclusively furnished by the internal uterine surface, and reach the cavity of the amnios by traversing its walls. We also believe, that the greater part of this liquid comes from the mother's organs; yet we must add that it also contains certain products, secreted by the foetus: for instance, it is frequently colored by some meconium, and besides, it is almost certain that the urine may be discharged into the amniotic cavity during the latter months of pregnancy. A few incontestable facts prove that such an evacuation is necessary to the maintenance of fcetal life; thus, Bil- 1 It is only necessary to recall our remarks oh the development of the amnios to refute this opinion. 188 GENERATION. lard and T. W. King record having seen cases of ruptured bladder, resulting from imperforation of the urethra; aud further, Desormeaux and P. Dubois have observed an obliteration of this canal in two stillborn children, which had given rise to an enormous distension of the bladder, ureters, and both kidneys; indeed, the latter were found transformed into two multilocular cysts. Similar facts have been presented before the Academy of Medicine by MM. Depaul and Moreau. According to some authors, the principal use of these waters is to contribute to the nutrition of the foetus, during, at least, a great part of gestation. (See Autrition of the Pectus.) However this may be, the waters of the amnios serve during pregnancy to maintain the insulation of the external foetal parts before the .skin becomes covered with the sebaceous coat hereafter to be described; to pro- mote the active movements of the foetus and its development, both of which would have been greatly incommoded without this intervention, by the pressure of the uterine walls; to protect the foetus from all external violence, and to afford it the means of conforming to the laws of gravity. They likewise favor a uniform expansion of the womb, and remove all pressure from the umbilical cord, thus assuring the integrity of the focto-placental circulation both during pregnancy and labor. In the latter, they seem destined to guard the child from the vio- lence of the uterine contractions, which, without them, would certainly compro- mise its existence; to aid in forming the amniotic bag, the engagement of which renders the dilatation of the neck more uniform and easy; to lubricate the pelvic canal, and thus facilitate the descent of the foetus; and lastly, they render ma- nipulations of every kind less difficult than they otherwise would be. § 5. Of the Chorion. The chorion is the most external envelope of the ovum. Writers are by no means unanimous in their views as to the elements of which it is composed. Thus, some of them, as we have had occasion to state, suppose that it is formed by the vitelline membrane, the external lamina of the blastoderm, and the allan- toid vesicle, uniting to constitute a single layer. According to others, on the contrary, the vitelline membrane will disappear soon after the doubling of the blastodermic vesicle, and the external lamina of the latter, conjoined with the allantois, will then form the chorion. As to ourselves, the reasons have hitherto been given that induce us to adopt the former opinion. But be that as it may, .the chorion certainly does not exhibit the same aspect at the advanced stages of pregnancy; for during early embryonic existence the external membrane of the ovum is thin, transparent, and perfectly smooth on its outer surface, whilst about the second week this surface presents some minute granular elevations, which increase in length very rapidly, and the chorion soon becomes studded with numerous villi. But at that time neither the chorion nor the villi have a proper vascular apparatus, since it is not until after the allantois, together with the umbilical vessels, has become applied to the chorion, that any vessels can be detected going from this membrane, either to penetrate into all the villi, or only, perhaps, into a portion of them. The chorion is enveloped in a great measure by the reflexed or epichorial deci- dua, which separates it from the parietal decidua; and is in contact, by a restricted surface, with the portion of the mucous membrane which constitutes the utero- MODIFICATIONS OF THE HUMAN OVUM. 189 epichorial or inter-utero-placental decidua. There is at the outset a considerable space between its external surface and the internal one of the pouch containing it, which space is occupied by its villi, and may become, as we have already stated, the seat of a considerable effusion of blood. Those villi which are in contact with the reflected decidua, penetrate at first, as they increase in size, into the substance of that membrane; they soon, how- ever, become atrophied, and dwindle away almost completely, the interval dis- appears, and the two membranes come into immediate contact. • As regards the villi of the chorion, not covered by the reflected decidua, so far from being atrophied, they speedily undergo a considerable development, penetrate, as do the roots of a tree the earth, into the thickened and softened uterine mucous-membrane (utero-epichorial decidua), and, intercrossing with the numerous vessels developed in its substance, contribute to the formation of that essentially vascular mass we are about to describe under the name of placenta. The chorion is in apposition by its internal face with the amnios at an advanced period of pregnancy; but, as previously noticed, these two membranes are not concentric in the earlier months, being then separated by a considerable space that is occupied by the umbilical vesicle and an albuminous liquid, which is the more abundant and limpid as the gestation is less advanced. After the development of the placenta, the chorion is a thin, transparent, colorless membrane, united outwardly to the decidua by some short, delicate fila- ments, the remnants of the atrophied villi, and inwardly to the amnios by an albuminous layer (tunica media). The part corresponding to the placenta is no longer in immediate contact with the decidua; it is thicker, and adherent to the fcetal surface of that vascular body, and the attachment is more intimate near the root of the cord. After what has already been stated, it were idle to discuss the vascularity of the chorion, for it evidently has no vessels until after the allan- tois has been developed; but from that period it consists of two laminae, the external or primitive of which, also called the exochorion, is wholly destitute of vessels, whilst the internal or allantoid is essentially vascular, and has been denominated the endochorion. ARTICLE II. OF THE ORGANS OF CONNECTION. § 1. The Placenta. (After-birth, Secundines.) The placenta is a soft, spongy mass, constituting the principal connection be- tween the ovum and uterus, being destined to the hematosis, and perhaps also to the nourishment of the foetus. It is a flattened body, about three-quarters of an inch in thickness at the centre; but tapering off towards the circumference, which does not often exceed two or three lines; in some cases it is very thin, but then is very large, and further, its figure and dimensions are exceedingly variable; thus, the ordinary diameter of the placenta varies from six to eight and a half inches, at times one diameter is longer than the others, and the shape, therefore, is circular, oval, &c, according to circumstances. The term battledoor-placenta has been applied to 190 GENERATION. that variety in which the cord is inserted on the border. As a general rule, only one placenta exists in simple pregnancies. However, a very curious exception was observed quite recently at the Clinique of the Berlin Hospital, namely, a double placenta for a single child. Dr. Ebert furnishes the following descrip- tion of thie anomaly : When displayed on a table, it was found to be divided into two exactly equal rounded parts, which were entirely distinct, having no connec- tion whatever with each other, excepting through the intervention of the cord and membranes; an interval of about three inches separated the two portions. The cord was twenty-one inches long, containing, as in the normal state, the three vessels spirally arranged, but this spiral form ceased nearly two inches from the bifurcation of the umbilical vein; at this point the two arteries were placed, one on each side of the vein, and only communicated by a trifling anastomosis. The vein bifurcated about four inches from the placenta; the two resulting branches were of unequal length, and the longest sent a branch to the opposite placenta. The arteries had a similar arrangement, one being sent to each after- birth. The one corresponding with the longest vein likewise sent a branch to the other placenta, but the interior subdivisions of the vessels offered no further anomaly. The membranes formed a single cavity for the fcetus and amniotic waters; they invested the two portions of the cord, the fcetal face of both placentas, and passed from one organ to the other, thus lg' establishing a kind of membranous bridge between them, which, with the cord, was the sole point of communi- cation between these two masses. (Arch. Gen., 1842, t. xiv.) A similar case has recently occur- red at the Clinique d'accouchement de Paris, a drawing of which has been prepared by M. P. Dubois. A placenta presenting the same anomaly, was recently exhibited by me to the Biological Society. This specimen derived additional interest from the fact, that it was the product of a double pregnancy, the other ovum having a distinct and regularly-formed placenta. A much more singular case has been obligingly communicated to me by Dr. Blot. In this instance, the placental mass presented nearly the usual appearance, but around it were distributed several entirely distinct cotyledons, which were connected with it only by the vessels proceeding from them to join the ramifications of the cord. (Fig. 52.) The after-birth presents a fatal, or internal, and an external, or uterine sur- face; also a circumference, or border. The internal surface is covered both by the chorion and amnion, and exhibits numerous ramifications of the umbilical arteries and vein, which generally converge about the centre of this body to form Placenta, with five separate Cotyledons. A. Chorion, b. Amnion, c. The Cord. D. rate cotyledons. MODIFICATIONS OF THE HUMAN OVUM. 191 the umbilical cord. The uterine surface is much less smooth, polished, and uniform than the preceding, and is slightly convex, whilst the former is a little concave. It is subdivided into a variable number of lobes, or irregularly-rounded cotyledons, held together' by a soft, lamellated, albuminous tissue, which is so easily lacerated, that a rupture may occur during the separation of the placenta, Fig. 53. Fig. 54. Fig. 53. The internal, or fetal surface of the placenta. Fig. 54. The external, or uterine surface of the placenta. so that after its expulsion, the cotyledons appear to be separated from each other by deep furrows or fissures. The external surface of the placenta is covered by the decidua, or inter-utero- placental mucous membrane; a true maternal placenta, which is thrown off in connection with the foetal placenta (see Structure of the Placenta), and which covers the convex surface of the cotyledons to the depth of about one-eighth of an inch. This maternal placenta is traversed by numerous vessels, the open orifices of which are seen upon the external surface of the after-birth (utero- placental vessels). The placental circumference is thin and irregular, and its extent, although very variable, is generally about twenty-five inches. The margin, according to M. Velpeau, is continuous, without a well-marked line of demarcation, with the double lamina formed by the folding of the deciduous membrane. But in the opinion of other anatomists, the periphery of this vascular mass is continuous with the chorion, and only contiguous to the double fold of the decidua, which is there thicker and more dense, and presents a kind of triangular sinus for the reception of the placental border. Our future remarks upon the structure of the placenta will serve to show that its circumference is continuous with both the chorion and the decidua; with the chorion by its foetal portion, which, after all, is formed by the hypertrophied villi of the chorion; and with the decidua or parietal mucous membrane by its ma- ternal portion, which is but a thickened part of this same uterine mucous mem- brane. Structure.—The placenta is an essentially vascular organ. The vessels enter- ing into its composition are dependencies of the vascular systems, both of the mother and of the child. 192 GENERATION. Their ramifications within the villi of the chorion adhere to each other, though not by means of a structure analogous to cellular tissue, as some authors would have it, nor by a plastic matter, as is thought by M. Velpeau ; but simply, as the investigations of M. Robin prove, by a limited amount of an amorphous substance, wbich is somewhat fibroid where most abundant, but without a trace of cellular or any other kind of tissue. The structure of the after-birth has been a theme of numerous discussions among embryologists; but the researches of MM. Blandin, Jacquemier, Flourens, and Bonami, in our own times, and even yet more recently those of Reid, Weber, Coste, Eschricht, and Robin, have thrown much light on this subject. We have sought laboriously for the truth amongst these different opinions; and in believiug that we have found it in the facts established by MM. Coste and Robin, we are no less convinced that their task has been greatly facilitated by the researches of their predecessors. In order to render justice to all, we con- sider it our duty to give an analysis of the principal investigations which have been made in reference to this interesting point of ovology. If, while the placenta is still adherent to the uterine wall, a careful effort be made to detach it, we can easily see that this detachment takes place at the ex- pense of a particular tissue, which at once separates and holds the two surfaces in contact. Now, this utero-placental substance is of an albuminous, or rather of a laminated character, consisting of numerous lamellae which interlace in all directions, and adhere to each other at certain points only of their surface; and, as a necessary consequence of such an interlacement, this tissue presents multi- tudes of cells or areola, which become more apparent by making a slight traction on the placenta and uterus, or by introducing a current of air under the contiguous parts. This membranous layer (that has also been accurately described by M. Jacquemier) is moulded, as it were, on the irregular surface of the placenta, to which the adhesion is more perfect than to the corresponding part of the womb; it dips into the fissures that separate the cotyledons, unless these should happen to be very deep, in which case, it merely passes from one lobe to another, thereby forming a species of membranous bridge; but a cellulo-mucous partition much thicker than the preceding penetrates deeply between the lobes. At term, this membrane is very thin; a delicate, soft, gelatinous layer remaining adherent to the corresponding portion of the uterus. The lamina clothing the external sur- face of the placenta is continuous with the decidua, without exhibiting any other difference, says the same author, than a considerable augmentation of thickness; a disposition that is apparently mechanical, being due to the relief made by the projecting circumference of the after-birth, and which thus determines around tbat organ a greater accumulation of plastic material. According to that able anatomist, this membrane offers all the physical characters of the decidua; and he seems quite disposed to consider them both as being one and the same. This inter-utero-placental tissue is traversed by a great number of venous and arterial vessels, which pass from the internal surface of the uterus to the placenta (utero-placental vessels); but it does not appear to be the ultimate termination of a single bloodvessel, since the cells it forms clo not communicate, as has been stated, with the uterine veins. No trace of the injection remained, in this tissue, in the preparations just alluded to, made by M. Bonami. MODIFICATIONS OF THE HUMAN OVUM. 193 Let us proceed, however, to the vascular structure of the placenta, properly so called ; and, as I have witnessed the injections of M. Bonami, I cannot do better than transcribe here the following parts of his thesis : " An injection, composed of spirit varnish, colored with red lead, was first thrown into the venous system of the uterus through the primitive iliac and one of the ovarian veins. A second, consisting of spirits of turpentine and indigo, was then made of the uterine arte- ries through the inferior extremity of the aorta, ligatures being previously placed on all the vessels capable of transmitting the injected fluids to the inferior extre- mities. " The uterine cavity having been opened at some distance from the placental insertion, and the foetus stripped of its membranes, a blackish liquid, which was nothing but the blood, was next squeezed from the vessels of the cord; then injections, having linseed oil colored with white lead and yellow ochre as their base, were thrown into the umbilical vein, and into one of the arteries." These injections were made with the greatest possible precaution, and the fol- lowing results were afterwards obtained from a careful dissection : " At first, the red liquid injected into the uterine veins could be distinctly perceived on the foetal surface of the placenta. But, by what canals could the injection have penetrated so far as this ? Here was a new subject of research; but, by carefully turning the placenta aside, a considerable number of small vessels could easily be recognized, leaving the internal surface of the womb, traversing the inter-utero- placental tissue just described, and plunging into the substance of the placenta. These consisted of arteries and veins, readily cognizable as such by the different colored injections." 1st. Arteries.—The number of these is large, and they are more abundant near the centre of insertion than anywhere else; still, a few very delicate ones are found about an inch from the placental circumference. Generally, they are quite small, varying from a fourth of a line to a line in diameter. They assume very sensibly a spiral arrangement, and their course is oblique, almost always creeping along for a third of an inch, sometimes more, before their terminal extremities are directed towards the anfractuosities of the placenta; and they evidently penetrate the proper substance of the latter, though towards the uterus they are clearly continuous with the uterine arteries. Lastly, they have but few ramifications, and these rarely anastomose with each other. 2d. The veins pass from the uterus, through the inter-utero-placental mem- brane, towards the placenta, but they have not the same disposition as the arteries. The calibre of these veins, says M. Bonami, is nearly equal to that of the arte- ries, sometimes even a little larger, some of them being from two to three lines in diameter. The characters by which we could distinguish these from the arteries, were conclusive in the piece under examination. Thus, these veins were penetrated by liquids thrown into the uterine venous system; they were rectilinear, and their exceedingly numerous ramifications anastomosed freely with each other, thereby forming vast plexuses on the cell-walls, which penetrated the uterine surface of the placenta at all points; and, on the other hand, by further dissection, could be seen with the naked eye terminating in the large uterine veins. Besides these, according to Meckel and Jacquemier, there exists a vein 13 194 GENERATION. which encircles the periphery of the placenta; but this coronary vein is rarely complete, as it nearly always exhibits one or more interruptions of an inch or two in extent, although its continuity is sustained by a series of veins anasto- mosing with one another, and its course exhibits numerous varicose-like dilata- tions. It communicates, at short distances, with the uterine veins, and receives contributions both internally and externally; some of these spread over the uterine surface of the placenta, and anastomose with the veins that penetrate this body at its centre; the others, which are less numerous,, ramify in the substance of the decidua, two or three inches from the circumference of the placenta, and communicate by their outer extremities with the uterine sinuses, that are situ- ated about two inches from the placental periphery; but the presence of this coronary vein is not constant, for neither Velpeau nor Bonami have ever met with it. There are, therefore, certain arteries and veins that penetrate the placenta, belonging to the maternal vascular system; but before studying their distribution, let us examine that of the umbilical vessels. These, consisting of the umbilical arteries and vein, having arrived at the fcetal surface of the placenta, divide into several large brandies that are found between the amnion and chorion. The first of these membranes may be detached with great facility; but the second intimately adheres to the vessels, which it completely envelopes, thus forming a sheath in which one artery and one vein are always found, the vein being much the larger ; shortly after, each trunk divides into two branches, each of these into two others, and thus they go on subdividing dichotomously almost ad infinitum. The two umbilical arteries communicate freely with each other in the substance of the same cotyledon, and this anastomosis may even be seen without the aid of an injection. Again, if a coarse injection be thrown into one of the arteries, it will shortly return by the other; though, if the pressure be continued, it will pass from the arteries into the umbilical vein; but, if we commence by filling the vein, the injection reaches the arteries with more difficulty. If a very pene- trating mixture be used, the whole uterine surface of the placenta will be con- verted into a very delicate plexus, which never affords an outlet to the injected liquid; patulous orifices do not exist, therefore, at the extremities of the vessels. When a placenta has been thus injected, and is then macerated, it soon ap- pears to resolve itself into a substance resembling woolly flakes covered by nume- rous particles of a soft pulpy tissue, that is detached from them with much difficulty. These flakes present under the microscope a large number of granu- lations, composed of small, convoluted, twisted vessels, like those in the chorial villi of the cow or the sheep. These small granules have been described as acin i, or little grains. The vessels become longer as the maceration is continued, and finally lose flexuosity almost entirely. On the whole, therefore, the placenta is formed by vessels belonging to the mother as well as by those appertaining to the child, and each of its cotyledons is constituted in the following manner: the maternal, or utero-placental vessels penetrate at all points of its uterine surface, forming in its substance a network of exceedingly delicate meshes, while the umbilical vessels that penetrate on the foetal surface present those infinite ramifications just described, and these twist around and embrace the contracted meshes of the maternal plexus in all direc- MODIFICATIONS OF THE HUMAN OVUM. 195 tions. Further, the connection existing between these two orders of vessels appears to result from the membranous sheath that envelopes them both, even into the substance of the placenta. This sheath is furnished to one set by the chorion, to the other by the lamellar prolongations of the inter-utero-placental tissue. In other words, being com- pressed and united with each other through the intervention of a common sub- stance, these divisions and subdivisions form a cotyledon of the placenta. Again, all the minute vascular ramuscules are so intimately connected that it is impossible to separate the vessels belonging to the mother from those peculiar to the foetus, and they can only be distinguished from each other by the different colored injections. But, although the two series thus interlace, the maternal branches never communicate by their terminal extremities with those of the fcetus; since the finest injections, when most carefully ma,de, have never estab- lished a direct communication between these two orders of vessels,—unless by rupture of the walls. The description of Eschricht is very analogous to that of M. Bonami; thus, the former concludes that two orders of capillary plexuses are in contact in the human placenta, and that the uterine arteries are continuous with the veins of the same name through a capillary plexus, equally delicate with the one existing between the umbilical arteries and veins. But the researches of Weber have led to different conclusions as to the mode in which the uterine arteries run into the veins of a similar name in the placenta, and these curious results deserve some notice, inasmuch as they seem to form a natural transition to the arrangement which we shall describe hereafter. He states that the uterine arteries enter the after-birth without giving off any arborescent ramifications; and, on the other hand, that the veins do not arise by delicate ramuscules, but present, at their very origin, large trunks, which by anastomosing with each other very frequently and at all points, seem to form in this manner a system of cells, whence the blood then passes by some venous trunks into the uterine veins. These latter are continuous with the arterial tubes from their origin; their walls are excessively thin in the placenta, being there reduced to the internal coat, and collapse, so as to be nearly invisible when they contain but little blood. The terminal ramifications of the umbilical vessels project into these venous sinuses; moreover, the thin tunic of the vein is pushed into the interior of the vessel by the fcetal villus resting against its outer surface, and it thus furnishes a sheath to the latter, which seems to penetrate to the interior even of the maternal vascular tube, though in reality it does not. Read, in August, 1840, easily verified, he says, the existence of the utero- placental vessels, when examining the uterus of a pregnant woman, who died at the seventh month. After having detached a portion of the placenta under water, my attention was drawn to a number of rounded bands passing between the uterus and the external surface of the placenta. When the least traction was made, their walls became thinner as their length increased, and had a cellular appearance, though they were easily lacerated; whilst sometimes, though more rarely, they seemed to separate like the tufts of the uterine sinuses. By cutting into one of the sinuses, these tufts could be traced, and seen to ramify in its interior; some 196 GENERATION. seemed to penetrate the patulous opening of the sinus only, while others sank in for about an inch, and appeared to penetrate even the surrounding sinuses. I could easily satisfy myself by injection and microscopical inspection, that these tufts were the ultimate ramifications of the umbilical vessels. It is scarcely necessary to add, that these tufts only penetrated the openings of the sinuses situated near the internal surface of the uterus, and not those more deeply seated. Their volume varies very much, some appearing to fill the open- ing of the sinus entirely, whilst others only occupy it in part. Again, although the tufts appeared loose, and floating in the interior of the maternal vascular tube, yet they were evidently surrounded by the internal tunic of the latter, which was reflected on their external surface. I have assured myself that some of the utero-placental veins contained no prolongation of the fcetal vessels, but in many others the villous tufts (the ter- minations of the umbilical vessels) could be recognized and followed into the uterine sinuses. In tracing these utero-placental veins that contain no foetal vessels through the decidua to the surface of the placenta, the internal membrane of such veins is found prolonged on the neighboring placental tufts; and further, by following a large utero-placental artery through the decidua, we may see that as soon as it arrives on the face of the placenta, its internal tunic is prolonged on certain tufts that are found plunged in its orifice. The numerous branches of the foetal tufts which stop at the placental surface of the decidua, and neither penetrate into the uterine sinuses, nor yet into the orifices of the utero-placental vessels, are fixed by their extremities to the pla- cental surface of this membrane. Consequently, the placenta is formed interiorly by numerous trunks and branches (each containing an artery and a vein), and each of these branches, both venous and arterial, is surrounded by a prolonga- tion of the internal tunic belonging to the maternal vascular system, or at least by a membrane continuous with that tunic. Hence, in adopting such ideas of the placental structure, it becomes evident that the internal tunic of the mother's vessels is prolonged on each placental tuft, in such a manner that the maternal blood, arriving by the utero-placental arteries, passes into a large sac formed from the internal lamina of these vessels, and the blood is thus divided into a thou- sand different directions by the placental villi, which project like fringes into these vessels, pressing in their thin, soft parietes before them, and forming sheaths therefrom which completely envelope each trunk and each branch. The blood returns from this sac by the utero-placental veins without any extravasation or abandonment of the vascular system to which it properly belongs. Therefore, the fcetal blood, and that of the mother, can have no action upon each other' excepting through the spongy parietes of the fcetal vessels and the thin sac that surrounds them. It will be seen, that but a single step has now to be taken in order to reach the description given by M. Coste, the truth of which is placed beyond cavil by the microscopic investigations of M. Robin. It is really impossible to obtain a correct idea of the structure and develop- ment of the placenta, without being acquainted with the nature and structure of the villi of the chorion, as also with the changes undergone by that portion of MODIFICATIONS OF THE HUMAN OVUM. 197 the uterine mucous membrane (utero-epichorial decidua) upon which the ovule is engrafted. A. Villi of the Chorion.—We have already stated that before the allantoid is developed, each villus of the chorion contains a canal, which is open at its base, but terminates in a cul-de-sac at its free extremity; after the allantoid is deve- loped, the terminal ramifications of the umbilical vessels, both arteries and veins, penetrate into this canal as into the finger of a glove. The villi, after having been thus rendered vascular, become atrophied, and finally disappear from all that Fig. 55. This figure represents the manner in which the villi of the chorion ramify.—c c. Trunk of the villus. e. Terminal ramification intact, a. A terminal branch broken off. v. A lateral branch. part of the chorion which is covered by the reflected or epichorial decidua. Those, on the contrary, which are in immediate contact with the utero-epichorial mucous membrane (inter-utero-placental decidua of authors), undergo a con- siderable development, and ramify ad infinitum. When viewed collectively at this period, they have the appearance of a soft, hairy mass, very tufted and flaky, and of a semi-transparent gray rose color. If the villi which compose this hair-like mass of the chorion be separated from each other and examined, the following characters will be found applicable to all: a common pedicle, forming the base or trunk of the villus, about one-sixteenth of an inch long, and one-half as wide, for an ovum of six weeks, the dimensions varying, however, with the size of the ovum. From this pedicle are put forth numerous branches, forming a bulky tuft. The largest of these branches, after dividing two or three times, are again subdivided into innumerable minute branchlets. Again, some of the smaller branches stand alone upon the surface of the chorion, in the interspaces of the tufted pedicles just mentioned. The extremities of the subdivisions of the third and fourth orders are here and there found to present a sort of cylindric or flattened swelling. 198 GENERATION. One of the principal subdivisions of the umbilical arteries and veins is distri- buted to each of these pedicles, and extends into all of its branches, ramifying as it goes. Inasmuch as the branches of any one pedicle have no communication with those of a neighboring one, it follows that each tuft of the chorion has a circu- lation of its own. Although the terminal villi become longer, their thickness is not sensibly increased, for their diameter is nearly the same after, as before the development of the placenta. B. Utero-epichorial Mucous Membrane.—These hypertrophied villi come in contact with a very thick and much softened portion of the uterine mucous membrane. As they grow longer, they penetrate into the tissue of the mucous membrane itself, excavating therein a species of cells or lacunae, which can be seen without difficulty upon the bottom of the receptacle represented in Plate II. Fig. 51. Since the arteries, but more especially the veins, are so developed at this point that the frequent dilatations of the latter form large cavities or sinuses, from one- eighth to one quarter of an inch in diameter, the vascular villi of the chorion necessarily come in contact with the walls of the uterine vessels. According to MM. Coste and llubin, the latter are even worn through by the villi of the chorion, which having thus gained entrance into their cavities, are suspended freely in the blood which fills them. We cannot regard this immersion of the branches of the umbilical vessels as proved, and therefore prefer the opinion of Reid, Weber, Bonami, and some others, that their relation with the maternal vessels is one of simple contact. In neither hypothesis can a direct communication be admitted, for, as we shall soon see, each terminal villus of the chorion is imperforate at its extremity, and contains an artery, which is continuous, without any line of demarcation, with a vein. Soon these infinitely numerous and elongated villi become united to each other by means of an amorphous substance, which is deposited in small quantity amongst them, so as to give to each tuft of the same pedicle the compactness which each placental cotyledon presents at a more advanced period of pregnancy. The villi taken from the placenta immediately after labor, differ from those described only in the greater number of their ramifications, and the larger size of the pedicles and of the principal branches which they put forth. The foetal portion of the placental tissue is formed, in short, of interlaced fila- ments, which are simply the chief branches of the villi of the chorion whose ramifications can be followed to their termination only by the use of a lens so inextricably entangled are they, and agglutinated by the amorphous matter of which we have spoken. They thus form, by their agglomeration, a tissue of a reddish-gray color, soft, elastic, giving way to pressure of the finger, and yielding a filamentous fragment by tearing. The structure of all the villi is not, however, identical at the termination of pregnancy. Although the greater number preserve until the end the double vascular canal which they presented at the beginning, the vessels of a few be- come atrophied, and like the non-placental villi, finally constitute a very slender filament devoid of a canal. Fig. 56, for which I am indebted to the kindness MODIFICATIONS OF THE HUMAN OVUM. 199 of M. Robin, exhibits these differences, besides showing very clearly the admi- rable disposition of the fcetal vessel within the villus itself.1 Thus H and t represent a terminal prolongation of the branches of a placental villus, ovoid in shape, with a contracted pedicle and obliterated cavity; at b is another terminal prolongation of the same villus, having the structure which almost all of them retain in the placenta. It is composed of an external enve- lope B, or wall of the villus, of a structure identical with that of the chorion. Its thickness, and consequently that of the substance separating the blood of the foetus from that of the mother, may be estimated approximatively. It is about •0004 of an inch. This villus presents internally a partition A, dividing its cavity into two vascular tubes. The tubes are situated beside each other, like the barrels of a double-barrelled gun; they bend toward each other at a", so as to form a single canal at the extremity of the villus, which is arterial at d e, but venous at g' g. This partition A has only half the thickness of the external wall b. It has a spur-like termination at a", and adheres by its base at a' to the wall of the villus. When this disposition of the terminal ramifications is once understood, all dis- cussion, as M. Robin remarks, respecting a direct communication between the maternal and foetal vascular systems, is ended. Each of the capillary vessels of this double canal empties into a corresponding one of larger size, at the point of junction or of separation of a ramification with a larger branch; for example (Fig. 56), the arterial tube D E empties at a' into Fig. 56. The figure represents a fragment of the villi of the chorion obtained from the placenta. It exhibits prolongations of various appearance. Magnified 360 diameters. the trunk of the same nature of the principal branch c v, and the venous tube g' g discharges at the point c. 1 The minute details into which I am about to enter, are the analysis of the researches of my learned colleague and friend, M. Robin. They are for the most part recorded in an excellent memoir published by him, and also in the thesis of M. Cayla, one of his pupils. 200 GENERATION. The placenta is therefore composed of two parts, which are very distinct, in a physiological point of view, although they are confounded in a single mass at the end of gestation. One of these is the fcetal portion, and is more especially adherent to the chorion, from which it takes its origin; the other, the maternal portion, is a greatly thickened part of the uterine mucous membrane. It is very difficult to say what is the real mode of connection between these two elements of the placenta, since such different results have followed the dissec- tions of the most skilful anatomists. Their continuity, or direct communication, is at present, however, out of the question, for all are united in regarding their relation as one of simple contact, a greater or less extent of adhesion. Simultaneously with the expulsion of the ovum, the maternal placenta is thrown off in connection with the fcetal portion, and forms a layer of about the one-sixteenth of an inch in thickness upon the convex surface of the cotyledons, aud of still greater depth in their interstices. Thus, notwithstanding the very active part which this portion of the mucous membrane has played during preg- nancy, it nevertheless shares the same fate with the parietal decidua, being ex- pelled with the after-birth at the moment of delivery. The placenta appears to be destitute of nerves and lymphatic vessels. All the cotyledons composing the placental mass, are, as we have said, united by the interlobular membrane. Occasionally, however, one or several of these lobes are separated from the others, and seem to form another placenta by their isolation; in this way it has happened that several placentas have been attributed to a single foetus, and, perhaps, the facts mentioned at the beginning of tbis article are to be accounted for in the same way. The placenta may be inserted upon any part of the uterine cavity and even upon its orifice, though most usually it is fixed near the fundus of the organ. It has been customary to account for these varieties of insertion, by saying that the latter is determined by the most vascular portion of the organ ; overlooking the fact, that although the point of attachment be indeed more vascular than any other part of the uterine parietes, it is simply because of the insertion, thus con- founding the cause with the effect. According to some authors, the weight of the ovule determines the point of insertion of the placenta, which, if true, should most frequently take place upon the neck. Observation, however, refutes' this opinion. Finally, according to MM. Moreau and Velpeau, when the ovule enters the womb, it is obliged to separate the decidua from the wall of the uterus, and therefore naturally tends towards the points of least resistance. The details which we have given respecting the mode of formation of the decidua, show that the latter opinion is without foundation. The following seems to us to be the most probable explanation: Generally, by the time the ovule enters the uterine cavity, the latter is filled to repletion by the folded and swollen mucous membrane. This state of things renders it almost impossible that it should progress very far, and the consequence is, that in the vast majority of cases it lodges in one of the numerous folds near the fundus, and becomes attached in the vicinity of the orifice of the tube by which it entered. The placenta is, in fact, generally found in this neighborhood. Why, in some cases, it should be situated in the inferior segment of the womb, is of more difficult MODIFICATIONS OF THE HUMAN OVUM. 201 explanation, except upon the supposition that fecundation was effected after the arrival of the ovule in the uterine cavity; in which case, in consequence of the less swollen condition of the mucous membrane, it may have been able to obey the laws of gravity immediately upon entering the cavity, and thus descend towards the lowest points. Sometimes the insertion of the placenta upon the lower segment of the uterus occurs in several successive pregnancies. Ingleby relates one case in which it happened three times, and says he knew the same thing to occur ten times in another. M. Dunal, from whom I quote the above, gives an observation of M. Menard, in which the woman had this unfavorable insertion twice consecutively. Whether this sort of habit can depend upon a peculiar disposition of the Fallo- pian tube or of the uterus, is a question which anatomical research only is competent to decide. § 2. The Umbilical Cord. The umbilical cord is the flexible trunk, which unites the abdomen of the child to the placenta ; it does not exist during the early weeks of pregnancy, and its formation only commences when the embryo is completely separated from the blastodermic vesicle, which thereby becomes the umbilical vesicle; when the allantois, by being confounded with the external lamina of the blastoderm, no longer constitutes a distinct vesicle, but is merely a simple cord upon which the two umbilical arteries and the vein ramify; and when all these parts have re- ceived an enveloping sheath from the amnios. Now it scarcely appears thus formed until towards the end of the first month, being composed at this period, in all normal embryos of the age of the one which we shall describe (page 204), of three distinct parts : 1, of an enveloping canal, whose walls are formed by a reflexion of the amnios, and which is continuous at the umbilicus with the skin of the embryo; 2, of two pedicles proceeding from the fcetal appendages, around which this amniotic canal forms a sheath, and which communicate, the one under the name of the pedicle of the umbilical vesicle, with the ileo-coecal fold of intes- tine, and the other, under that of urachus, or the pedicle of the allantois, with the bladder. But soon after, as the development progresses, and the pedicle of the umbilical vesicle is absorbed, the cord becomes simplified, and is reduced to the amniotic sheath and the urachus, accompanied by the umbilical vessels, with which this sheath is confounded by the obliteration of the canal that constitutes it. The effacement of this canal, along which only the urachus and its accompanying vessels pass, progresses from the chorial extremity of the cord towards the umbi- licus, or abdomen of the embryo; and, as the progressive obliteration approaches the latter, it encounters the gut which advances beyond the umbilicus, and forms a hernia in the cord itself; but this rupture is naturally reduced, in consequence of the pressure exercised on the intestine by the progress of effacement, which ultimately reaches the navel, and presses back into the abdomen everything met with outside of its cavity. However, in some instances this process is not com- pleted in so efficacious a manner, and the intestine in such cases remaining beyond the umbilicus, produces the malformation known as congenital hernia ; a hernia that is nothing more than the persistence of an anatomical disposition, which always exists temporarily at a certain period of the embryonic life. 202 GENERATION. The cord, at the end of the first month, is still thin, cylindrical, and very small; but from the fourth to the eighth, and even the ninth week, it acquires a considerable proportional volume; and it exhibits either some enlargements, vesicles, or swellings, two, three, or four in number, which are separated from each other by a corresponding number of bands, or contractions. During the third month it diminishes in size, in consequence of a retraction of these tuberosities ; but again, commencing from this latter period, it continues to grow proportionally to the other parts of the fcetus until the end of gestation. The cord varies greatly in length at term: generally, it is from twenty-one to twenty-three inches; some have been observed, however, from six inches to five feet (one metre fifty-three centimetres); others, still more rare, have reached five feet nine inches in length (one metre, seventy-five centimetres). I delivered a woman with the forceps, June 23d, 1841, in whom the head had been retained above the superior strait, and where the cord was only nine inches long. These extremes are very rare; nevertheless, they are not the utmost varieties the cord may offer in its extreme limits, for it has been known not to exceed five inches, and has even been as short as two inches. In a case reported by Mende, it was so short that the placenta absolutely seemed fixed to the child's abdomen. Its size likewise varies in different sub- jects, being generally about that of the little finger, sometimes much smaller, and at others very large; but in all these cases its volume depends much less on that of the vessels than on the quantity of fluids accumulated in the surrounding tissue. The nerves and lymphatic vessels, which certain authors have described as belonging to the cord, are still a subject of research; admitted by some and denied by others, their existence is at least problematical. The arteries are two in number, and, following the course of the blood, they arise from the bifurcation of the abdominal aorta in the fcetus, and reach the umbilicus, whence they traverse the entire length of the cord, describing nume- rous flexuosities as far as the placenta, in the tissue of which we have already followed their ramifications. The vein, still following the route of the blood, arises from the numerous ramuscules studied in the placenta; the venous radicles of each lobe unite to form branches, which, in their turn, aggregate on the fcetal surface of the after-birth, to form there the trunk of the umbilical vein; and the latter, having arrived at the umbilical ring, abandons the two arteries, and runs towards the liver. (See Circulation of the fcetus.) The vein is nearly equal in size to the two arteries united; but it is much less flexuous, and consequently its course is shorter. These vessels are wound upon each other in a way nearly similar to the twigs of osier forming the handle of a basket; they give off no branches in the cord, and it has been remarked that the twisting of the vessels, which only begins after the second month, takes place, nine times in ten, from left to right. The vein usually occupies the axis of the cord, and the arteries wind uniformly around it. Of course, this enrolling must depend somewhat on the torsions of the embryo itself, and then the entire cord, together with its sheath, is involved, as not un- frequently happens; but when the cord is straight, and the arteries are twisted at least more than it is, these contorsions seem to result from a more rapid growth MODIFICATIONS OF THE HUMAN OVUM. 203 of the vessels within the sheath, than of the sheath itself (Haller). Now, the embryo and placenta being immovable, the turns starting from these two points will necessarily meet each other, and this indeed frequently takes place. Two, and even three umbilical veins have been met with in some cases; in others, instead of two arteries there is but one. Osiander once found three of the latter. It is worthy of remark, that neither the arteries nor the veins have valves at any part of their course. These vessels are surrounded by a gelatinous substance called Wharton's gela- tine, which is variable in its quantity, thereby giving rise to the division made by accoucheurs into the thin and fat cords. This substance is continuous on one part with the sub-peritoneal cellular tissue of the foetus, and, on the other, ac- companies the vessels into the placenta. Being spongy in character, it is consti- tuted by a clear, tenacious liquid, contained in the cellular areolae, that commu- nicate so freely with each other. The cord frequently has one or more knots when it is very long, some of which are formed during pregnancy, and often even at an early stage; but others are only produced at the period of labor: they never become so tightened (in gestation) as to compromise the life of the child, to whose movements they are certainly due; but we can understand that the cord may become tightly drawn during labor, from being shortened by circular turns around the trunk or neck; the knots, in such cases, may be so hardened as to intercept the circulation completely, and the death of the foetus will necessarily result if the labor be prolonged. In one case, figured in the work of M. Bau- delocque, the cord was knotted three times at the same place, and was interlaced like a mat.1 M. Soete, an accoucheur at Gheluwe, has described a very singular case of double pregnancy, in which the two foetuses pj„_ 5^ were enclosed in the same bag, and the two cords formed a perfect knot with each other. Besides these knots, true nodosities like- wise exist at times in the cord, produced either by the duplicature or the varicose state of one of its vessels. We have already stated that the cord is attached by one extremity to the umbilicus of the child, and by the other to some point of the foetal surface of the placenta; but this, however, is not always the case, for the facts are tOO numerous which go to ab anomaly, described by Benckiser. prove that the cord may indeed be inserted on the head, neck, shoulders, and other parts of the foetal trunk, not to admit some of them, at least; such, for example, as the one observed by M. Jules Cloquet, at Brussels. The placental extremity of the cord also presents some anomalies; it is usually fixed very near the centre, but sometimes is found attached to a part of the periphery, bearing 1 The ancients thought they could determine the fecundity of the female by these knots : thus, according to Avicenna, the more knots the more will be the future conceptions; and if they occur at some distance apart, the pregnancies will also be more distant from each other.—(Isrcelis Spachii gynceceorum libri.) 204 GENERATION. then the title of the battledoor placenta. Nor is it always attached to a point of the foetal surface of the placenta. For instance, Benckiscr has collected in his thesis numerous cases in which the cord was inserted at some point on the peri- phery of the membranes; and having arrived there, the vessels of the cord then divide into five or six large trunks, the branches of which, by ramifying between the membranes, reach the placental circumference, and plunge into the paren- chyma of this body. (See Fig. 57.) All such modifications, however, merely depend on the way in which the allan- tois contracts its adhesions with the point of the ovum in contact with the womb. In fact, the placenta is always developed there, and if the allantois happens to strike the chorion at a part somewhat removed from that which is in apposition with the internal uterine surface, the umbilical vessels must evidently have a tendency towards the latter, just as the roots of a plant always stretch towards the spot which will afford them the most nourishment. CHAPTER IV. OF THE F03TUS. We shall not attempt to study the fcetus by describing the different organs, and the various tissues successively, that enter into its structure at the moment of birth, nor by tracing each of them through the modifications it undergoes at the divers periods of the intra-uterine life; for such a course would evidently compel us to overstep the limits imposed by the nature and character of this work. Therefore, laying aside all embryological researches, we shall content ourselves with mentioning a few interesting particulars of organogeny; and while considering the foetus in a general manner, we shall point out succinctly the suc- cessive development of its form and its external parts. But before entering upon this subject, we believe it will prove profitable to present, in a figure, the various details already furnished, as such an exposition will complete the description previously made, and facilitate a knowledge of the facts we have yet to speak of. EXPLANATION OF THE FIGURES IN PLATE III. Fig. 58. The human ovum, of its natural size, at about the thirtieth or thirty-sixth day. Fig. 59. 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. Fig. 60. 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 ft IE. Fi§. 58. ■ : ;'•■ WF'u ..■ ;:&<: ;.■■■ .-•.v.,'(i.H'>!''l>i''4k.% * ^ . , ?\..:i « ■3-^" a Fig. 60 ,; k ° M 7' Smthnrs hilt flilladu OF THE FCETUS. 205 the umbilical cord has also been split up, for the purpose of showing how the append- ages of the fcetus 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 hf a'. 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/ b/, is directly continuous with the umbilicus or the abdominal walls c c of the embryo. d. The umbilical vesicle, and r/ its pedicle. n//. The point where this pedicle communicates with the intestine e. e. The loop of 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. y. 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. o. 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. AKTICLE I. DIMENSIONS AND WEIGHT OF THE FCETUS AT THE DIFFERENT PERIODS OF INTRA-UTERINE LIFE. At the time when the embryo first begins to be distinct, that is, about the third week, it is oblong, swollen in the middle, obtuse at one extremity, though drawn to a blunt point at the other, and straight, or nearly so, being somewhat curved forwards. It is therefore vermiform in shape, of a grayish-white color, semi-opaque, almost without consistence, and gelatinous, varying from two to four lines in length, and weighing one or two grains. At this period, the only trace of the head is a small tubercle separated from the rest of the body by a notch, but no rudiments of the extremities are observed, nor is there a cord at first. The embryo is clearly surrounded by the amnion, which lies quite near it, in 20(3 GENERATION. the form of a delicate membrane, leaving it, however, always free. The abdo- minal cavity is opened for a very considerable extent in front. The embryo becomes more consistent towards the fifth week : its head then increases greatly, in proportion to the remainder of the body, and the rudimentary eyes are indi- cated by two black spots turned towards the sides; the development of the thoracic extremities is announced by two small, obtuse nipples, situated on the sides of the trunk; it is nearly two-thirds of an inch long, and weighs about fifteen grains; the cord exists in a rudimentary condition, and the abdominal members are likewise present, in the form of two rounded pimples. The vertebral divi- sions are quite apparent, all along the back, although the caudal vertebrae closely approach the front part of the head, in consequence of the anterior curvature of the embryo. Already does the heart exhibit, in its external form, a tolerably close resem- blance to that in the adult; for we may even now observe the fissure that will afterwards separate the auricles, as also one corresponding to the inter-ventricular partition; but there is, in reality, only one ventricle, from which both the aorta and the pulmonary artery arise. And, further, there is but one auricle; or, rather, the two communicate so freely that the intermediary contraction which should divide them is still very imperfect; for the partition is formed by the progressive contraction of the orifice of communication, and this incomplete open- ing, which sometimes persists in the septum until birth, is known under the name of the foramen of Botal. But, after birth, the opening becomes oblite- rated, and the two auricles are thenceforth isolated by a complete partition. The single ventricle will be converted into two cavities, by the intervention of a septum, which will be gradually developed from the summit towards the base, being placed between the two arteries (the pulmonary and aorta), and so disposed that one of them shall open into the right and the other into the left cavity. The lungs at this period are constituted of five or six lobules, in which we can readily distinguish the bronchial extremities, terminating in slightly swollen cul- de-sacs. Moreover, two large glandular structures lie along the vertebral column at this period, extending longitudinally on each side, from the lung to the bottom of the pelvis. These are the Wolffian bodies. They are constituted by an excre- tory canal, which runs throughout their whole length, being placed on their external margin, and terminating below in the transitory cloaca. The canal puts forth, on one of its sides only, a series of more or less elongated coeca, which roll or curl up, so as to form a considerable mass by their agglomeration. These coeca secrete a liquid, which is subsequently emptied into the cloaca by means of the canal. The Wolffian bodies anticipate the function of the kidneys until the latter are developed, and hence they have been denominated the false kidneys; but they disappear as soon as the true organs can replace them, leaving no trace of their past existence. Just alongside of the excretory canal, in the Wolffian body, a second one is seen to accompany it throughout, and even in like manner 'to empty into the cloaca. But this second canal is perfectly distinct from the other, and will become, in the adult, either the oviduct or the vas deferens according as the new being shall be of the male or female sex. OF THE FCETUS. 207 In the early stages of embryonic life, there likewise exists on each side of the neck, in the human foetus, as also in the mammalia, four transverse fissures which open into the pharynx. These are separated from one another by certain bands, or fleshy partitions, that correspond with the branchial arcs of fishes; for the vascular apparatus distributed there affects, to a certain extent, the same form temporarily, that it has permanently in the inferior vertebratae. We, therefore, see that the bulb of the aorta, instead of curving immediately in a single arch, divides, on the contrary, into three or four branches, on each side of the neck; and after these branches have each accompanied a branchial arch, they reunite, at a common point, to form the descending aorta; however, they are soon effaced, along with the corresponding fissures, and but two remain on the left side, one of which is converted into the arcus aortae, while the other, after having existed as an arterial canal, will form the common trunk of the pulmonary arteries. The branchial fissures just under consideration also disappear, with the excep- tion of a single one (the first on each side), which is converted into the external ear, as may be seen in the figure. (See Plate III.) At this period, the upper jaw is still composed of two papulae, one for each side. These pimples, or isolated mandibles, gradually approach the median line, and there unite in a single body, which forms the jaw such as we find it in the adult. The nostrils are separated by the incisive papulae, which keep them apart for some time; then, as the latter diminish in size, they approach each other and assume their definitive form; but, in the meanwhile, they are separately split down to the mouth, and it is the permanence of this transitory state that con- stitutes the double hair-lip. All of the branchial fissures have disappeared by the sixth week, leaving only a slight cicatrix behind. The first centres of ossification appear during the seventh week, first on the clavicle and then on the lower jaw. The intestine still extends for a considerable distance along the interior of the umbilical cord, but the omphalo-mesenteric canal is nearly obliterated, although it may yet be traced as far as the umbilical vesicle, where it is reduced to a very delicate thread. The anus remains closed ; and the bodies of Wolff alone exist near the vertebral column. It is only then that the kidneys and capsulae renales begin to appear, and soon after them the sexual organs. The urinary bladder is first manifested under the form of a tumor that is continuous with the urachus. At this time, the embryo is nearly an inch in length. At two months, the tubercles of the extremities become more prominent. The forearm and hand can be distinguished, but not the arm ; the hand is larger than the forearm, but it is not supplied with fingers. The cord has not as yet assumed a spiral arrangement, but it is infundibuliform in shape, the base corresponding to the abdomen, being continuous with it, and containing a large quantity of in- testine ; it is four to five lines in length, and is inserted near the lowest point of the abdomen. A small tubercle, furnished with one or more very contracted openings, may be distinguished between it and the termination of the spine, which are the rudimentary external organs of generation; but the extreme length of the clitoris renders the distinction of the sexes difficult at this period. 208 GENERATION. The embryo is from one and a half to two inches long, and weighs from three to five drachms, the head forming more than one-third of the whole. The eyes are prominent, but the lids, from being still rudimentary, do not cover the eye- ball ; 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 in length, and weighs an ounce or an ounce and a half. The palpebrae, having be- come more apparent, descend in front of the eye, and the puncta lachrymalia are now visible; the buccal fissure, which has increased in size, begins to be oblite- rated by the commencing development of the lips. The thoracic parietes are apparent; hence the heart's movements cease to be visible. The fingers are distinct, and the toes look like little tubercles held together by a soft substance. The cord is longer than the embryo, and begins to assume the spiral arrangement; it is less infundibuliform than previously, and is not inserted so low down on the abdomen, but its base always contains a portion of intestine. At the end of the third month, the embryo weighs three to four ounces, and measures from five to six inches; the eyeball is seen through the lids; the mem- brana pupillaris is more manifest; the forehead and nose are clearly traceable, and the lips well marked and not turned outwards. The neck now establishes a visible separation between the head and thorax; the latter cavity is closed at all points, but is still very slightly developed relatively to the other cavities. The cord contains no intestine, and its spiral turns are more numerous and evident. The nails begin to appear as thin membranous plates; the sex is distinct, and the integuments, which heretofore were only a soft, viscous covering, acquire more consistence, but are still very thin, transparent, of a roseate hue, and without an apparent fibrous texture. At the fourth month, the embryo takes the name of faitw ; its growth is not so rapid in the commencement as at the end of this month. The body is six to eight inches in length, and weighs from seven to eight ounces. The fontanelles are very large, as are also the sutures; and some short, whitish, silvery hairs may be observed on the head. The face still remains but little developed, al- though more elongated than it has previously been. The eyes, nostrils, and mouth are closed, and when the occlusion of the lids happens to be incomplete, it is generally at the internal part. The tongue may be distinguished behind the buccal fissure, and the projection of the chin is observable. The cord is inserted higher up on the abdomen, whence the centre of the body is an inch or two above the umbilicus. The skin has a rosy color, and begins to be covered by down, and some fat, tinged with red, is deposited in the areolae of the sub- cutaneous cellular tissue, and the muscles now produce a sensible motion. A fcetus born at this period might live for several hours. Whilst I was Interne at the Hotel Dieu, I received one that had scarcely reached the fourth month. It lived, however, from half-past seven to half-past eleven o'clock. At five months, the length of the body is eight to ten inches, and it weighs from eight to eleven ounces. The skin is more consistent, and many patches'of sebaceous matter may already be seen, but the pupils cannot be distinguished. OF THE FCETUS. 209 At six months, the length is eleven to twelve and a half inches, and the weight about one pound (avoir.). The hair is both longer and thicker, the eyes closed, the eyelids somewhat thicker, and their margins, as well as the eyebrows, are studded with very delicate hairs. Agreeably to most authors, the membrana pupillaris always exists; on the contrary, the pupil at this period has seemed very large, both to M. Velpeau and myself. The skin is better organized, for the dermis and the epidermis may be distinguished, though its surface is wrinkled and puckered, owing to the small quantity of subcutaneous fat. The nails are solid already. The scrotum is very small, quite red, and empty. At seven months, the foetus acquires a length of twelve and a half to fourteen inches; all its parts have become firmer and more voluminous, and their respec- tive dimensions better proportioned. The bones belonging to the vault of the cranium exhibit near their centres a considerable prominence at the point where the first rudiments of ossification occur, whence it follows they are less uniformly arched than at the succeeding periods, and more curved than in the former months, when they were in reality nearly flat. The pupillary membrane disap- pears completely; indeed, according to M. Velpeau, this membrane does not exist at any period of the intra-uterine life. The iris commences as a simple ring, which then grows in a concentric manner, leaving at last only the opening called the pupil. The eyelids are partly open, and the testicles begin to descend into the scrotum. At eight months, the foetus seems to grow, as Desormeaux remarks, rather in thickness than in length; it is only sixteen to eighteen inches long, and yet weighs from four to five pounds. The skin is very red, and covered with long down, and a considerable quantity of sebaceous matter.1 The lower jaw, which was at first very short, is now as long as the upper one. The scrotum usually contains one testicle, generally that on the left side. Finally, at term, the foetus is about nineteen to twenty-three inches long, and weighs from six to seven pounds. Although, in consequence of the development at the inferior part of the trunk, the umbilical ring is now considerably removed from the hypogastric region, yet the insertion of the cord does not correspond, • as has been stated, with the centre of the body. Thus, in a foetus whose total length is twenty inches, we shall generally find ten and a half to eleven inches from the crown to the umbilicus. Indeed, from the researches of M. Moreau, communicated to the Academy of Medicine, it appears that in ninety-four children born at nine months, four only had the umbilical insertion in the middle of the body, while in ninety others it was below this. The mean of the variations was nearly an inch. M. 1 About the middle term of the intra-uterine life, the skin is covered by a constantly- increasing mass of a fat, slippery, viscous substance, yellowish-white in color, called the sebaceous coat. This substance is more abundant on some embryos than on others, and is in greater quantity on certain places, as, for example, the head, axilla, and groins ; it is insoluble in water, alcohol, and oil, and only partially soluble in potash. It is not a pre- cipitate furnished by the amniotic liquors, as some persons have imagined, for there is none of it on the external surface of the amnios, nor on the umbilical cord; it is a secre- tion of the fcetal skin, and, so far as we can judge by its composition, is a mixture of effete epidermis and matters furnished by the sebaceous glands, which assists perhaps in the hour of labor by facilitating the expulsion of the child. 14 210 GENERATION. Ollivier, of Angers, has also observed the same thing in thirty children ex- amined by him. The weight and length of children at birth have been wonderfully exagge- rated in many cases; thvis, some are recorded of a yard or more in length, and others that weighed eighteen, twenty, twenty-four, and even thirty pounds. These statements must certainly be great exaggerations; for the most voluminous of three thousand children, born under my charge, either in the Hotel Dieu or at La Clinique, weighed ten pounds, and it was an enormous one. Of four thousand children delivered at La Maternite, one only weighed twelve pounds. (Lachapelle.) Baudelocque asserts, that he superintended the delivery of one of twelve pounds and three-quarters; and M. Merriman, one weighing fourteen pounds; Richard Crofts, another of fifteen pounds; lastly, Mr. J. D. Owens, a surgeon at Hay- moor, near Ludlow, has seen a stillborn infant that weighed seventeen pounds twelve ounces, and had the following dimensions: Occipito-frontal diameter, ----- 7^ inches. Occipito-mental " - - - - - - 8$ " Bi-parietal " ----- 5 " Total length, - - - - - - - 24 " In the month of May, 1819, I was called in consultation by Dr. Riembault in a case of shoulder presentation. Several attempts at version had been made by himself and another physician, and it was with the greatest difficulty that I suc- ceeded in accomplishing it. The child, which was born dead, appeared to me a very large one, and I estimated its weight at from ten to twelve pounds. After my departure, M. Riembault, who, like myself, had been struck with its size, weighed it carefully, once with a steelyard, and twice in different balances, and ascertained its weight, by the three trials, to be eighteen pounds. Its extreme length was two feet one and a half inches, the bi-acromial diameter nine inches, the greater circumference of the head sixteen and one-eighth inches, and the lesser circumference nine inches. M. Riembault has assured me repeatedly, that he could guarantee the accuracy of these statements, since being himself as- tonished at the results of the measurements, he had taken the precaution to* repeat them several times. The mother stated that her last menstrual period occurred July 12, 1848, and that she expected to be confined about the 12 th of April, 1849. The size of the abdomen had been so great since March, as to lead her to suppose that she was pregnant with twins. The first pains were experienced on the evening of the 6th of May, that is to say, nearly a month later than-she had anticipated. Whether the pregnancy had really run over its usual term, and whether the extraordinary size of the child was attributable thereto, are questions which it is impossible to decide. On the whole, therefore, we may conclude that the fcetal growth is rapid for the first three months, then slackens off about the middle of pregnancy, and again becomes greatly accelerated during the last three months. Chaussier has given the following as the proportions exhibited by the different parts of the foetus at birth (taken from a child nineteen and a half inches long), namely: OF THE FCETUS. 211 From the top of the head to the pubis, . . . 12^ inches. " the pubis to the feet, . . . . . 7^ " " the clavicle to the bottom of the sternum, . . 2 " " the latter to the pubis, ..... 6£ " With regard to the transverse measurement, he found as follows: From the top of one shoulder to the other (bis-acromial or transverse diameter of the thorax), ..... 4| inches. From the sternum to the spine (antero-posterior diameter), . 3| " " ilium to ilium (transverse diameter of the pelvis), . 3 " " one femoral tuberosity to the other, . . . 3£ " We shall examine hereafter the dimensions of the head. Fortunately, these diameters are reducible; thus, the bis-acromial in particu- lar, which presents four and three-quarter inches, may be reduced to three and three-quarter inches, by compression. ARTICLE II. HEAD OF THE FffiTUS AT TERM. The head of the foetus merits the particular attention of the accoucheur, as being really the most voluminous and least compressible part of the child. It is, therefore highly important to ascertain whether its several diameters are pro- portional to those we have heretofore studied in the pelvis. The head is likewise, in the majority of cases, the part which presents during labor; consequently, it is very necessary that we should be fully acquainted with all its characters, in order to recognize them at this period. The fcetal head, considered as a whole, is ovoidal in form, the larger extremity being posterior, and the smaller anterior; as, in the adult, it is composed of the cranium and face; but as the latter does not claim a particular notice, we refer, for a knowledge of its different parts, to the works on anatomy. Several bones enter into the formation of the cranium; they are— The frontal.—A symmetrical bone, forming the forehead, as well as the supe- rior-anterior part of the face. It is divided in the fcetus into two portions. The two parietal.—One upon the right, the other on the left side, meeting at the median line; they are situated upon the superior lateral parts of the head, and concur to form the vault of the cranium. The occipital.—A symmetrical bone, constituting the posterior part of the skull, as also a portion of its base. The temporal.—Two bones, placed, one on the right, and the other on the left side, below and beneath the parietal, completing the lateral portions of the cranium, and contributing to the formation of its base; lastly, the sphenoid and the ethmoid, which belong exclusively to the base. These bones are not united to each other at birth by serrated articulations, as they are in the adult (immovable synarthrosis), but are separated, those of the vault especially, by membranous intervals, of greater or less extent, according to the degree of ossification. The intervals have received the name of sutures, or fontanelles. 212 GENERATION. This arrangement of the vault of the cranium has several advantages. It facilitates the development of the brain, and what is hardly less important in the view of the accoucheur, it allows of a certain reduction of the diameters of the head. When the latter is compressed forcibly, the margins of the bones ap- proach each other and may even overlap. The extent of this overlapping is liable to be thought greater than it really is, for, as M. Malgaigne remarks, if we examine the matter closely, we shall find that the membrane interposed between the parietal bones is too firm to be drawn out, and too narrow to permit a notable overriding; and further, that it usually maintains these two bones so close together, that the superior margin of one laps over the other, leaving even on the dried skull a true normal crossing. Some of those sutures, or fontanelles, are highly important in an obstetrical sense, and we shall next proceed to their consideration. The Sagittal Suture.—This great or antero-posterior suture extends from the root of the nose to the superior angle of the occipital bone; being formed in front by the interval that divides the frontal bone into two halves, and in the middle, and posteriorly, by that between the parietals. At the superior and in- ternal angle, formed by the two portions of the frontal bone, this suture is joined at the sides by the two fronto-parietal or transverse (coronal) sutures, which are formed by the space existing betwixt the superior border of the frontal and the anterior margin of the parietal bones, and crossing the former suture nearly at right angles. Having arrived at the superior angle of the os occipitis, it seems to bifurcate, and give rise to two oblique lateral sutures formed by the posterior borders of the parietal bones, and the superior one of the occipital. These latter are called the lambdoidal sutures, probably from their resemblance to the Greek capital A (lambda). Just at the points where the fronto-parietal and the lambdoid sutures join the sagittal one, two membranous spaces, much larger than those just de- scribed, are found to exist, which have received the name of the fontanelles. The great or anterior fontanelle is the one formed by the junction of the two transverse sutures with the sagittal. It is also called, from the fact of its corre- sponding with the bregma, the bregmatic fontanelle; in general, it presents an extensive surface, bounded by four bony angles, produced by the lateral sutures leaving it nearly at right angles. It is lozenge-shaped, and is usually much more prolonged into the frontal than between the parietal bones. Sometimes even, according to M. Gerdy, Jun., it scarcely ceases short of the nose, the margins of the coronal suture being parted throughout their whole extent by an interval which gradually diminishes from above downwards, being only about one or two lines wide toward the root of the nose. It is not at all uncommon to find at the lower part of this suture a rounded or oval membranous space, varying from three to seven lines in its diameter. The posterior or occipital fontanelle is formed by the union of the two lamb- doid sutures with the termination of the sagittal suture; it is smaller than the preceding, and of a triangular form, being bounded by three bony angles. The lateral sutures leave it at an acute angle. The bony angles are generally found in contact, no membranous interval being left between them. Sometimes the two portions of the os occipitis are not fused into each other at birth, and in such OF THE FCETUS. 213 cases a median suture exists, which separates them, and terminates in the pos- terior fontanelle. The latter has then a lozenge shape, and is subtended by four osseous angles, and can only be distinguished from the anterior by the obliquity of the lambdoidal sutures. The opposite condition is observed at times, the triangular space known as the posterior fontanelle not existing at all, because the projecting angle of the occiput then fits in and fills up the entering one formed by the parietal bones; still the convergence of the three sutures, and the promi- nence of the bony margins which overlap each other, will aid the diagnosis (Malgaigne); for when the head is engaged in the excavation, and has become strongly compressed, the superior angle of the occipital bone is completely con- cealed by the internal or supero-posterior angles of the parietals; and if the touch is resorted to under such circumstances, the finger can only recognize the position by detecting the little hollow formed by the depressed occipital angle. Of course, particular attention must be given in this case to the oblique direction of the lambdoidal sutures. The not unfrequent existence of spaces upon the cranium, where the ossifica- tion is less advanced than usual, is another source of error. For this defective ossification is substituted a membranous expansion, which might be mistaken for a fontanelle. Such an error might the more readily have occurred in the four cases of this kind which I have had an opportunity of observing, from the fact of the acci- dental fontanelle being situated just in the course of the sagittal suture, about equi-distant from the anterior and the posterior ones; and as this point is pre- cisely where the finger first falls, in practising the touch, we might mistake it for a fontanelle. But, by a little attention, it will always be easy to avoid this error, by ascertaining that no lateral sutures pass off from this membranous interval. There yet remain some other sutures, and some other fontanelles on the in- ferior lateral parts of the cranium ; but as they are devoid of interest we shall not describe them. Diameters of the Head.—The term diameter has been applied to certain ficti- tious lines, which traverse the head in a determinate direction. To avoid over- loading the memories of students, we shall not multiply their number as some have done; but, following the example of M. Velpeau, shall describe only seven at first, as it will be very easy to supply the deficiency hereafter in treating of the mechanism of labor. Seven diameters, then, may be distinguished for the fcetal head, which we divide, in order to facilitate their study, into the antero-posterior, the transverse, and the vertical. 1st. The antero-posterior diameters are: the occipito-mental, a b (Fig. 61), extending from the posterior fontanelle to the chin; this is the longest of all, being five and a quarter inches. The occipito-frontal, d e, which extends from the occipital protuberance to the frontal boss (also called the antero-posterior diameter): it measures four and a quarter to four and a half inches. The sub- occipito-bregmatic, c f, extends from the middle of the space between the fora- men magnum and the occipital protuberance (to the anterior fontanelle.— Transl.), and is three and three-quarter inches. 2d. The transverse diameters are two in number : one the bi-parietal, a b 214 GENERATION. (Fig. 62), goes from one parietal protuberance to the other; it is from three and a half to three and three quarter inches long. The other, the bi-temporal, c d, Fig. 61. Fi*- 62' passes from the root of the zygomatic process on one side to the same point op- posite. It is two and three quarters to three inches long. 3d. Lastly, there are two vertical diameters: first, the vertical diameter, pro- perly so called, or the trachelo-bregmatic, ig, traverses^the head perpendicularly, passing from the most elevated point of the vertex to the anterior part of the occipital foramen. It is three and three quarter inches long. Professor Moreau points out another diameter, which he calls the cervico-bregmatic, ch (Fig. 61); this leaves the preceding somewhat obliquely, and runs from the anterior part of the occipital foramen to the anterior fontanelle; it is three and three-quarter inches in length; the second, the fronto-mental, or the facial, d a, extends from the frontal boss to the point of the chin. This is three inches. Circumferences.—A circumference has been assigned to each of the above- mentioned diameters, since it is very easy to describe from the middle of every one of them, as a centre, a circle whose radius is equal to one-half of the diameter, and whose circumference shall pass through the two extremities of the latter. As a matter of course, the greatest circumference of the head corresponds with the occipitomental diameter, and passing at the same time obliquely over the sides of the face and through the extremities of the diameter, has a nearly hori- zontal direction. Most authors describe it as dividing the head into two equal lateral halves,— a mode of regarding it, which, as M. Jacquemier judiciously remarks, is devoid of meaning as applied to obstetrical practice. The occipitofrontal periphery, agreeing with the diameter of the same name, runs, horizontally, a little below the extremities of the transverse diameter, and separates the vault from the base. The sub-occipito-bregmatic circumference passes through the extremities of both the occipito-bregmatic and the bi-parietal diameters, being thus common to both. The two latter are the most important of all, because they successively come into relation with the parietes of the pelvis in the progress of natural labor. The circumferences belonging to the other diameters scarcely offer any interest, and we shall therefore, merely mention them in passing; in number they equal the diameters. The fronto-mental circumference, however, should be noticed as passing over the forehead, cheeks, and chin: being also called, on that account, the facial circumference. The diameters just described, although but slightly reducible in their dimen- OF THE FCETUS. 215 sions, are not absolutely invariable. Thus it is only necessary to witness a few difficult labors to become satisfied, that in such cases, the head is most frequently elongated in the direction of the occipito-mental diameter, and flattened in its transverse one. And we further learn, from the experiments of Baudelocque, that the bi-parietal diameter (see art, Forceps) may be reduced one-fourth, or one-third of an inch, by the aid of instruments; indeed, we have even known this diameter to be diminished much more than that under the efforts of the womb alone, without any accident occurring to the child. Independently of those variations in length of the diameters of the head in individual cases, which it is impossible to foresee, there is one which is almost uniform for each sex, and of importance to be acquainted with. The head of the male foetus is generally larger than that of the female; the difference, accord- ing to Clark, being about the one-twenty-eighth or the one-thirtieth. This dif- ference exerts a notable influence upon the duration of labor even in well-formed women, and may consequently have an injurious effect upon the health of the mother, and upon both the life and health of the foetus. Thus it is shown by the researches of Dr. Simpson : 1. That the majority of the children which die during labor are males: the proportion of still-born boys to still-born girls being as 151 : 100. 2. That of children born living, there are more boys than girls presenting some morbid condition, or some lesion produced during labor, and consequently more likely to succumb within the first weeks of their existence. 3. That of the mothers who die during labor, or in consequence of it, the majority have given birth to boys. It will be readily understood that the sex of the child will have a still greater influence upon the result of the labor where the pelvis is slightly contracted; and that with the same diameters, the life of a male foetus would be often compro- mised when a girl might pass with little difficulty and no danger. We present, in the following table, the diameters of the fcetal head, as also those of the pelvis, before described; hoping that, when thus collected, their study will be rendered more easy: Diameters of the pelvis. (In inches.) Antero-Posterior. Transverse. Oblique. Sacro-cotyloid. Superior strait, . . . Inferior strait, . . . Excavation, .... 4* 4£ to 4f 4£ to H H 4| 4a 4 to 4£ 43. *4 4 to 4| a u u u FCETAL HEAD. ( Occipito-Mental, . b\ inches. Longitudinal diameters, . . < Occipito-frontal, . 4J do. (^ Sub-occipito-bregmatic, 3f do. Transverse do. . . (Bi-parietal, . . 3£ to 3| do. (Bi-temporal, . . 3 do. Vertical do. . . i Trachelo-bregmatic,. 3£ to 3| do. I Fronto-mental,. . 3 do. The fundamental principles of midwifery are deduced from the correspondence between the fcetal dimensions and those of the pelvis. It happens, in fact, that the child at term can only clear the pelvic canal by presenting one end of its long diameter; that whichever extremity this may be, the delivery will still 216 GENERATION. remain impossible if the head should present in such a manner as to have its occipito-mental diameter parallel to those at the inferior strait; that, conse- quently, the occiput must always engage before the chin, or vice versa; and, lastly, that the most favorable position of the head requires the latter to be strongly flexed upon the trunk, so that its smallest diameter (the sub-occipito- bregmatic) shall be parallel to the plane of the strait; and that to be in its most favorable relation with the pelvis, the occiput must correspond with one of the extremities of an oblique diameter. The articulation of the head with the vertebral column, and the movements it permits, should also be carefully studied: thus, the occiput is connected to the atlas by a close union, which only admits the motions of flexion and extension, which in the fcetus are far more extensive than in the adult; the atloido-axoid articulation, on the contrary, being ginglymoid, only permits a rotation, which is limited to the fourth of a circle. Whence the conclusion is manifest, that when- ever the head is caused to rotate—the body being fixed—great care must be exercised not to pass the limits indicated; for generally the foetus would thereby suffer a mortal lesion. We say generally, not always, because two cases cited by Prof. Paul Dubois evidently prove that children may not only survive this acci- dent, but even seem to experience no bad effects whatever from it. The great laxity of the articular ligaments in the infant can alone explain the little danger attending an occurrence which would prove so disastrous in the adult. Finally, the natural situation of the head is such in the new-born child, that the chin descends much lower than the occiput, and the axis of the trunk traverses the cranium obliquely from base to summit, and from before back- wards, passing a little iu front of the posterior fontanelle. ARTICLE III. POSITION AND ATTITUDE OF THE FCETUS. The foetus lies curved on its anterior plane within the bag formed by the membranes; usually, the head is somewhat flexed, the chin resting on the anterior superior part of the breast; the neck is so short that a slight degree of flexion will, says M. Dubois, pro- duce this effect; the feet are bent up in front of the legs—the latter strongly flexed on the thighs, and these again are applied to the anterior surface of the abdomen; the knees are separated from each other, but the heels lie close together on the back part of the thighs; the arms are placed on the sides of the thorax; the forearms are flexed and thrown across the sternum, so as to receive, as it were, the chin between the hands. The fcetus, thus folded on itself, constitutes a nearly ovoidal mass; the longest diameter of which is about eleven inches, having its larger extremity represented by the breech, Fig. 63 The usual position of the child in the womb OF THE FCETUS. 217 which is turned towards the fundus uteri, while the smaller, formed by the head, is directed downwards. Now, it is evident that this constrained position could not have been produced by the mere pressure of the uterine walls on the child, since the latter is in a cavity much larger than its whole volume; hence, it must be referred to the individual itself. The dependent position of the head at term is so common, that we are natu- rally led to inquire why such should be the case ? Formerly, it. was supposed that, after having reached the uterus, the head occupied the fundus for the first seven months of gestation, and the pelvic extremity its inferior part; but that towards the expiration of this period, the foetus reversed its position; the head approaching the orifice, and the breech going above. This was the received doctrine until the arguments of Delamotte, Smellie, and more especially of Baudelocque, completely subverted it; and since then, it has been generally admitted that the foetus, suspended, so to speak, in the amniotic fluid, by the umbilical cord, would naturally observe the law of gravity: that is, the head being the heaviest part would descend. This explanation was almost universally adopted, when M. Dubois, after re-examining the question, proposed another theory. He urged the following objections (whose value we fully acknow- ledge) against the influence of specific gravity, to which the great frequency of vertex presentations had been so uniformly attributed, viz.: 1. If a child be plunged into a considerable quantity of any liquid, contained in a bathing-tub, for instance, so that its descent will be very slow, in order to afford the head suf- ficient time to exert its superiority in weight, we shall find all parts of the foetus to descend with an equal rapidity, and, consequently, either the back or one shoulder will first reach the bottom of the tub. This result, which is contrary to the general belief, is more in accordance with what is learned from an atten- tive examination of the foetal structure; indeed, when a comparison is made, between the volume of the cephalic and the pelvic halves of the foetus, it would naturally appear that their weight must be nearly balanced; the cranial cavity, it is true, contains a well-developed brain, but the abdomen encloses the liver, which is no less so, as also the intestines and bladder, together with the meconium and the urine accumulated therein during pregnancy; 2. It is really impossible to believe that the foetus is suspended by the cord alone, except during the early stages, for even at the third month the cord is longer than the greatest diameter of the uterine cavity, and therefore its insertion near the pelvic extremity can in nowise contribute to the more frequent presentation of the head; 3. Besides, those women who maintain the horizontal position during gestation on account of ill health, are not the less liable to exhibit the same phenomenon; 4. If the laws of gravity alone determined the position, the head being more voluminous rela- tively to the trunk, during the early months, the foetus should present, in cases of abortion, by the cephalic extremity still more frequently than at term; but observation establishes the contrary; 5. Lastly, in animals the lowest part of the organ does not correspond with the neck, but rather to the fundus, of the womb; nevertheless, the fcetus is much oftener delivered by the head than the pelvic extremity. After having tried to combat the generally-received opinion by the objec- tions just given, M. Dubois endeavors to prove that the vertex presentation is 218 GENERATION. a consequence of the instinctive will of the foetus itself......The child, in its mother's womb, has the faculties of perception and motion; for the regular and nearly constant succession of the perception of impressions, and the move- ments which follow, sufficiently indicate the same connection in the fcetus, be- tween these two functions, that should exist after birth. Now, the objects of these fcetal movements are partly certain, partly presump- tive; consequently, they may be regarded as really instinctive determinations; again, it is in consequence of such a determination that the head in the mam- malia is usually found at that part of the uterus nearest to the pelvic outlet. We frankly confess that M. Dubois seems to us more skilful in destroying than in building up; and though the reasons by which he combats the doctrine hitherto received appear very strong, yet those whereon he founds his opinion are not fully convincing. He is entitled to credit, however, for having sought, in a higher order of ideas, the explanation of a singular fact, which does not seem, in the present state of our science, capable of elucidation by the material reasons heretofore given. If we might be permitted to hazard an opinion, after so many others, we should unhesitatingly say they have erred by seeking only in the foetus, its form and structure, for the cause of the various positions which it assumes in the uterine cavity. Already have several authors endeavored to account for the rarity of trunk presentations, by the vertical, or the nearly vertical direction of the long diameter of the uterus, which would naturally force the greatest foetal diameter in the same line: for instance, the cause of trunk presentations, says Wigand, must be re- ferred less to the foetus itself than to a change in the ordinary elliptic form of the uterus. Now, by advancing a step further in the path they have marked out, may we not find a satisfactory explanation of the great frequency of vertex pre- sentations in the form of the uterus, and especially in its mode of development at the different periods of pregnancy? For, when we reflect that the uterus, being developed during the first six months at the expense of its fundus, is spread out superiorly, but, on the contrary, is much contracted below, does it not be- come evident that the pelvic extremity, which, from the folded condition of the lower limbs, is much more voluminous than the head, must naturally lie in the largest cavity, that is, towards the fundus; and, consequently, that the cranium will descend to the cervix ? There can be no doubt that the inferior part spreads out in the last three months nearly as much as the fundus; but, then, the foetal vertical diameter is too long to permit it to traverse the transverse diameter of the uterus; and hence, with some few exceptions, the child is forcibly retained in the position it first assumed. Finally, can we not explain by this circumstance the position of twins, in cases of double pregnancy, where it frequently happens that one fcetus presents by the pelvic extremity, and one by the head ? In a word, the child, shut up in its close sac, and constantly subjected to movement, must assume, not instinctively but mechanically, such a position as will bring its largest parts into correspond- ence with the most spacious portions of the organ. OF THE FCETUS. 219 ARTICLE IV. FUNCTIONS OF THE FCETUS. The functions of the child, while it remains in the uterine cavity, that require our particular attention, are its nutrition, respiration, and circulation. § 1. Of Nutrition. Few questions in physiology have given rise to more discussion than this of foetal nutrition. However, it is universally admitted that the nutritive materials are furnished by the mother's body; but authors are not as unanimous in regard to the mode of their introduction into the interior of the product of conception. For instance, some think that the liquids secreted by the internal uterine sur- face transude through the membranes, so as to reach the amniotic cavity, to be there taken up by the fcetus. Others regard the maternal placenta as designed to supply the child with nutritive matter, and find in the umbilical cord the only means of conveying it. It is necessary to admit at the outset, that there can be no discussion of the question until after the placenta is developed, or at least, until after connection is established between the mother and child by means of the allantois. Now, as nothing of the kind exists in the early periods of pregnancy, it must be acknow- ledged that during this time, at least, the maternal fluids must reach the foetus by endosmosis through the membranes of the ovum. The nutritive matters cannot all be derived from the same source at the various periods of gestation. Thus, when the ovule quits the ovarian vesicle, it carries with it a portion of the granules which formed the proligerous disk; and it is probable that these may subserve its nutrition during its progress through the first half of the Fallopian tube. In its passage through the other half, an albuminous matter secreted by the walls of the tube envelopes the ovule, and probably also penetrates through the vitelline membrane. Arrived in the uterine cavity, the ovule comes in contact, at all points, with the mucous membrane of the uterus. The villi of the chorion undergo a con- siderable development, and until the placenta is formed, are all capable of im- bibing the fluids secreted by the internal surface of the organ. As the canal with which each is provided opens into the cavity of the chorion, they are won- derfully adapted to this purpose; and notwithstanding the closure of their ex- tremities, the uterine secretions pass by endosmosis through their thin walls; like the roots of a tree, they serve to convey the nutritive fluids into the space separating the chorion from the amnion. These fluids are in fact found therein, where they constitute what we have described as the reticulated body; they also, probably, furnish the fluid of the vitellus. From thence, the nutritive juices transude through the walls of the amnion into its cavity. A certain portion of them is conveyed into the body of the foetus through the canal of the umbilical vesicle. But as soon as the vascular connections, which, as we have learned, are esta- blished between the maternal and fcetal placentas, begin to be formed, the non- placental villi of the chorion tend gradually to waste away; the development of 220 GENERATION. the amnios obliterates the cavity which separated it from the chorion, and along with it also disappear the vitriform body and the umbilical vesicle. It now becomes a question, whether the nutritive matters supplied by the mother can penetrate into the amniotic cavity through the two membranes of the ovum, without collecting to an appreciable amount during the passage ? Or, on the other hand, are they absorbed by the vascular radicles of the foetal placenta, and introduced into the body of the embryo by means of the umbilical cord ? The partisans of the former opinion have endeavored to prove: 1, that the amniotic fluid is derived from the mother; 2, that it contains nutritive matter; 3, that it may enter the embryo in several ways. A. It is almost certain that the fluid is supplied by the mother, for it is the more abundant as the child is less developed, and its quantity diminishes rela- tively to the foetus, in proportion to the advancement of gestation. Now, the contrary should be true, were it a product of the foetus itself. Besides, foreign matters introduced into the stomach of the mother, or injected into her veins, have been discovered in the amniotic cavity. It is also true, that they have nearly always been found at the same time in the blood of the embryo and in the placenta. So that, strictly speaking, it is difficult to say into what part they were first distributed. Arery dissimilar observations having reference to this subject are on record. Thus, for example, in the case of an embryo of five months, the mother of which had been poisoned by sulphuric acid, Otto found that wherever the skin had come in contact with the amniotic fluid, it was of a reddish-brown color, and as hard as parchment. On the other hand, in the case of a woman four months pregnant, who had been poisoned by arsenic, MM. Mareska and Lados found, by analysis, traces of the poison in the body of the fcetus, in the uterus, and in the placenta, whilst it could not be detected in the waters of the amnion. Mayer, however, injected cyanide of potassium into the trachea of a rabbit, and afterwards discovered it in the amniotic fluid, the pla- centa, and the organs of the fcetus. B. The amniotic fluid must be nutritive, for it contains albumen, osmazome, and some salts; in fact, young calves have been sustained two weeks on fresh amniotic liquor. Finally, the quantity of this fluid, and more especially that of the animal and nutritive substances found in it, is much diminished towards the end of pregnancy. c. Supposing it to be furnished by the mother, and to possess nutritive pro- perties, it remains to be shown how it is enabled to enter the body of the foetus. There are numerous hypotheses in reference to this point. The liquor amnii may reach the body of the fcetus in various ways. 1st. By cutaneous absorption. When the umbilical vesicle ceases to furnish nourishment to the embryo, the skin becomes developed, and, very probably, absorbs the surrounding amniotic liquid; it is even possible that the lymphatic vessels, which are highly developed in the foetus, are formed as a consequence of this absorption, just as bloodvessels are called into existence by the circulation. Brugmans proved this absorption by an experiment: thus, after having ex- tracted several living embryos of animals from the waters of the amnios, he noticed that the cutaneous lymphatics were filled, and that those of the intestines were not so; then plunging the limbs, previously tied, into this liquid, he found, OF THE FCETUS. 221 after the lapse of some time, the lymphatics below the ligature were filled with lymph. The epidermis is so excessively thin, that it can offer no obstacle to the imbi- bition, and the liquor amnii itself contains a large proportion of water. Again, the sebaceous matter which covers the fcetus at birth, only becomes manifest at an advanced stage of pregnancy; and, lastly, this absorption has been directly proved in animals both by experiments and dissection. 2d. By the intestinal canal. Though the cutaneous absorption may suffice for the nutrition of the embryo, as is sufficiently proved by the birth of monsters and anencephalous foetuses with closed mouths, nevertheless, it is highly probable * that the child makes some efforts at deglutition, at least towards the termination of pregnancy, thereby determining the introduction of fluids into the intestinal canal. Thus, embryos may occasionally be observed executing motions of respi- ration with their jaws, during which the waters would necessarily be swallowed; indeed, in ova, that have been frozen after their extraction from the cow, an un- interrupted band of ice has been found extending from the mouth to the stomach. And when the meconium is mixed with the amniotic liquid, it is sometimes detected in the throat, pharynx, and stomach. Lastly, hair is occasionally found there, which could only happen as a result of deglutition. Besides these two modes of absorption, by the skin and the intestinal mucous membrane, some physiologists have supposed this fluid might be taken up in other ways: thus, according to some, the mammary glands are provided with conduits that act the part of lymphatics, absorbing the waters, and carrying them to the thymus gland, to be there elaborated. Others suppose that the liquor amnii may enter the trachea and bronchia, and there undergo some modification which may render it suitable for nutrition. Lastly, Lobstein seems to think it might possibly enter through the genital organs. But all these opinions are merely hypothetical. With all deference to their ingenuity, these hypotheses are still far from being satisfactory. The introduction of the liquor amnii into the intestinal canal as a regular and normal occurrence, is by no means proved by the facts cited in its support. It is, indeed, more than probable, that the movements of deglutition which the child has been seen to make, were really respiratory efforts determined by the suspension of the placental respiration; also that the icicles, the hairs, and the meconium, found in the stomach, had entered it but a short time before the death of the child; in short, where the antecedent death of the mother, the com- pression of the cord, or the separation of the placenta had begun to produce asphyxia. Supposing the cutaneous absorption of the liquor amnii to be proved by the experiment of Brugmans, it would still seem unequal to the development of the foetus, which must have some additional source of nutrition. Looking beyond the membranes, there evidently can be no other source of supply than the maternal placenta, and, in fact, many modern authors regard the placental circulation as the principal agent in the nutrition of the foetus. It is unnecessary to suppose a direct communication between the maternal and foetal vessels, in order to understand how that, by means of the extensive contact exist- ing between the vascular apparatus of the two placentas, a transudation may take 009 GENERATION. place of the more fluid parts of the maternal blood, which are absorbed and mingled with the foetal blood; also that this transuded fluid being charged with oxygen is subservient to the haematosis of the fetal blood, at the same time that it supplies it with nutritive material. (Van Huevel.) It may, perhaps, be allowed, that all of the villi of the chorion, in the midst of which the placenta is developed, may not be applied to the formation of the radicles of the umbilical vessels, but that some of them may continue to exercise their primitive functions, and still absorb the fluids secreted by the utricular glands of the utero-epichorial mucous membrane. What we have already said regarding the structure of the chorial villi of the placenta lends countenance to this supposition ; for we have seen (Fig. 55), that ■ beside the vascular villi, some are found to be solid, and destitute of any ramifi- cation of the umbilical vessels, although still adhering by their pedicle, and communicating with a larger branch of the villus. This fact seems, indeed, to have been anticipated by some authors: thus, although Eschricht regarded the placenta proper as being in reality the respiratory organ of the foetus, he sup- posed that the utricular glands of the womb secrete a fluid designed for the nourishment of the embryo, which fluid is taken up by other branches of the umbilical vessels than those by which the placental respiration is effected. MM. Prevost and Morin also regard the placenta as the organ in which the absorption of the plastic matters supplied by the mother is accomplished by the vessels of the foetus. According to them, this fluid, which is deposited upon the internal surface of the womb, is taken up by the vessels of the cotyledons. Thus, in the ruminantia, if the ovum with its cotyledons be extracted from the womb towards the end of gestation, by which, consequently, the foetal and maternal placentas are separated from each other, the separation being easily effected without laceration, a whitish fluid is discovered in the uterine car- uncles, and a similar one can be expressed from the vascular brushes of the cotyledons. However this may be, it is very probable that the nutritive fluids reach the fcetus through the umbilical vessels properly so called. When mixed with the foetal blood, the nutritive elements supplied by the mother, are, like the chyle in the adult, devoted to the development of the organs. Lee supposes, however, that they undergo certain changes, first in the liver, and afterward in the intestine. When thus brought by the umbilical vein into the large liver of the foetus, these elements experience changes which result in the formation of a new albuminous and nutritive compound which is poured along with the bile into the duodenum; there the mixture is separated into a recre- mentitial part, which is taken up by the absorbents, as in the adult, and an excrementitial part, charged with carbon, which forms the meconium. In fine, until the placenta is formed, the nutritive elements reach the interior of the ovum by means of endosmosis ; at a later period the growth of the foetus is maintained by an absorption through the skin of some of the nutritive matters contained in the liquor amnii, and by the assimilation of those which the radicles of the umbilical vessels take up in the placenta. OF THE FCETUS. 223 § 2. Respiration. Does the foetus respire in the amniotic cavity ? If something analogous to respiration in the adult be sought for in the func- tions of the foetus, this question will doubtless be answered negatively; because the atmospheric air, having no access to it whatever, the foetal blood could not possibly obtain any elements from it. But does it, therefore, follow that the sanguineous fluid will experience no similar modification at any part of the cir- cuit ? Most physiologists think otherwise, and I share their opinion. According to some, the liquor amnii is the modifying agent for the blood, and Beclard supposes that the lungs are the seat of such changes, the amniotic liquid reaching them through the air-passages. Agreeably to M. Geoffroy St. Hilaire, the whole surface of the child's body absorbs air, or a vivifying gas, like insects, by a species of air-tubes, or by minute fissures which exist on the lateral parts of the neck in young embryos. The resemblance between those fissures and the branchial apparatus in the fish has given rise to the belief of an analogous func- tion ; hence, they are called the branchial fissures. But, says Bischoff, in the mammalia and man, these arcs never have an organization justifying in the least the supposition of their being intended for respiration : they never have internal nor external branches; nor do we ever see, as in the branchia, vessels distributed either on their surface or in their interior. Latterly, M. Serres has attempted anew to explain how respiration may take place in the embryo before the placenta is fully formed. He says the breathing apparatus of the human ovule consists of the chorion, the two layers of the de- cidua, the liquid contained between the latter, and of a particular class of villi, called by him the branchial, which, after having traversed the reflected decidua, come into contact with this liquid. On the one hand, the reflected decidua is perforated by multitudes of foramina, which may be aptly compared to those on the cribriform plate of the ethmoid bone ; and on the other, the chorial villosities, the branchial villi, entering the substance of this membrane, lodge in those openings, and thus are brought into immmediate apposition with the liquid. M. Serres believes that this arrangement presents all the conditions of a branchial respiratory apparatus; but this mode of respiration only lasts during the first fifteen or twenty days of the intra-uterine life; because, as the embryo is deve- loped and grows, one part of the villi of the chorion is transformed into the pla- centa, and the foetal respiration in the uterus then commences the second time, as the placental respiration. Then the branchial function decreases, the appa- ratus atrophies and disappears: at first, the branchial villi of the chorion wither away; the cavity of the decidua is contracted; the liquid diminishes; and, finally, the two laminae of the decidua being brought into apposition, unite and become confounded with each other. This hypothesis, though ingenious, is evidently based upon badly-observed facts, and cannot be sustained after the description of the decidua which we have given. After the allantois is developed, the villi of the chorion, which have then become vascular, are in immediate contact with the hypertrophied vessels of the mucous membrane, and from this moment the fcetal blood derives therefrom the 224 GENERATION. elements necessary to haematosis. In proportion as the contact becomes more intimate and extensive, the organization of the placenta progresses, and soon forms a compact mass, which is the seat of the placental respiration. In fact, this body is formed throughout iu such a manner as to establish the greatest possible approximation between the maternal blood and that of the embryo; and, therefore, whether the interlacement we have described from the preparations of M. Bonami be admitted, or the disposition pointed out by Weber be considered as an ascertained fact, in which the vascular fasciculi of the foetal placenta dip into the venous sinuses belonging to the maternal one; in either case, we say, a prolonged contact between the two vascular apparatuses would necessarily result. And this mediate union, in which the two liquids are separated by fixed membranes, establishes between the fcetal and the ma- ternal blood the same relation that is known to exist in the lungs of the adult, betwixt the venous blood and the atmospheric air: thus, in the pulmon- ary organs, the blood is brought within the influence of the inspired air; true, there is none of the latter in the after-birth, but the maternal vessels are found there in great abundance, whose exceedingly delicate walls remain for a long time in contact with the umbilical radicles, the parietes of which are also thin and transparent. Therefore, if nothing but thin, transparent membranes divide the foetal blood from that of its mother, is it not possible for the first to communicate some of its elements to the second? for, does not the air act through the walls of the pul- monary vessels of the blood contained therein? And further, is not such a modification of the foetal blood in the placenta sufficiently proved: 1st. By the early death of the child, when the umbilical cord becomes flattened from com- pression, and its circulation thereby arrested. 2d. By the pathological pheno- mena of asphyxia, which are always revealed by the autopsy in such cases. 3d. By the antagonism known to exist between the after-birth and the lungs; in fact, the new-born infant may dispense with the pulmonary respiration, so long as its connection with the placenta remains uninterrupted, and this communica- tion may be broken without danger as soon as it respires through the lungs; if it breathe freely, the blood no longer passes along the cord, and, should respira- tion cease, it shortly flows anew. And 4th. By the difference in the blood cir- culating in the umbilical vein, and that in the arteries,—a distinction not very manifest upon simple inspection, but which has been detected by physical and chemical experiments. Now, in the adult pulmonary respiration, the blood not only absorbs a certain proportion of oxygen from the air, but it also gives off some carbonic acid. Thus far, we have only learned that the foetal blood de- rives from the placenta a vivifying principle; but we have not observed the separation of those materials from it, which may be unsuited to the nutrition of the child. We may state, however, that most physiologists believe the liver is destined to the performance of this last elaboration, and to the removal of its superabundant carbon and hydrogen, which latter are employed in the formation of the bile, and contribute to the complete development of the organ. We know, in fact, the growth of the liver follows that of the placenta, that both have a perfect organization at the same periods, that the bile is a highly carbon- ized fluid, and that the liver has a similar chemical composition. OF THE FCETUS. 225 § 3. Secretion. As it is not our intention to treat of all the various secretions which occur in the foetus, we shall confine our remarks to those of the bile, meconium, and urine. 1. Secretion of Bile.—The liver is the most voluminous of all the fcetal organs. At three months its texture is soft and pulpy, not yet having the granular character visible at term; the gall-bladder at ]that period resembles a white thread, its inferior extremity being the largest, and its cavity exceedingly contracted. At five months the volume of the liver is much greater, the texture more condensed, and the gall-bladder more apparent; the secretion of bile then begins, and continues to augment thereafter throughout pregnancy. We have just stated what appear to us to be the principal elements of the bile. At the seventh month, the gall-bladder is filled with a yellow secretion, and a consider- able quantity of this is also found in the intestinal canal. 2. Meconium.—During the early periods of the intra-uterine life, the diges- tive canal is merely moistened by a little fluid, but a more abundant secretion begins to take place towards the third month. According to Lee, the stomach then contains a clear, acid, and non-albuminous fluid; whilst at the upper part of the small intestine a substance similar to chyme is found, consisting of pure albumen, and there is an analogous albuminous liquid in the biliary duct. The meconium exists in the small intestine only, prior to the fifth month, and is of a greenish-brown color, but after that period it reaches the large in- testine, becomes of a darker hue, and finally accumulates in the rectum. This fluid is a mixture of bile with the products secreted by the intestinal mucous membrane. 3. Urine.—The urine never fills the bladder entirely in the human embryo; now, as the kidneys are developed early, and their secretion commences at once, the urine must certainly be evacuated by some outlet. On this account, certain embryologists have supposed that the bladder communicated originally with the allantois by means of the urachus, and that the cavity of this membrane was the ultimate reservoir of the urine. However, this is not the generally received opinion, for, as we have elsewhere proved, the allantois ceases to exist in the human species as a distinct vesicle long before the development of the kidneys; and the urine must therefore be expelled through the urethra into the amniotic cavity. That its evacuation is necessary is proved by the facts already cited, in which the existence of an imperforate urethra led to extreme distension and even rup- ture of the bladder. § 4. Circulation. a. The foetal vascular apparatus exhibits certain anatomical peculiarities that do not exist in the adult, and which must be noticed, in order to render the account of the circulation comprehensible. Now, these characteristics evidently depend on the absence of the pulmonary respiration, for they disappear as soon as it is established; thus :— 1. It is well known that the heart in the adult is composed of four cavities : namely, a right and left auricle, and a right and left ventricle, each auricle com- 15 226 GENERATION. municating freely with the corresponding ventricle, but not with its fellow, being separated from it by a complete partition. In the fcetus this dividing wall ex- hibits an opening, called the foramen of Botal, which becomes smaller as the pregnancy advances, and is wholly obliterated after birth, in consequence of a valve being developed on its inferior margin, which gradually diminishes the freedom of the passage, and is large enough at term to obliterate the orifice entirely. 2. In the adult, the pulmonary artery divides into two large branches, one for each lung: these ramify throughout its ultimate tissue, distributing therein the venous blood derived from the right ventricle ; the blood is next taken up by the radicles of the pulmonary veins and carried back by them to the left aurisle. This vascular circle is interrupted in the fcetus, in which the two pulmonary arteries are very small, although their common trunk gives origin to a volumi- nous canal which opens directly into the arcus aortae, and is called the arterial canal or the ductus arteriosus. 3. The abdominal aorta bifurcates, so as to form the primitive iliac arteries, and each of these again divides into two branches, the hypogastric and the ex- ternal iliac. In the foetus, the hypogastric seems to be continuous with a large vascular trunk called the umbilical artery, but this is nearly obliterated in after life. The two umbilical arteries run forwards and inwards along the lateral and superior parts of the bladder, and soon curve forwards so as to reach the inner surface of the anterior abdominal wall, along which they ascend to the umbilicus, then pass along the cord, and ultimately ramify in the placenta. 4. Lastly, the fcetus further differs from the adult in having an umbilical vein, which, commencing by numerous ramifications in the placental tissue, tra- verses the whole length of the cord, and reaches the abdomen by passing through the umbilical ring; then, running upwards and to the right in the substance of the suspensory ligament of the liver immediately behind the peritoneum, it gains the horizontal or umbilical fissure of this organ at its anterior part, where it gives off a few branches that ramify in the right and left lobes. Just at the point where the two fissures of this viscus intersect each other, the umbilical vein becomes enlarged, and then divides into two branches : the posterior of which, called the venous canal, or ductus venosus, is a continuation of the primitive trunk, and goes sometimes to the vena cava inferior above the diaphragm, though at others it joins one of the hepatic veins, and the common trunk thus formed empties into the vena cava; the other branch is much larger, and runs to the right; it leaves the principal trunk lower down and more in front than the venous canal; then it unites with the vena portae, producing a canal whose diameter is double its own. This is called the canal of reunion, or the confluence of the portal and umbilical veins. After a short course, this vessel subdivides and rami- fies in the substance of the liver, anastomosing with the hepatic veins, which (as in the adult) finally reach the vena cava a little above the ductus venosus. Plate IV, together with the accompanying explanation, illustrates the whole vascular apparatus of the fcetus, and to it the reader is referred. a PI. IV. 1'■ Smrtatrt '■''■ I'luJ'"*" OF THE FCETUS. 227 EXPLANATION OF PLATE IV. WHICH EXHIBITS THE WHOLE VASCULAR APPARATUS OF THE FCETUS. a. The heart, b b. The lungs, c. The spleen, d. The liver, n. The lobulus spigelii. e. E. The kidneys, f. The thymus gland, g. The upper extremity of the rectum, i. The bladder, k. The ureters, h. The womb. o. The umbilical cord. 1. The aorta. 2. The brachio-cephalic trunk. 3. The left primitive carotid artery. 4. The left subclavian artery. 5. The pulmonary artery. 6. The ductus arteriosus. 7. The vena cava superior. 8. The right internal jugular and the right subclavian veins. 9. The left subclavian vein. 10. The abdominal aorta. 11. The primitive iliac arteries. 12. The umbilical arteries, coming off from the bifurcation of the primi- tive iliac. 13. The external iliac artery. 14. The umbilical vein. 15. The ductus venosus. 16. Vena cava inferior. 17. The vena portarum. 18. The renal artery and veins. 19. The splenic artery. 20. The ovarian vessels. B. Now, having acquired these anatomical views, let us see what is the course of the blood in the foetus. A part of this fluid, circulating in the umbilical vein, is, therefore, discharged by the venous canal directly into the vena cava; another part is distributed to the liver, where it probably undergoes, as before stated, some purification, and thence is brought back by the hepatic veins to the vena cava. Consequently, all the blood from the umbilical vein reaches the vena cava inferior either directly or indirectly. The blood contairied in the latter is therefore a mixture of that which returns from the inferior extremities of the foetus and of that poured into the liver by the vena portae, with the addition of the portion contributed by the umbilical vein. This compound reaches the right auricle through the ascending vena cava, where it only mixes partially with the blood of the upper extremities, which has been brought back by the descending vena cava; because, in passing into the auricle, the ascending or inferior vena cava is directed towards the foramen of Botal, and hence its blood passes in a great measure through this opening into the left auricle, and thence into the left ventricle. By the contractions of this latter the fluid is then forced into the aorta, its impetus being broken against the great curvature of this artery; and the blood then passes into the vessels which arise from the arch, and is distributed through them to the head and superior extremities, a very small portion of it only reaching the descending aorta and the lower parts of the body. The blood, after having thus supplied the upper half of the body, is collected by the veins, which, by their successive union, form the superior or the descend- ing vena cava; the latter empties into the right auricle, where a small quantity of its blood probably mixes with that brought by the ascending cava; but much the largest part passes directly into the right ventricle, which forces it into the pulmonary artery. This vessel sends but a trifling portion to the lungs; the rest being thrust into the ductus arteriosus, which discharges its contents into the aorta: that is to say, the blood that has contributed to the nutrition of the superior parts of the body, and has traversed the descending vena cava, the right auricle, the right ventricle, and pulmonary artery, and then has passed through the ductus arteriosus, finally mingles with the remnant of blood still existing in the descending aorta. The 228 GENERATION. whole now descends to the inferior part of the latter vessel, where a small por- tion of it is sent through the arterial trunks to supply the inferior extremities, whilst much the largest quantity is driven into the umbilical arteries, and is car- ried by them back to the placenta; where, after having undergone the modifica- tions produced by the placental respiration, it is again taken up by the radicles of the umbilical vein to once more traverse the same circuit. c. Of the Changes in the Circulation after Birth.—It is difficult to explain the cause of the first inspiration; by some, it has been attributed to an iustinctive movement of the foetus, from the " besoin de respircr" (necessity of respiring) experienced by it, after a separation from the placenta; but these reasons are not satisfactory to me, for the air is only introduced into the lung as a conse- quence of the enlargement of the cavity of the chest, and not, as some imagine, to fill a vacuum which never existed. Now this expansion of the chest has for its sole cause the violent, jerking, spasmodic contraction of the diaphragm, which is always the result of a suffering condition of the foetus, caused by the suspen- sion of the utero-placental circulation, the sudden impression of cold, or the different characters of the media to which the child is successively and rapidly subjected. Finally, also, by the artificial excitations (friction on the surface, irritation of the mucous membranes, &c.) resorted to when the infant is feeble. As soon as the respiration becomes established, the sanguineous current takes another direction ; because, on the one hand, the fluid flows towards the lungs in greater quantity; and, on the other, the placental circulation is forcibly inter- rupted. Below, I subjoin the results of the labors of Billard, who has devoted particular attention to the modifications then observed in the organs of circula- tion, as they are interesting alike to the accoucheur and the medical jurist. 1. Period of Obliteration of the Fcetal Openings.—The foetal openings are generally obliterated in the course of a week after birth, still, they may remain patulous at that age; and, I may add, that either the foramen of Botal or the arterial canal may continue pervious at two or even three weeks, without the child's experiencing any particular disadvantage therefrom during after-life. The umbilical arteries are usually closed on the second day ; even at twenty- four hours they have already become smaller in the vicinity of the ring, and they are obliterated by the third or fourth day as far as their junction with the hypo- gastrics, by gradually changing into a fibrous cord; the whole process being completed in three weeks. The umbilical vein is never obliterated until after the arteries have become impervious, and the same is true of the ductus venosus; however, both are quite empty, and considerably contracted on the fourth day, and they are generally closed up by the sixth or seventh. The arterial canal and the foramen of Botal are the last to undergo this pro- cess ; but they rarely persist beyond the eighth or ninth day, although the foramen sometimes remains open much longer, being only effaced completely towards the end of the first year. 2. Mode of Obliteration.—If the ductus arteriosus and the umbilical arteries be examined during the progress of obliteration, their parietes will be found to grow gradually thicker; this hypertrophy is particularly observable in the arteries OF THE FCETUS. 229 near the navel, as may easily be verified by making sections of them at this point; but the thickness gradually diminishes towards their origin from the iliacs, and their canal is likewise obliterated precisely in the same order of progression. Of course, the contractility of its walls will also contribute towards effecting the occlusion. The arterial canal undergoes a similar hypertrophy and parietal retraction, which takes place in such a manner that, whilst the absolute size of the vessel does not appear diminished, its orifice is greatly contracted, resembling a pipe whose fracture is quite thick, and opening at its centre of very moderate calibre. The obliteration is therefore the immediate result of the retraction and concentric hypertrophy of the walls; nevertheless, it must not be supposed that this is the primitive cause, for if the same quantity of blood flowed into those vessels, such a retraction evidently could not take place; but from the very first inspiration, this fluid is driven by the contraction of the right ventricle (see hereafter) almost entirely into the pulmonary arteries, scarcely any of it passing by the ductus arteriosus; and, on the other hand, the very oblique angle at which the umbilical arteries pass off satisfactorily explains why the .blood, that flows into them in such great abundance when it has no other outlet, no longer enters them at all, or at least only very feebly, when the establishment of respiration has completed the vascular circle of the new-born child. But the umbilical vein and the ductus venosus are not obliterated in this way. and their walls exhibit no remarkable increase of thickness; for, after the cord has been cut, these vessels receive no more blood, excepting in those cases where it regurgitates from the vena cava, and then the walls fall in and become con- tiguous, just like any other canal, when the liquids that habitually traverse it are cut off; nevertheless, the umbilical vein and the ductus venosus retain their cavities free for a long time, for a large probe may easily be introduced into them; but this cannot be done in the arteries nor in the ductus arteriosus.1 The foramen of Botal is the last to disappear, although an effort at obliteration may be observed there sooner than in any other of the foetal openings : thus, the two auricles are nearly confounded in one in the early stages of intra-uterine life, and the diminution of the foramen ovale only begins to take place about the third month, by the development of a semilunar valve on its inferior border. This valve, composed of a double membranous layer, containing fleshy fibres in its substance, gradually rises along the margins of the opening towards the left auricle, by contracting adhesions with the circumference of the foramen, and it ultimately forms the fundus of the fossa ovalis, as also, the little semilunar fold seen in the auricle. In this way the partition is completed, being merely perfo- rated by an oblique canal occasionally found in young subjects, which also dis- appears after a time.3 i A case of persistence of the umbilical vein in the adult, which communicated at one extremity with the vena portae, and at the other with the crural vein through the superficial abdominal veins, is reported by M Cruveilhier, in the 16th number of his Pathological Anatomy. 2 According to Dr. Tyler Smith, the expansion of the lungs produces a compression of the ductus arteriosus by the left bronchus, and thus assists in its obliteration. The change effected in the position of the heart also aids mechanically the occlusion of the foramen 230 GENERATION. The following summary will enable the reader to appreciate the influence of those vascular modifications upon the circulation : Immediatel) after the first inspiration, and from the sole fact of the distension of the pulmonary cells, the branches of the pulmonary artery, ramifying in the mucous membrane, and contributing to the formation of their walls, are suddenly rendered permeable throughout their whole extent, and a vacuum is therefore produced, into which the blood is sent from the right ventricle; consequently, from that period, the route travelled by this fluid, from the right ventricle to the aorta, is much longer than heretofore, and the ductus arteriosus, being thus emptied, will retract at once, and have its calibre very much diminished. The right auricle, which could scarcely force all the blood that it received from the venae cavae, through the foramen of Botal, now sends the most of it into the right ventricle. Prior to birth, the left auricle only received the blood by the foramen ovale, but it is henceforth filled with that brought through the four pulmonary veins. Moreover, the relation that existed, in the quantity of the blood deposited in each auricle, is changed from .that time; for the right, which was distended beyond measure, now relieves itself with facility, while the left, that scarcely re- ceived any before, is filled with the blood brought by the pulmonary veins; so that it would flow from the left to the right auricle, through the foramen ovale, if the semilunar partition, which acts as a valve, did not prevent such a movement. BOOK IV. OF ABNORMAL PREGNANCIES. The pregnant condition is liable to present varieties, in regard both to the number of foetuses, and to the place where the product of conception undergoes its development. In the former case it receives the name of multiple pregnancy ; in the latter, it is termed extra-uterine pregnancy. We shall describe both these varieties under the head of abnormal pregnancies. The hydatiform mole we regard as a disease of the ovum, and shall speak of it briefly when treating of abortion. CHAPTER I. OF TWIN PREGNANCY. The term, compound or multiple pregnancy, has been applied to that in which two or more foetuses are enclosed in the uterine cavity. Certain females seem ovale; and, finally, the depression of the liver, by the respiratory act, closes the umbilical vein by flattening its walls. (The Lancet, Sept. 1848.) None of these assertions appear to us to be sufiiciently well proved, and therefore demand further investigation. OF TWIN PREGNANCY. 231 to be greatly disposed to these anomalies; thus, cases are recorded where six, seven, and even eleven children have been born at three successive confinements. Double pregnancies are quite frequent: that is, one case is met with in about seventy or eighty labors. Triplets, on the contrary, are very rare, since there were but five in the records of 37,441 accouchements that occurred at La Mater- nite in Paris. Further, we cannot call in question those instances in which there were said to be four at a birth ; for such men as Viardel, Mauriceau, Hamil- ton, and many others, furnish examples of it.1 Both Peu and Lauverjat declare that they have witnessed cases of five at a birth.3 And lastly, must we consider those cases of six, seven, eight, and nine children, or even more, at once, so many examples of which are found in the authors, as true statements or as fabu- lous tales ? It is a very difficult matter to point out the causes of this anomaly in the pre- sent state of our science; true, numerous explanations have been offered, but all are nothing more than pure hypotheses: for example, it is said that a single 1 The following statistical account is extracted from Churchill's work. In 161,042 pregnancies, there were 2477 cases of twins, or 1 in 69, and 36 triplets do., or 1 in 4473 (English accoucheurs). In 36,570 pregnancies, there were 582 cases of twins, or 1 in 110, and 6 triplets, or 1 in 6095 (French accoucheurs). In 251,386 pregnancies, there were 2967 cases of twins, or 1 in 84, and 35 triplets, or 1 in 7185 (German accoucheurs). Total, in 448,998 cases, there were 5776 instances of twins, being 1 iu 77|, and 77 trip- lets, or 1 in 5831. The same author furnishes the accompanying information as to the sex of the twins : Dr. Joseph Clarke states, that in 184 twin cases, both children were boys 47 times, girls 68 times, and one boy and one girl 71 times. Dr. Collins reports 240 cases, in which there were two males 73 times, two females 67 times, and male and female 97 times ; and Dr. Lever 33 cases, two males 11, two females 11, and male and female 11. 2 M. Pigne informed me that he saw a single placenta at Strasbourg, from which five separate cords arose, although only a single sac existed, which was composed of three membranes, decidua, chorion, and amnion, in which the five embryos were enclosed. Dr. Kennedy (London Med. Gazette) presented to the Royal Society the history of a woman who aborted at three months of five embryos. There were three ovums, one being double, and each ovum had a placenta and its own proper membranes. M. Bourdois (Gaz. Mid., p. 569, 1840) describes a quadruple pregnancy, in which the delivery occurred at the seventh month. The second child was born twelve hours after the first, and the other two a few minutes subsequently. The second accouchement was attended by a new discharge of waters; there were two placentas, one of which had three cords and was adherent, and some portions of it remained behind in the uterus. Dr. Hull, of Manchester, deposited five little twin foetuses in the Museum of the London College of Surgeons, that he had obtained from a woman who aborted at the fifth month of gestation. Chambon records an instance of quintuple pregnancy, where the children survived their baptism. A woman of Naples was delivered of five infants at seven months. (British and Foreign Med. Review, 1839.) Dr. Kennedy (Every) states (in the Dublin Med. Journal, Jan. 1840), that a woman aborted of five embryos between the second and third months of gestation; and finally, Dr. Francis Ramsbotham has collected three cases of quintuple pregnancy from the public journals. 232 GENERATION. fecundation may affect both ovaries, or two of the Graafian vesicles in the same ovary; and again, that several impregnations may occur successively in a short period, that is, before the first fecundated ovule has arrived in the uterus. Both take it for granted that two ovules are detached, either at the same time or suc- cessively, from the ovary, and, consequently, that two corpora lutea are deve- loped. Several well-attested facts prove, however, that a different state of things may take place : thus, for instance, two ovules have sometimes been found in the same Graafian vesicle, and it is evident that the rupture of this vesicle alone, in such a case, might produce a double fecundation; at other times, two yolks have been seen in the same ovule, and in such a condition a twin pregnancy might certainly occur, although but one ovule be fecundated. Hereafter we shall see, that these peculiarities serve to explain the varied dis- position exhibited by the membranes in compound gestations. It is frequently possible to recognize the presence of twins during pregnancy; indeed, the abdomen is ordinarily more voluminous then than at other times, and the belly is generally flattened on the median line, instead of presenting there a well-marked protuberance; the middle is depressed, in consequence of the two children lying one upon each side; nevertheless, this sign may fail when one child happens to be placed before the other. The form of the uterus varies also with the position of the foetuses, their num- ber, and the amount of amniotic fluid. Thus, when the head of one is above, and that of the other below, there may result therefrom two corresponding de- pressions and projections, as M. Hergott has represented. Should both present by the head, the fundus of the womb will be very much dilated, and the con- trary is the case when they present by the pelvis. In a case which occurred at the Clinic of Strasbourg, the shape of the womb was irregular and oblique; the two heads occupied the angles of the uterus, and formed two tumors separated by a depres- sion; the one at the right being much the higher. The twins were born by the feet. The slight blows perceived by the mother are sometimes felt at one and the same time in two distant parts of the abdomen; and the importance of auscultation as an element in this diagnosis has already been pointed out. (See p. 148.) The bellows murmur can, I think, rarely furnish useful information. Still, it is as- serted by Holl, that in sixteen twin preg- nancies, the murmur was heard seven times on both the right and left sides simultaneously, and nine times on one side only; and he af- firms, that when the latter was the case, there was a common placenta, whilst in the other instances there were two. He is also of the opinion, that a double souffle is diagnostic of a double pregnancy, even though the sound of the heart be heard at a single point only. We cannot admit the last conclusion, since we have already denied the very relation which Iloll would establish between the OF TWIN PREGNANCY. 233 seat of the murmur and the insertion of the placenta; besides which, we have often heard a souffle on both the right and left sides in single pregnancies. Again, as the two foetuses mutually interfere with each other, neither of them presents itself to the vaginal touch, and of course the ballottement is then ex- ceedingly difficult, if not wholly impossible; for, even if the finger should easily reach the presenting part, the presence of another child would interfere with the ascending movement of the first. Desormeaux, however, cites a case where the ballottement was manifest in a twin gestation, but even here a large quantity of water was present at the same time. Whilst in charge of the Clinic of the Faculty, in 1845, I observed on two occasions the same fact noticed by Desor- meaux; for the existence of dropsy of the amnion rendered the ballottement very perceptible, although two children were present. The course of twin pregnancies is sometimes accompanied by peculiarities which it is important to be acquainted with. Thus, the two foetuses do not always attain to the development which we have indicated. One of them may die, and yet the other continue to grow. In such cases, which, however, are rare, the dead body may either remain in the womb, where it hardens, withers, and is expelled during labor, or, by irritating the uterus, may bring on the contractions which expel it from its cavity, while the .development of the other constantly progresses. In my course of 1853,1 exhibited a placenta obtained from a woman who was delivered at term of a living and well-developed child. It was provided with two amniotic bags, one of which belonged to the living child, and presented no unusual appearance. The other, which was much smaller, contained barely a trace of fluid, but enclosed a small mummy-like foetus, about the size of one of four months' development. Lastly, the twin that died during the gestation may still remain in the womb, in consequence of the adherences which its placenta has contracted with that organ, for a long period after the expulsion of its living brother, that occurs at the ordinary term of gestation. Guillemot furnishes one of the most curious observations of this kind (Heureux Ace, livre ii, p. 225) on record, in which the artificial extraction of the dead body did not take place until two years after the accouchement. But what is the cause which thus determines the death of one foetus ? Mauriceau and Peu thought it might be attributed to the fact that one child, by receiving all the nourishment, becomes strong and vigorous at the expense of the other, thereby rendering it feeble and languishing, and causing its early death. M. Guillemot believes that one child, in its growth, gradually compresses the second against the uterine wall, and the latter, not having sufficient space for its development, soon after dies. Lastly, M. Cruveilhier explains the atrophy of the foetus by a gradual separation of the placenta, founding his opinion on a single case, in which the hemorrhage was great enough to account for the early death of one of the twins; but in the greater number of cases that have been recorded, no mention whatever is made of any hemorrhage during the pregnancy; whence, of course, the opinion of M. Cruveilhier would not be applicable to them. For my own part, I believe these cases, in which the death and atrophy of one foetus takes place, should rather be attributed to some disease of the infant or placenta, 234 GENERATION. or of some parts of its envelopes. It may be urged, indeed, that these altera- tions are not observed at the time of accouchement, which it is not to be won- dered at, considering the state of degeneration exhibited by all parts of the ovum; and, although no positive fact sustains this opinion, it seems to me more admis- sible and more rational than the others. It not unfrequently happens that twin pregnancies terminate before full term, owing, doubtless, to the great distension of the uterus, which is often as large at seven or eight months as in a simple pregnancy at nine months. The same labor generally suffices for the expulsion of both, though such is not always the case; for, after the first child is born, the uterus may retract upon the remaining twin, and leave it unexpelled for eighteen or twenty-four hours. A still longer interval, several months even, may separate the two parturitions; and it is upon such facts as these, that some persons have improperly admitted the doctrine of superfoetation. A reference to the latter is, however, unnecessary to explain these observations, for the cause of premature delivery is dependent solely on the enormous distension of the uterus, because as soon as one infant is expelled the womb retracts, the cause of irritation no longer exists, and we can readily con- ceive that the gestation may continue on until term. A child born at seven months may live equally well with one delivered at the end of pregnancy. The peculiarities just studied in twin pregnancies, may also present themselves in cases of triplets, &c. Thus, in a case cited by Portal, after the delivery of the first child and its placenta, which were healthy, he was obliged to extract two others that had apparently been dead for a long time, and were thoroughly dried. Again, the membranes are not always disposed in the same manner in these pregnancies; and on this head we may admit, with M. Guillemot, who has par- ticularly studied the subject, four distinct varieties: thus, in the first, two ovules are fecundated, and each embryo becomes developed, and is surrounded by its own proper membranes; in the second, the ovule contains two germs, though each fcetus has but a single envelope, the chorion being a common membrane; in the third, both embryos are enclosed in a single cavity, which appears never to have been divided by any membranous diaphragm; and, finally, the last variety is met with when the ovule contains a second germ, and both become developed together, which gives rise to what are called monstrosities by inclusion. Adopt- ing this classification as the basis, let us now proceed to the different modes of termination presented by these pregnancies, according to the species to which they belong. 1. In the first variety, both ovules are developed, retaining their proper mem- branes, the chorion and amnion; at first, each ovum has its own reflected decidua, but generally that portion of the latter which forms the partition is very thin, and becomes absorbed as the gestation advances, and a single decidua then appears to envelop both. The two chorions repose against each other, being only separated by some very fine areolar tissue, so that the children are divided by one very thick partition com- posed of four layers. The placentas are sometimes separate, though usually con- founded with each other, or else are united by a kind of membranous bridge; but, notwithstanding this continuity of tissue, there rarely exists any vascular com- OF TWIN PREGNANCY. 235 munication between them, and this fact is so uniform that the exceptions to the law are very rare indeed. From all which it must therefore be evident that two distinct ovules have been fecundated, whether they are deposited separately, or are contained in the same vesicle. The first variety is the most frequent. 2. In the second variety of compound pregnancy, the chorion is common to both twins, and each fcetus has but a single envelope formed of the amnion—the •two laminae of which, resting against each other, constitute the median partition. MM. Dance and Mancel have furnished an example of this variety in which there were but two children. Brendelius reports that a woman was delivered of two girls after three days' travail, but she died before the extraction of the third infant, which was found dead on opening her body; the placenta was single and very large, and the chorion had been common to all three, although each fcetug had a distinct amnion. There is therefore only a single placenta, and a communication nearly always exists between the ramuscules of the two cords, as I have verified myself, on a placenta, which was presented by one of my former pupils, an Interne of the Ursuline Hospital, where he obtained it. In this, as in the preceding variety, one fcetus may die, the other continuing to live; but it is easily foreseen that an expulsion of the two children cannot take place separately. 3. Further, it may happen that the foetuses are not separated by any parti- tion, and are all shut up in the same amniotic cavity; and to the examples of this kind, already cited, I may add a case observed by my friend and colleague, Dr. Fournier. The two cords arise, most frequently at least, from a distinct point of the placenta; but sometimes they are observed to come from a common trunk, which bifurcates at a variable distance from the placental surface. In this variety, the expulsion of one foetus must evidently be followed by that of the other; but I do not know to what extent we can justly say that the death of one uecessarily endangers the other's life, if not speedily delivered by nature. (Bau- delocque.) This inclusion of two foetuses in the same amniotic cavity, is often met with in those cases where one of them is destitute of an important part of its body : thus, the monstrosity that I presented to the Royal Academy of Medi- cine was enclosed in the same sac with its twin brother. But it is nearly or wholly impossible, in the present state of ovological know- ledge, to explain this strange anomaly, the existence of which, however, has several times been clearly verified. In accordance with what we have said respecting the formation of the amnion (see Art. Ovology), this membrane emanates from the embryo itself, and con- sequently the amniotic membranes should equal the foetuses in number; but, without admitting the theory of Pockels and Serres on the development of the amnion, a theory which, notwithstanding its want of probability, derives, from the facts alluded to, a certain degree of support, we cannot explain them but by supposing that two amniotic membranes existed primitively, and that the parti- tion produced by their contact has been somehow destroyed. Most generally, there are numerous communications existing between the umbilical ramifications, as we have stated, when the chorion, and especially the amnion, are common to both, which is not always the case. Thus, Dodd reports a case of triplets, where the placentas were consolidated into one, two of the children being enclosed in a 236 GENERATION. common chorion, whilst the third had a special one; the umbilical vessels did not communicate with eaeh other. In another instance, recorded by Davis, the three foetuses had a common decidua; two of them were surrounded by the same chorion and amnion, but the third had its chorion and amnion distinct from the others; the placenta formed a single mass, but the vessels had no communication with each other. (London Med. Gazette, 1841 ) 4. Finally, the fourth variety of compound pregnancy that we have admitted,* along with M. Guillemot, constitutes what has been called a monstrosity by inclusion. It consists of the complete inclusion of the elements, whether more or less numerous, of one foetus in the body of another fcetus, which is otherwise well formed. M. Ollivier (d'Angers), who has published a very interesting article on this monstrosity, admits that the inclusion may take place in two different ways: for instance, the contained fcetus is sometimes shut up in the abdominal cavity of the other child, thereby constituting the profound, or abdominal inclusion. At others, it is merely enveloped by the integuments of the latter, which form an external tumor, without any communication whatever with the visceral cavities of the foetus that carries it; this is the cutaneous, or exterior inclusion. This latter has again been subdivided into two varieties, according as the tumor occu- pies the scrotum or the perineum; but as the character of this work evidently prohibits me from entering into a discussion of the various opinions put forth as to the nature and the mode of formation of this kind of monstrosity, I can only allude to them here; and I refer for more complete details to the memoir of M. Ollivier (Archives, 1827), as well as to that of M. Lesauvage de Caen, and still more especially to the admirable Traitc de Teratologic, by M. Isidore Geoffroy St. Hilaire. CHAPTER II. OF EXTRA-UTERINE PREGNANCY. The fecundation, as elsewhere stated, most frequently takes place in the ovary. and the impregnated ovule is then received by the fimbriated extremity of the tube, which applies itself on this organ, doubtless by a kind of spasmodic con- traction. Having been once deposited in the tubal canal, the ovule traverses its whole length, and falls into the uterine cavity, where its development continues until term. Such is the course observed in normal, or uterine pregnancy; but it may happen that the ovule is arrested, or diverted, in the route it thus travels. and engrafting itself, so to speak, upon the point of stoppage, is there developed; in the latter case, the pregnancy is called an abnormal, or an extra-uterine one. This species of gestation has been subdivided into several varieties, which have received different names, according to the part of the passage where the ovule becomes fixed. Thus, we may admit with M. Dezeimeris the following divisions, namely:— OF EXTRA-UTERINE PREGNANCY. 237 1. The ovarian pregnancy. 2. The sub-peritoneo-pelvic pregnancy. 3. The tubo-ovarian pregnaney. 4. The tubo-abdominal pregnancy. 5. The tubal pregnancy. 6. The tubo-uterine interstitial pregnancy. 7. The utero-interstitial pregnancy. 8. The utero-tubal pregnancy. 9. The utero-tubo-abdominal pregnancy. 10. And the abdominal pregnancy. 1. The Ovarian Pregnancy is that variety in which the ovum is developed in the ovary itself; or rather, the fecundated ovule is found on the interior of the envelope or ovarian vesicle that contained it prior to fecundation; or else, after having ruptured this vesicle, it remains adherent to the surface of the ovary, thus constituting two varieties, the first of which has been denominated the in- ternal ovarian pregnancy. Among the recorded observations of our science, bearing on this point (which, however, do not appear very satisfactory to M. Velpeau), is one reported by Boehmer, about which it would be useless to raise a serious doubt; for the author carefully describes both the proper membrane of the ovary and its peritoneal envelope; and, unless we contest the accuracy of his details, it is impossible to deny that the foetus was really in the substance of the ovary itself. But M. Velpeau, who rejects this variety of extra-uterine pregnancy, says, that a conception cannot occur without the direct contact of the fecundating liquid with the ovule; and as this junction evidently requires the previous rup- ture of the ovarian vesicle, an internal ovarian pregnancy, properly so called, that is, where the ovu!e is developed within the interior of the vesicle, is wholly impossible. We acknowledge the speciousness of the argument, but shall reply, like M. Dezeimeris, that, in the present state of our science, the manner in which the sperm exercises its influence upon the ovule cannot be positively determined; and that, between a simple theoretical view, however in- genious it may be, and a well-observed fact, the most cautious cannot long remain undecided. The second variety is designated under the term of the external ovarian, though it might also be called the ovo-abdominal, because the ovule is partly developed in the abdomen, partly in the substance of the ovary itself. In the first variety of ovarian pregnancy, the product of conception is evi- dently exterior to the peritoneal cavity. 2. Sub-peritoneo-pelvic Pregnancy.—Under this appellation, M. Dezeimeris designates a species of extra-uterine pregnancy, in which the ovule, after having quitted the ovarian vesicle, is unable to pass into the external opening of the Fallopian tube, but gets between the two laminae of the broad ligament, and is there developed. Of course, the ovule is situated without the peritoneum, and it lodges principally in the pelvic cavity. According to this author, this species is not very rare, and from the situation of the ovule it is one of the least consequence; indeed, its situation signally favors the spontaneous expulsion of the foetal debris, or at least renders them 238 GENERATION. more accessible, in case their extraction should at any time become necessary. I am inclined to believe the case observed by M. P. Dubois, at the obstetrical clinic of Paris, in 1837, the details of.which are furnished by M. Voillemier, in the Archives Generales de Medecine, belonged to this particular variety. 3. Tubo-ovarian Pregnancy.—In this, the cyst, which surrounds the fcetus, is formed partly by the ovary, and partly by the opening of the dilated tube, whose extremities have contracted some adhesions with the ovarian tunic. The following case of Dr. Jackson's is justly quoted by M. Dezeimeris as serving for a type: A woman, aged thirty-two years, was seized, in consequence of a violent blow on the epigastrium, with some inflammatory symptoms, to which she speedily succumbed; at the autopsy, a large quantity of blood was found diffused in the abdomen, and a foetus of about ten weeks was found enve- loped in an enormous clot; the fundus uteri rested against the pubis, and its cervix near the middle of the sacrum. This change from its natural position had been produced by a tumor situated on the left side of the womb, which tumor was formed by the ovary, the Fallopian tube, and the broad ligament, that had become considerably thickened and modified in their structure; the fringed ex- tremity of the tube adhered intimately to the ovarian envelope, and a cyst was formed by these two organs, whose distension by the body contained therein had produced the rupture. In another case, related by Bussieres, which seems to me equally conclusive, the tube on the right side was extremely dilated at the extremity; and this dila- tation, which was an inch in its largest diameter, extended for rather more than an inch and a half in length, gradually diminishing as it approached the womb. The portion of the tube thus dilated was curved on itself, and embraced nearly the whole ovary, to the membrane of which it was so adherent that it could not be separated without rupturing the attachments. An unctuous, limpid fluid escaped as soon as it was opened, and then the ovum appeared, which was about the size of a hazelnut, and was surrounded by the liquid; three-fourths of it had already escaped from the hole made in the ovary, so that it no longer seemed to rest there; yet, on attempting its removal, it was found attached by a hard pedicle covered with bloodvessels. 4. Tubo-abdominal Pregnancy.—It is evident that, if the tube be obliterated near the enlarged extremity, the ovule which has scarcely entered its canal will be arrested; and if the development occurs at this point, the tubal walls will necessarily be dilated, and one portion of the surface of the ovum be free in the abdominal cavity; to this variety the name of tubo-abdominal is applied. The placenta is attached in the interior of the tube, and the fcetus developed in the abdominal cavity, and both are surrounded by a cyst, the walls of which are partly made up by the parietes of the tube. 5. Tubal Pregnancy.—This is the most frequent of all the varieties of extra- uterine pregnancy; which fact is readily accounted for by the length and nar- rowness of the canal, and by the adhesions and morbid obliterations presented by its walls. Under such circumstances, the ovule is arrested and developed at some point between its abdominal extremity and the spot where it enters the uterine parietes; and by its continual growth distends enormously the fibres of the tube which constitute the envelope of the foetal cyst. To the numerous cases of this kind reported by Velpeau and Dezeimeris, I might add another, OF EXTRA-UTERINE PREGNANCY. 239 already published by me in the Bulletin de la Societe Anatomique, but so many examples are everywhere met with that it seems useless to reiterate their details. 6. Interstitial Tubo-uterine Pregnancy.—In an anatomical point of view, it is important to distinguish this variety from the succeeding one, with which most authors have confounded it, for it exhibits the peculiarity of the ovule being arrested in that portion of the tube which traverses the substance of the uterine walls. At this point the parietes undergo a considerable distension, and press back the surrounding proper tissue of the organ, so that the latter always forms the most internal part of the cyst that encloses the product of conception, and consequently the uterine extremity of the tube is often imperforate. 7. Interstitial Uterine Pregnancy.—Again, the ovule reaches that part of the tube which traverses the uterine walls; but having arrived there, it opens a way through the tubal parietes, penetrates into the midst of the fibres of the womb, and thenceforth has no further relation with the tube; hence, the surrounding cyst is formed by the muscular fibres of the womb alone. This anomaly appears wholly inexplicable, without referring it to the canal previously described (p. 67), the existence of which can alone, in my esti- mation, account for the disposition here manifested. After having been once located among the uterine fibres, the ovum may either take an inward or an out- ward direction, and consequently may become seated near to the mucous layer, or else to the peritoneal coat. In a preparation belonging to M. Pinel Grand- champ, the volume of the uterus was about the same as at six weeks or two months of pregnancy; at its left angle, a small tumor, slightly ruptured behind, constituted the cyst containing the product of conception. The tube, which passed behind it, communicated with it by an almost microscopic orifice, and presented nowhere any increase of calibre. The cyst was about large enough to contain an almond. 8. Utero-tubal Pregnancy.—Notwithstanding the free communication existing between the tube and uterine cavity, there is no absurdity in the supposition that the ovule may become deposited in a little depression of the mucous mem- brane, and there stop and engraft itself, just at the internal orifice of the canal. In this case, phenomena similar to those of the tubo-abdominal gestations will arise: that is, the ovule, which may have contracted some intimate adhesions with this extremity, may, by its development, encroach upon the uterine cavity itself; and I do not hesitate, therefore, to consider this variety of gestation as possible. 9. Utero-tubo-abdominal Pregnancy.—In this species, examples of which have been furnished by Patuna, Hunter, and Hoffmeister, the foetus is found in the abdominal cavity; the cord leaving the umbilicus enters the Fallopian tube, tra- verses its whole length, and is inserted in the placenta, which itself is attached to the internal surface of the uterus. However extraordinary these facts may appear, I think that no one can doubt them after reading the subjoined case, taken from the memoir of M. Dezeimeris.1 1 Helen Zopp, aged 35 years, had been married for twelve years, and had given birth to eight children, two being twins. As she was preparing for church on Sunday, July 10th, 1763, she was suddenly attacked, 240 GENERATION. 10. Abdominal Pregnancy—-The long-contested question of abdominal gesta- tion is now established by so many facts, observed both in the human female and in animals, that we can no longer justly deny its possibility. No doubt the after a violent fit of anger, with a profuse flooding and the pains of childbirth (being then at term) ; however, she did not pass the waters, but what proved to be pure blood; and she felt the motions of her child up to the last moment. The midwife, summoned on the occasion, declared at once that the accouchement was at hand; but, after the lapse of several hours, as the loss of blood continued without any positive signs of an approaching delivery, a physician and a surgeon were simultaneously sent for. the former of whom soon arrived, and recognizing at once the imminence of the danger, he ordered the administra- tion of the sacraments, at the same time prescribing divers remedies for the discharge. The venesection of the cephalic vein was followed by a profound syncope, without causing the least abatement of the metrorrhagia, and the sacraments had scarcely been adminis- tered, when the patient died, at 11 a. m. on the same day. Patuna and his father (the public surgeon to the city) arrived just as she was expiring. After assuring himself of her death, he immediately made a Cesarean section upon the right side, where the abdomen offered the most resistance, and, as soon as the ventral walls were divided, an enormous foetus, resembling a child nine months old, presented itself; the position was such, that its back corresponded with the abdominal parietes of the mother; the head was somewhat inclined, was directed towards the vertebra, and rested immediately under the diaphragm; the knees flexed towards the head, the right hand upon the thighs, and the left near the navel: the umbilical cord was of a considerable length; it ascended to the right, wound around the neck, and then entered the Fallopian tube on the right side. A case of extra-uterine pregnancy being new to Patuna, although acquainted with most of the published examples, his researches were made in the most careful manner. Having enlarged the opening made in the abdomen, so as to examine its cavity to better advantage, he sought for the foetal envelopes with all possible attention, but in vain ; for he neither found the amniotic liquid, nor fluids of any other kind in this cavity. By tracing the umbilical cord with his hand, he found that it penetrated into the right tube at the distance of a finger's breadth from the uterus; the uterine portion of the tube was more voluminous than that part which ran to the ovary, whence he judged that the cord passed through the former into the womb. This organ was larger than the fist, and had the natural pyriform shape, but not the least vestige of any rupture ; not the smallest cicatrix could be seen, and it hardly rose above the pelvis. These observations being concluded, Patuna incised the tube from the entrance of the cord towards the uterus: this presented nothing peculiar, excepting the adherence to the cord where the latter perforated it. The uterus was then opened, and exhibited no trace in the interior of any previous laceration whatever; the walls were an inch and a half in thickness, and their substance was nearly bloodless; the placenta was found within ad- hering to a narrow space at the fundus, a little to the right; it extended more towards the left, but was there detached. It was about two fingers' breadth in thickness, and four inches in diameter, and it commenced very near the uterine opening of the right tube, and adhered more strongly there than at any other place. The extremities of some vessels were evident both on its convex surface and at the fundus uteri upon which it was en- grafted ; its concave face, from the middle of which the cord arose, was covered by two membranes : one, the interior, being thicker and vascular, while the exterior was very thin and translucent; but these joined when they approached the border of the placenta, form- ing there a more solid substance, and having some very delicate vessels ramifying through it. The internal uterine orifice would hardly admit the little finger. Everything else remained in a natural state, excepting the change in the situation of the intestines. (Barthelemy Patuna.) OF EXTRA-UTERINE PREGNANCY. 241 ovarian or other pregnancies have often been confounded with it, but in most of the published cases it is incontestable that the ovum had no relation with the internal genital organs whatever. M. Dezeimeris has divided the abdominal gestation into primitive and secon- dary varieties : in the former of which the product of conception has never had any other domicile than the abdominal cavity, into which it fell immediately on quitting the ovarian vesicle; in the latter, on the contrary, the ovule was first developed in the ovary, the tube, the walls, or the cavity of the uterus; but the excess of distension, or some pathological alteration in the parietes of the tumor, has destroyed its attachments, and the ovule, being driven wholly or in part from the containing cyst, escapes into the abdominal cavity, where it is subsequently found. I cannot, however, admit any such distinction; for the secondary abdo- minal pregnancy of M. Dezeimeris seems to me to be nothing more than an ovarian, tubal, or interstitial gestation, which is terminated by the rupture of the primitive cyst; and whether this rupture takes place at an early period or only at the regular term of gestation, it can only be considered as a mere anomaly, and in no case can it constitute a distinct variety. We shall therefore restrict the term abdominal gestation to that species in which the ovule, at the commencement, engrafts itself on apart clearly separated from the internal genital organs. The spot where this may take place varies almost ad infinitum, the placenta being sometimes known to adhere to the peri- toneum covering the right or the left iliac fossa, sometimes to the mesentery or a portion of the large or the small intestines, again at others to the anterior abdominal parietes. We have not been able, from the restricted limits of this chapter, to bring forward a larger number of cases, but sufficient has been said to furnish an idea of the importance that Ought to be attached to the different varieties of extra- uterine pregnancy admitted by us. The reader may consult with benefit the article of Professor Velpeau, in the fourteenth volume of the Dictionnaire de Medecine, the learned memoir pub- lished by M. Dezeimeris, in the fourth year of the Journal des Connaissances Medico-Chirurgicales, and the able articles of Messrs. Breschet, Meniere, and Guillemot. The physiological and pathological history of these different pregnancies is yet to be given, and we shall therefore commence with their pathological anatomy. § 1. Pathological Changes. The anatomo-pathological examination of extra-uterine gestations evidently comprises the peculiarities offered both by the product of conception and the parts of the mother. A. Product of Conception.—In these pregnancies the ovule has its proper membranes, the chorion and the amnion. 1 may state that I was utterly asto- nished to hear several honorable members contend, in a recent discussion before the Academy of Medicine, that the envelope of the ovule, in abdominal gesta- tions, was only composed of the amnios, and that no chorion existed; for although, in certain very old pregnancies, the most exterior fcetal membrane is confounded 16 242 generation. with the walls of the cyst, it is not fair to conclude, from thence, that it did not exist at the commencement. Indeed, it is only necessary to recall our remarks on the mode of development of the ovum, to comprehend that the absence of the chorion supposes that of the allantois, and without the latter no circulatory relations can be established between the embryo and its mother. The structure of the walls of the cyst varies according to the species of extra- uterine pregnancy. In the tubal variety, they are formed by the walls of the tube itself, and in the ovarian, by the integuments of the ovary and its peritoneal envelope. In the sub-peritoneo-pelvic gestation, or whenever the ovule, that was origi- nally located in the ovary, tube, or even the uterus, is transferred, after the rupture of the cyst which enclosed it, to some part of the abdominal cavity, there is besides a pseudo-membranous cyst, representing the uterine decidua, produced by the inflammation which the presence of the ovule determines around it. But this enveloping membrane, the cyst, does not exist in primitive abdominal preg- nancies. M. Dezeimeris thus explains the latter circumstance: When a fecun- dated ovule gets into the abdominal cavity immediately after quitting the ovary, we can readily believe that a corpuscle so minute, soft, and fragile could only produce a very slight irritation at the point of arrestation, and that the extent of this excitation will not pass beyond the limits of contact with the little foreign body; in a word, it cannot produce an acute inflammation, or extensive adhe- sions, nor an exudation of plastic lymph sufficient to form an enveloping cyst. Now, if it has not primarily caused all these derangements, the neighboring organs will not be injured by its ulterior development, because they become gra- dually habituated thereto; and the ovule, having obtained a right of possession, lives, grows, and presents to the smooth, polished surfaces which touch it, a sur- face equally smooth, polished, and moistened at their expense; and, not having occasion for any other protecting envelope, no cyst is formed. But when a volu- minous product of conception suddenly bursts, and its contents, placed at first like it in the tube or ovary, are transported to the peritoneal cavity, the ovule becomes there a foreign body, wounding and irritating the abdominal organs which are unaccustomed to its vicinity, and determining an acute inflammation around it, which results in the exudation of plastic lymph; this, by coagulating, forms a cyst, and completely isolates the foreign body. If, under these circum- stances, the displacement of the foetus is such that it completely escapes from the amniotic cavity, and suddenly locates itself with its surrounding liquid in the midst of the intestinal mass, an inflammation occurs, and the cyst we have just described forms around it; the new cyst then completely environs the foetus. But in some cases the displacement is not so complete—the largest part of the trunk may still remain in the amniotic cavity after the rupture, a portion only being displaced, and the latter alone first determines an inflammation around it, and then the exudation, which is transformed into a false membrane; this, by uniting with the lacerated margins, forms only a part of the fcetal cyst, the re- mainder being constituted by the old fcetal envelope, the walls cf the Fallopian tube, for instance, in the case of a tubal pregnancy. The same relations may be established with the membranes of the ovule when the chorion and amnion are OF EXTRA-UTERINE PREGNANCY. 243 ruptured at an advanced period in a case of primitive abdominal pregnancy. For instance, in a case cited by M. Dubois, the cyst that enclosed the fcetus was formed of a membrane which was not altogether uniform in its structure and appearance: thus, for the greater part of its extent, the internal surface was of a light brown color, owing perhaps to the imbibition of the adjacent liquids, and simulating, both to the touch and sight, the aspect of the mucous membrane of the small intestines, or, still better, the accidental membranes that occasionally line fistulous canals; while at other points, those for instance which were near the circumference of the placenta, and on the largest part of this surface itself, the cyst was more smooth and polished; presenting, in fact, the ordinary ap- pearance of the amnion. The cyst was simple, and about a fourth of a line in thickness at the part where it exhibited the brown and villous character above alluded to ; but on the contrary, where the surface was smooth and polished, it evidently consisted of two membranes (the chorion and the amnion). When an extra-uterine pregnancy is somewhat prolonged, these envelopes are sometimes destroyed, being perforated with fistulous canals, communicating directly with the intestinal canal, vagina, bladder, uterus, or an external abscess. At times, the destruction of the cyst is partial, at others complete; so much so, indeed, as to leave in certain cases no vestiges of its former existence; on the other hand, the envelopes sometimes undergo osseous or cretaceous transforma- tions, which may convert them into solid shells. As a general rule, the foetus exhibits nothing peculiar in its development: for example, in several cases studied anatomically a long time after the term of pregnancy, the osseous system appeared to have a better development than in the ordinary child of nine months. The existence of several teeth has frequently been noticed, or else traces of the eruption of these little bones, which would seem to afford an indication that the fcetus continued to live and grow beyond the ordinary term of gestation. The most common of the numerous alterations which it may undergo, is the putrescent dissolution of its soft parts, from macerating in a compound of am- niotic liquor, blood, and pus; the separation of the various pieces of its skeleton, and their discharge through the divers routes just mentioned. At other times. it seems to have undergone a kind of mummification, a complete drying up. Again, in other cases, all the tissues appear to be transformed into an osseous or cretaceous substance, or into one resembling the fat of a dead body—and here, it is doubtless unnecessary to add, it is no longer possible to discover any trace of the fcetal membranes. B. Tissues of the Mother.—Some very large vascular canals are seen to deve- lop themselves in those parts where the ovum is attached, however devoid of bloodvessels they might have been previously; and several great veins are found to ramify under the peritoneum towards the circumference of the placental attachment; and where the ovary or the tube happens to be the seat of preg- nancy, it presents a soft tissue, apparently fungous in character, and impregnated with blood. The womb does not continue so indifferent to the advancement of the extra- uterine pregnancy as might be supposed; for its volume increases in a remark- able degree, the tissues become softer, and the mucous membrane hypertrophied 244 GENERATION. and more vascular, so as to form from the outset a true decidua. M. Velpeau, however, disputes this last assertion; but I have endeavored to refute his opinion in the Bulletin de la Societe Anatomique (Sept. 1836), to which the reader is referred. This hypertrophy of the uterine mucous membrane is of short duration. For, as the ovum does not enter the uterus, it has no office to perform, and therefore, like every other useless organ, becomes atrophied, loses its vascularity, and in a few months has returned to its usual condition. A gelatinous substance, a kind of thick, ropy mucus, is also frequently found in the neck of the uterus; but, when the pregnancy has advanced beyond term, the womb gradually regains its natural condition. Finally, in certain cases, the calibre of the Fallopian tube has been found obliterated at some part of its length. (See page 248, et seq ) § 2. Progress of Extra-uterine Pregnancy. During the early months, it is exceedingly difficult to recognize the existence of an extra-uterine pregnancy; for the modifications which then occur in the size, form, and consistence of the body and neck of the uterus, will certainly lead to error, and give rise to the belief of a true gestation. With regard to the menstruation and the lacteal secretion, no constant rule is observed. Sometimes the menses continue to appear; at others, they do not. In some instances this function is not re-established, even after the period when the accouchemeDt should have taken place; and similar variations are met with in the secretion of milk. Again, menstruation has been known never to appear during an extra- uterine pregnancy, which lasted more than thirty years, while the lacteal flow continued throughout the whole of that time. There are, likewise, some abdominal pains, at an epoch not very distant from the date of conception, more or less analogous to the uterine pains, and at times a constant, fixed, circumscribed one in the pelvis, groin, or umbilical region. (The woman whose preparation I presented to the Anatomical Society, had on this account been treated for a partial peritonitis.) Not unfrequently, there is an inability to lie upon one side. When the tumor, whilst still small, falls into the lesser pelvis, it pushes the uterus forward, the neck being directed in front and quite high behind the pubis. This displacement of the neck of the womb, together with the presence of a large tumor occupying the excavation posteriorly, and the dysuria occasioned by the pressure made upon the neck of the bladder, has been mistaken for retroversion. Several examples of this error are men- tioned by Burns. At a later period the tumor rises above the superior strait. The motions of the child are felt at the usual time, but they appear to be more superficial, and are generally felt on one side only. The labor-pains come on at the natural term, or at the seventh month, or even sooner, generally lasting for three or four days, but occasionally much longer; and, should the pregnancy be unusually prolonged, they are apt to return at varied intervals, and again pass off. Schmidt reports a case where the gestation lasted three years, within which period the labor-pains were renewed eight times, and on each occasion continued for several weeks. OF EXTRA-UTERINE PREGNANCY. 245 In another gestation, of ten years' duration, the pains returned annually at the period corresponding to the term of pregnancy. These pains are not produced by contraction of the walls of the cyst, as many have stated; because, excepting the cases of tubal and interstitial pregnancy, they never contain any muscular fibres, and hence we must search for the cause in the uterus itself; for the great development exhibited by this organ, and the mucous and albuminous matters enclosed in its cavity, the expulsion of which requires some contractions, sufficiently account for the pains experienced by the patients. But it is exceedingly difficult to explain in a satisfactory manner their frequent coincidence with the usual term of gestation. The physical signs which require our notice are, the changes in the uterine body and neck, just indicated, the more or less irregular development of the belly, and the possibility, in some cases, of distinguishing two tumors, one being the uterus, while the other is formed by the abnormal cyst. In the sub-peritoneo-pelvic variety, the product of conception, by occupying the pelvic excavation, displaces and compresses the organs there situated, the vagina and rectum, for instance, and pushes them to one side. Frequently, the different parts of the foetus may be detected by the vaginal touch. The fcetus seems to be much nearer the surface in the abdominal pregnancy than in either of the other varieties, hence its motions are more easily perceived, and are more distressing to the mother, and the forms of the different parts more clearly distinguishable. Besides, the rounded and regularly circumscribed tumor formed by the uterus in a normal gestation is not present. In the tubal and ovarian varieties, says Baudelocque, the foetal movements should be less vague, and its limbs more retracted. The body of the uterus is associated with the tumor formed by the foetal cyst, and can neither be separated nor readily distinguished from it. I have thus brought forward the various signs by which authors endeavor to detect the different species of extra-uterine gestation, although they have, in my estimation, but little practical importance; nor do I see that auscultation itself could render us much service in determining the diagnosis. I ought to observe that the possibility of a fresh fecundation is a feature com- mon to all the varieties of extra-uterine pregnancy. Perhaps it may be serviceable to note that the vacuity of the uterus might be detected by the touch. Very frequently its habitual position will be changed by the pressure of the tumor, more especially when the latter occupies the excava- tion, and urges it against some part of the pelvic walls. Terminations.—It is but rarely that an extra-uterine pregnancy is prolonged beyond the fourth or fifth month; for generally the walls of the cyst give way, in consequence of their distension, before it has had time to become very large. Sometimes, however, the fcetal envelopes resist the pressure to which they are subjected, and if the foetus itself do not perish through want of nourishment, or by some accidental disease, its development may progress until term, and it may even live for some time after the expiration of the ninth month. Such is re- ported by Dr. G-rossi to have been the case with a lady, who, in all probability, carried an extra-uterine foetus, whose motions were perceived clearly by himself and several consulting physicians, through a space of fourteen months. Usually, 246 GENERATION. the child perishes either before, or shortly after, the term of pregnancy; and we shall now proceed to point out the possible consequences of its retention. A. Rupture of the Cyst.—When left to itself, an extra-uterine pregnancy will generally terminate in a rupture of the cyst; but the time and consequences thereof are very variable. Were we to class these pregnancies according to the frequency of the rupture, and the early period of its occurrence, they would stand as follows : the interstitial, tubo-interstitial, tubal, ovarian, sub-peritoneo- pelvic. and the abdominal. It is very rare for the period of the rupture to extend beyond the middle term of pregnancy except in the latter varieties. The rupture, which is usually spontaneous, always gives rise to exceedingly grave phenomena, which may be described as the primitive and secondary conse- quences. Thus, the patient at once suffers from violent pains for several hours, then, after a pain which is much stronger than all the others, a perfect calm conies on. The abdomen sinks, or becomes flattened, and the former tumor dis- appears ; a gentle and equal heat spreads over the abdominal cavity, and, if the pregnancy is well advanced, the patient feels as though a voluminous body had been suddenly displaced; the skin loses its natural hue, faintings come on, the pulse is small and contracted, a cold sweat covers the whole body, and death fre- quently follows, because the rupture of the cyst is often the immediate cause of a hemorrhage that speedily proves fatal. Should any circumstance whatever arrest the hemorrhage, the first symptoms that follow the displacement of the product of conception, and the transference of the waters, blood, or even the foetus itself, to parts not accustomed to such contact, are those of a very violent peritonitis. The patient generally dies, though sometimes she is able to resist the violence of the first inflammatory symptoms, in which case, the course of the disease differs from that time, according to whether the debris of the pregnancy are to be enclosed in a cyst of new formation for the remainder of the patient's life, or whether they are to be eliminated in various ways. In the first case, the foetus may undergo all the transformations described under the head of the pathological anatomy; and in the second, the symptoms vary with the manner in which the elimination is effected. b. Prolonged retention of the Cyst.—As we have already stated the pecu- liarities of extra-uterine pregnancy, when the integrity of the cyst allows the development of the foetus to proceed until term, and even somewhat beyond it, we shall not reconsider it. We would, however, add, that in some cases the dis- orders of the general health, produced by the development of these abnormal pregnancies, have been so great as to prove fatal, without there being any dis- coverable lesion to account therefor. Thus, says M. Jacquemier, the autopsy reveals neither rupture of the cyst, nor a trace of hemorrhage, peritonitis, nor process of elimination going on in the cyst; the unfortunate sufferers appearing to have succumbed under a kind of exhaustion of vital power. The development of the cyst ceases with the life of the fcetus, the circulation in its walls becomes feebler, the vessels which maintain the connections necessary to the support of the foetal life, gradually become atrophied, and even in great part obliterated; so that the fcetus and its envelopes are thenceforth a foreign body within the organism of the mother. Occasionally, the latter becomes accus- OF EXTRA-UTERINE PREGNANCY. 247 tomed to their presence; for some women carry a foetal cyst for many years with- out their health appearing to be much injured thereby : we have mentioned what transformations the fcetus and its envelopes are liable to undergo in such cases. Sometimes, however, the weight of the tumor, and the pressure which it exerts upon the neighboring parts, disturb the general functions so seriously, as to make the female demand earnestly to be relieved of the cause of her suffering by an operation. Whether the tumor be the cause of acute pain to the woman or not, it is likely, after the lapse of an indeterminate period, to become the seat of an in- flammation, which extends rapidly to the neighboring parts. In consequence of this inflammation, which may progress with greater or less rapidity, adhesions are contracted between the walls of the cyst and the parts adjacent; ulceration begins at the points of adhesion, perforation follows with the formation of com- munications between the cavity of the cyst and that of one of the neighboring organs, or with the exterior, in case the abdominal walls be invaded by the ulceration. The foetal debris find their way to the exterior, at times by the bladder, rec- tum, vagina, and even the stomach, at others by means of an abscess opening into the perineum, or through the anterior abdominal parietes. Furthermore, since these latter communications are common to all kinds of extra-uterine preg- nancies, we can understand that the situation of the foetus in the sub-peritoneo- pelvic variety, which, as before stated, is the most deeply engaged in the exca- vation, will render its expulsion by the vagina or rectum more frequent than in the others. Most generally, some one of the above-mentioned organs serves as an excre- tory canal, but in certain cases several of them are simultaneously attacked by the adhesive inflammation: of course, ulceration and perforation soon follow; and the wreck of the foetus escapes at once by the anus, the vagina, and through a fistulous opening in the abdominal walls. This expulsion greatly endangers the mother's life—for very often the inflam- mation and suppuration of the cyst, by spreading to neighboring parts, exhausts the patient, and sooner or later she succumbs. In the more fortunate cases, the sac is gradually emptied, cleansed, and contracted, the suppuration ceases, and the wound cicatrizes, or at least becomes a simple fistulous ulcer. The long continued suppuration, and consequent exhaustion of the patient's strength, will always render a complete expulsion of the foreign bodies highly desirable, for nothing else will put an end to the suppuration and allow the fis- tulas to close. Unfortunately, the hair, teeth, and pieces of bony substance, adhere very strongly to the walls of the cyst, in which they seem to be imbedded, and are detached with difficulty; yet it is very necessary to be careful not to use too much force for their extraction, lest the walls of the cyst should be torn, and an opening made between it and the cavity of the peritoneum, rendering liable the occurrence of a quickly fatal peritonitis. The interference of the surgeon should be restricted to the dilatation of all the openings and fistulous passages by means of compressed sponge, to cleansing injections within the cyst, and to the withdrawal, by means of forceps, of the completely detached portions of bony matter which present themselves at the openings. In no case, I repeat, should any effort be made to detach the strongly adherent portions. 248 GENERATION. § 3. Causes. Nothing can be more obscure than the causes of extra-uterine pregnancy, although numerous facts would seem to prove that the effects of terror, coinciding with the time of fecundation, may produce such an effect as to prevent the im- pregnated ovule from being ulteriorly transported into the uterus; but notwith- standing the high authority of those who have adopted this doctrine, it does not appear to me admissible, since the ovule does not abandon the ovary at the mo- ment of conception, but several days after or even several days before this event. M. Dezeimeris brings forward one case that seems to prove that a blow on the hypogastrium a short time after a fruitful coition may be the cause of this anomaly, though I should rather refer it to a particular disposition of the mother's organs. When, indeed, we consider the narrowness of the tubal canal, we can readily conceive that any deviations, even slight ones of the Fallopian tube, any paralysis or spasm, an excess or defect of length, an engorgement, the swelling and ulceration of the mucous membrane, or hardening of its pavilion, or any retraction at the external orifice : in one word, all the anomalies and alterations described by authors may take place there, and give rise to it. I myself have had an opportunity of observing two cases (reported in the Bulletin de la Societe Anatomique) in which the tube was obliterated between the point where the ovule was developed and the internal orifice of this canal.1 1 The obliteration of the tube in the case referred to is so remarkable an occurrence, that I endeavored to learn, by referring to various authors, whether similar cases had been reported. Most of them have not observed the state of permeability or impermeability of the tube; others, on the contrary, have given their attention to this point. Thus, Smellie (vol. ii, p. 77) quotes an observation of Dr. Fern, in which an obliteration, or rather an ex- cessive retraction of the tube was described. In the memoir of M. Breschet, on intersti- tial pregnancy, I found several instances where the obliteration of the uterine orifice was also noted. M. Mayer communicated a case to M. Breschet, where the fcetus was deve- loped in that part of the tube which traversed the substance of the uterine walls; M. Mayer further remarks, that the right tube was dilated at its fringed extremity, contracted in the uterine portion, and was completely obliterated at about three lines from the uterus; the left one, in which the ovule was developed, was permeable as far as the morbid mass, but from this point to the uterus the canal ceased. He adds: It is very probable that an induration of the uterine substance formerly existed at the insertion of the left tube, which caused the occlusion of its orifice, and furnished an obstacle to the passage of the ovule. M. Schmidt reports that in an example of interstitial pregnancy, of six weeks, the in- ternal orifice of the right tube was completely closed. (The ovule was developed on the right side of the womb.) M. Meniere (Archives, June, 1826) furnishes a case of interstitial pregnancy located in the left cornua, and he says the left tube was impermeable at its internal part. M. Gaide, in a similar instance (Journal Hebdomadaire, t. i), ascertained that the right tube had no uterine orifice. Another case is reported in the Archives of a mortal hemorrhage produced by tubal pregnancy. The author adds : " The left tube (the ruptured one) formed a consistent membranous sac, and its free extremity embraced the whole ovary; below the dilatation, and in the uterine portion, the canal was completely obliterated, in such a manner that it was wholly impossible to reach the uterus through it." I might cite a greater number of examples, but I think these will suffice to prove that an obliteration of the tube is sometimes met with in extra-uterine pregnancies ; for, when- ever we find the canal effaced between the ovule and uterus in a tubal gestation, it seems OF EXTRA-UTERINE PREGNANCY. 249 Finally, if we take into consideration the singular anomaly described by M. G-. Richard (see page 65), we may suppose that the fecundated ovule might, in its natural to suppose that, if the product of conception has been arrested in the course it has to travel in order to reach the uterus, some mechanical obstacle has opposed its passage! and that the effacement is the cause of such hinderance in the progress of the ovule ; con- sequently, the cause of this variety of gestation, at least, seems to me clearly indicated. But how long has the effacement existed ? Was it prior or subsequent to the conception ? In reply, it may be said that, according to the ideas generally admitted by physiologists, an obliteration of the tubes is an infallible ground of sterility, and when met with in a preg- nant woman it would be absurd to suppose that such an obstacle was in existence before impregnation. In this case, the seminal flnid could not reach the ovule, for its only way is closed up and the fecundation cannot occur. Let us examine, however, whether this is the only admissible opinion; it is well known that the obliteration of a canal, lined internally by a mucous membrane, can only result either from the coagulation of a secreted liquid, the chronic engorgement of its walls, or from their adherence to each other; and in either of these cases it is necessary to suppose the existence of a previous inflammation; but in neither of the instances mentioned have I no- ticed that the females exhibited any peculiar phenomena during the early periods, those im- mediately following the fruitful coition. Again, even supposing the inflammation is latent, and too feeble to produce any sensible effects, we must admit that its progress has then been very slow, and that it could not determine an obliteration of the walls (whatever be the mode of its action) until after the lapse of a considerable time ; now the ovule, at the ear- liest, arrives in the womb about the tenth day, and therefore the inflammation and the subse- quent effacement must take place within that short period; but, even admitting this hypo- thesis to be true, some cause for this phlegmasia in the tube must be assigned, and the partisans of that opinion have not hesitated to assert that it is either produced by the irri- tation, and the sanguineous congestion, experienced by all the genital apparatus at this period, or by a spasmodic condition of the tubal walls, or, further, by the presence of the ovule itself. I shall reply to this perfectly hypothetical explanation, by simply presenting a single fact. It is this. In some of the cases related in the memoir of M. Breschet, and in several others from different writers, not only was the tube that served as the seat of gestation obliterated, but also the one on the opposite side; and consequently in these instances, at least, we can- not admit that a spasm of the walls, or any irritation from the ovule's passage was the cause of effacement, and therefore we have to believe that it existed previously. From all which it follows, as a natural consequence, that, contrary to the opinion gene- rally received, it is not necessary for the sperm to pass successively through the uterus and the Fallopian tube, so as to approach and fecundate the ovule; and. further, this con- clusion permits the adoption of certain facts which have been rejected as improbable ; for we can explain by it how, in some females, there may happen to be a complete occlusion of the os tincae at the period of labor; how, in others, the fecundation has taken place without a proper introduction of the membrum virile, the physical proofs of virginity even remaining at the time of labor. But how, then, can conception be explained? Without adopting the theory of the aura seminalis, Chaussier, Mad. Boivin, and M. Duges thought it was only necessary for the sper- matic fluid to be deposited at the entrance of the vagina, so that, by absorption, it might be taken into the circulation, and then be brought back through the bloodvessels to the ovary, where the fecundation occurred. This hypothesis would indeed explain all the anomalies; but it is not founded on a single anatomical fact, nor yet upon any direct ex- periment, and further, it is at variance with the researches of modern ovologists; so of course I shall not dwell further upon it. Perhaps comparative anatomy might throw some light on the question before us : thus, in certain mammalia, such as the hog, cow, &c, the Fallopian tube is not the only canal that affords a passage to the sperm; for M. Gartner, of Copenhagen, has announced the 250 GENERATION. progress along the tube towards the uterus, escape through one of those accidental openings, and so fall into the abdominal cavity. existence of a particular duct in these animals, which extends from the external parts through the substance of the broad ligaments. In 1826 he came to Paris, and, conjointly with M. de Blainville, made some new researches on this point, the results of which the French naturalist has communicated to the public in the Bulletin de la Sociiti Philomatique, t. 9, p. 109, 1826. The latter says, that if the vagina of a young sow be carefully examined, a particular canal will be discovered, having its external orifices on each side of the meatus urinarius, and running through the mnscular fibres of the vagina ; it becomes contracted near the neck of the uterus, but does not the less continue in the uterine tissue. This canal at first follows the body of the womb, then abandons it, and runs in the substance of the broad ligament parallel to the corresponding cornua and close to the origin of the Fallo- pian tube, where it is lost by seeming to spread out, or to subdivide in two or three fila- ments, which can scarcely be distinguished from the vessels, and more especially from the proper tissue of the broad ligament. M. de Blainville says he has searched in vain for similar canals in women, but he has not met with anything of the kind. Analogy, however, renders their existence probable in the human species ; and this probability becomes still stronger from the account of a case com- municated by M. Baudelocque to the Academie de M£decine (Arch, de Mid. 1826), as an unique anomaly in the science; although it is a very singular fact that Dulaurens, according to the report of Mauriceau (Traite des Maladies des Femmes Grosses, p. 12, t. 1), had several times observed that the tube, after arriving at the angle of the uterus, separated into two distinct canals, the larger and shorter of which was inserted in the fundus uteri, while the other, being narrower and longer, terminated at the neck, near its internal orifice. De Graaf (Opera Omnia, p. 212) thought he had found canals in women similar to those described by M. Gartner as existing in certain mammalia. Lastly, Mad Boivin declares she has met with cases analogous to the bifurcated canal of M. Baudelocque. Hence, in these examples, at least, there is good ground for supposing that a conception may occur, even when the internal orifice of the tube is wholly obliterated. Now, if, as Mauriceau and Dulaurens say (whose researches the modern authors seem to have entirely overlooked), such anomalies were found at a period when dissections were much more rare than at the present time, we may conclude that, if the writers of our own day have not realized that disposition, it is because their efforts are not directed to the same end. I shall close these remarks by bringing forward a case, reported by M. Reynaud, in the 2d volume of the Journal Hebdomadaire, An. 1829, as follows : A young woman, aged 21 years, died at La Charite in consequence of a vertebral caries. At the autopsy, the uterus was found as large as the pregnant organ at six weeks, and its enlarged cavity was occu- pied by a false membrane having just the same shape, but in which no opening was dis- covered. The adhesions to the walls were easily broken up, and three or four ounces of a yellowish liquid were found enclosed within. No trace of the internal orifice of the tubes existed, and they were equally obliterated at the free extremity. The long diameter of the ovaries exceeded an inch in length, and their surfaces exhibited evident traces of numerous cicatrices. Both of them contained in their interior a rounded body of a brownish-red color (a true corpus luteum), and small fibrous pouches were detected in several places, with wrinkled and retracted walls. Numerous little ovoidal bodies, about the size of hemp- seed, resembling the ovules, existed along the course of the tubes and in the thickness of the broad ligament. It was very remarkable in this case that, notwithstanding a complete obliteration of the tubes, the organs of generation were found in a condition'similar to what is observed at the commencement of the generative action. However, I shall deduct no direct conclusion therefrom ; but I would ask your attention to the confirmation it affords of the ideas pro- promulgated in this report (Report of M. Cazeaux, extracted from the Bulletin de la Sociiti Anatomique.) OF EXTRA-UTERINE PREGNANCY. 251 § 4. Treatment. It is evident that no operation could be attempted in the earlier months of pregnancy, even if we should be fortunate enough to ascertain with certainty that the ovule was not developed in the uterus. It is my opinion, however, that frequent copious bleedings should be resorted to in such cases, for the double purpose of causing the death of the foetus, and of preventing (possibly) a congestion, or rather too great a determination of blood towards the point at which the ovum is being developed. Indeed, it seems clear to me, that not only does the constantly-increasing weakness of the walls of the cyst, but also the local congestions so common during pregnancy, contribute to render rupture of the cyst more frequent. Venesection, practised within the limits authorized by the general health of the patient, will be the more indicated here, as its unfavorable influence on the child's life is not to be dreaded, since its death is the most fortunate event that could occur. Might this latter result be obtained by passing electric shocks through the cyst? Still, if no obstacle can be opposed to the constant develop- ment of the foetus, every operation must be proscribed at this period for extract- ing the fcetus from its mother's body, because an operation would be as dangerous as the anticipated accident. Even when the spontaneous rupture of the cyst, during the early stages, occasions a just fear of mortal hemorrhage, we can only employ those general means which are the best calculated to prevent profuse discharges, such as rest, refrigerants, &c. Again, supposing that a well-marked case of extra-uterine pregnancy has advanced almost to term, or that the labor has actually commenced, we may still justly dread the laceration of the cyst as a consequence of the expulsive efforts; and the question then arises whether gas- trotomy, which has been successfully practised in similar cases, ought to be resorted to. If the child's safety be alone considered, this question is easily resolved. But is not the life of the mother almost necessarily compromised by such an operation ? How shall we persuade the patient, when the proper period for operating has arrived, if she herself does not suspect the danger she encounters by refusing? Or how, indeed, can we ourselves decide, when the possible consequences are foreseen, the whole difficulties of a delivery appreciated, and the necessity staring us in the face of leaving open in the abdomen a vast cyst, the inflammation and suppuration of which are so difficult to dry up, and are of themselves sufficient to endanger the sufferer's life ? In such cases, who can doubt, says M. Dezeimeris, that if there was any measure at all that could suspend the commencing labor, the ties of humanity alone would render its employment a duty? And I fully embrace the same opinion. Now among the means calculated to restrain the ordinary uterine contractions, I know of nothing more serviceable than opium, when exhibited in large doses per anum, and I certainly should not hesitate to employ it under these circum- stances; but if the labor continues, notwithstanding its use, gastrotomy may then be authorized. The cyst is generally opened through the abdominal parietes. the place of 252 GENERATION. selection being the same as in the common C;osarean operation, though, in case the head be felt through the vagina during the expulsive efforts, less danger would certainly accompany an incision through the walls of the latter. The child may be extracted by turning, or by the forceps, if necessary. In two cases, one of which is attributed to Lauverjat, both mother and child were saved by an operation of the kind. In three other cases, collected by Burns, the child was extracted alive, but the mother perished. Finally, it is evident that if a prolonged labor has produced a rupture of the cyst, no operation would be permissible. The first efforts should be directed towards moderating the hemorrhage, and when the first dangers have been removed, every means of preventing and op- posing consecutive inflammation should be energetically employed. But the primitive phenomena once calmed, whether there be a rupture or not, our art may evidently interpose to prevent the consecutive accidents that have been enumerated, and which compromise to so great an extent the health and even the life of the patient. When the inflammatory symptoms have ceased, it is proper to wait; and especially after the cyst is ruptured, hasty action becomes unnecessary. In fact, a considerable period is requisite in such cases for the development of a new cyst around the displaced parts, and a certain length of time is necessary for the adhesions to form between them and the adjacent parts, and it would be exceedingly rash to interfere with this salutary action by any inopportune opera- tion on our part. In old abnormal pregnancies, the resources of art vary with the particular case, Sometimes, indeed, an eliminatory effort has already com- menced by an inflammation of the integuments placed just in front of the tumor, whereby an abscess is formed; and the only question then is, whether to open it, or by suitable incisions to enlarge the spontaneous solutions of continuity; in either case we encounter a vast abscess, which must be emptied and cleansed by the usual methods. When some portions of the foetus get into the bladder, and we are assured of that fact by the use of the catheter, the operation for stone may be practised either through the vagina or by the hypogastrium. Again, a woman may pre- sent herself with an extra-uterine foetus of one or several years' standing. Can the resources of art afford her any relief? We reply, that if the gestation is a source of severe suffering, and it renders her incapable of discharging her duties; and if, besides, the tumor may be reached through the vagina without difficulty, the vaginal incision should doubtless be performed. But if she is otherwise in good health, would it be prudent to interfere for the mere purpose of anticipating the accidents to which she will probably be afterwards exposed ? Or is there any ground for hoping to extract the fcetus en masse, by a prudent and metho- dical operation ? This last question is far more difficult to solve. In a case of this kind, where the head of the foetus, from being wedged at the superior strait, could readily be felt through the posterior superior part of the vaginal parietes, I knew Professor P. Dubois (notwithstanding sharp opposition from several of his brethren in consultation) to resolve upon incising freely the vaginal wall, as well as the cystic envelopes, intending to apply the forceps on the head, and thus extract the fcetus bodily; but the walls of the cyst and vagina having been cut DISEASES OF PREGNANCY. 253 through, an intimate adhesion was discovered between the former and the fcetal head, which caused the operation to be abandoned. It was not without benefit, however, for in the course of a few days it was followed by the discbarge of a putrid mass, comprising all the soft parts of the fcetus; the detached bones of the skeleton were gradually extracted by the aid of long pincers, and frequently re- peated injections; the cystic walls contracted slowly; and when, at length, nothing remained, and the parietes were cleansed, the opening gradually closed up, and by the end of two months the patient was completely cured. At the time of operating she had been pregnant twenty-two months. This plan, I think, ought to be followed up in similar cases, more especially if the female's health is visibly affected. Incision by the rectum has been practised in some few instances where the vulva was obliterated. Finally, gastrotomy alone would be practicable when the fcetus, from its high situation in the abdomen, is inaccessible by the vagina or rectum; but this ope- ration must be regarded as the last resource, and only to be resorted to where the patient's life is seriously endangered. BOOK V. PATHOLOGY OF GESTATION. The pathology of gestation properly comprises all the functional derangements that may occur in the pregnant female, and all the spontaneous or accidental lesions of the ovum, sufficient to compromise the life of the fcetus; but we shall pass over the latter, as they most generally happen unperceived, or are not re- vealed to the physician until it is too late to remedy them; in fact, all we could say would be limited to a few general considerations of pathological anatomy, altogether foreign to the object of this work. CHAPTER I. DISEASES OF PREGNANCY. Those who have studied the various affections of the womb, are well aware that its diseases excite numerous sympathetic disorders. The commencement of the physiological acts which devolve upon it, and their periodical fulfilment, exert upon the functions of the alimentary canal, and upon those of the nervous system, an influence which has for a long time attracted the attention of practitioners. It were useless to mention all the morbid phenomena which so often precede, accompany, and follow the first menstruation. These are more striking when 254 GENERATION. the latter is postponed or difficult. In some individuals they appear at each menstrual epoch for a long time, thus seeming to show an impossibility on the part of the organ to perform its functions, without occasioning extensive disturb- ances of the economy; and it is only, so to speak, when the sensibility of the womb has been blunted by habit, that the return of the menses ceases to produce the general disorders which accompanied it previously. If the diseases of the organ, and even the simple monthly congestion, are capable of giving rise to such troubles, it is easy to foresee that pregnancy, which changes simultaneously the form, size, and even the structure of the uterus, can hardly pass through its various periods without deeply affecting all the functions. The effects produced by the pregnant condition vary greatly, as regards both the degree and the nature of the symptoms; all of them being influenced by the constitution of the female. Occasionally, it results in a salutary change in the entire system, better health being then enjoyed than at any other period. In the majority of cases, however, tiresome, or at least, very disagreeable symptoms are experienced, which are the expression of the unpleasant influence exerted by the uterus upon important functions. These troubles, which are so slight in some individuals as to amount merely to discomforts, are, in others, so great as to injure their health, and even to excite fears for their existence. These accidents may appear at almost any time; for though some persons begin to suffer at the very outset, and are relieved by the third, fourth, or fifth month, others are attacked only in the latter half of gestation. The pregnant condition operates differently at the different periods of gestation, in the production of the acompanying discomforts or diseases; this fact, which is important in a therapeutical point of view, was felt vaguely to be so by Burns, but clearly expressed by M. Beau, who, I think, has thrown much light upon the pathology of pregnancy. Most of the functional disturbances may occur in the early, as well as in the latter months. At first they were regarded as the result of the numerous sympa- thies existing between the uterus and the digestive apparatus, and, at a later period, the purely mechanical difficulties produced in the neighboring organs by the pressure of the uterine tumor were thought to assist in their production. Now, the pressure of the womb is of quite secondary importance, if, indeed, it be of any whatever; for, according to 31. Beau, the following is what usually occurs: The womb, as modified by pregnancy, affects the digestive functions through sympathy, giving rise to the dyspeptic symptoms described hereafter. The disturbance of these results necessarily, if prolonged, in deficient nutrition, which, in a woman who is obliged to furnish the material for the development of the child, must soon occasion a greater or less diminution of the blood corpuscles, and a considerable increase of the serum; in short, to all the anatomical charac- teristics of chlorosis or polyaemia. Now, this impoverishment of the blood soon occasions new morbid symptoms in the pregnant woman, as well as in the young chlorotic female; and so serves to explain the reappearance of the disorders of digestion, vertigoes, headaches, congestions of the face, palpitations, and difficult respiration, so frequently ob- served at an advanced period of pregnancy. We thus see that the functional disorders, which at the outset are purely sympathetic, become afterward iuti- DISEASES OF PREGNANCY. 255' mately connected with the chlorosis which themselves helped to produce. (See Disorders of the Circulation.) Though we shall have occasion to treat hereafter of this latter etiological peculiarity, we cannot help calling attention, at present, to the importance of taking it into consideration in the choice of remedial mea- sures. For, though it be proper at the commencement to reduce the over-excite- ment of the uterus, and the sympathetic irritation produced by it in other organs. by soothing remedies, as.baths, mild laxatives, antispasmodics, and sometimes even by moderate bloodletting, an entirely different course should be pursued toward the end of gestation. All the restorative agents, as iron, animal food, and tonic wines, are here the surest means of opposing the plethora and remov- ing the disorders which it occasions. Still, it is right to observe, that beside the chlorosis, which plays the principal part in the production of the disorders of the latter months, the uterus still retains its sympathetic influence, and is subject at all times to congestions, which increase its irritability, and cause it to react upon other organs; of all which, account should be taken in the treatment. The sub- ject will claim attention hereafter. Finally, the connection which we have endeavored to demonstrate as existing between the sympathetic troubles of the beginning of pregnancy and the chlorosis of the latter months, cannot always be readily discovered. The sympathetic in- fluence of the uterus upon the digestive functions is not always manifested by vomitings, nausea, and strange and depraved appetites. All these symptoms may be wanting, and yet the stomach fail to perform its functions with its normal regularity. Nutrition may be disordered, giving rise to a dyspepsia, which 31. Beau proposes to distinguish as latent; a dyspepsia which cannot fail to occasion eventually a general deterioration of the blood. Exactly the same thing occurs in young girls whose menstruation is either difficult, irregular, or imperfect. Confirmed chlorosis is always preceded in them by sympathetic disorders of digestion; though sometimes the deranged function is evinced by very marked symptoms, at others, it is hardly a cause of discomfort. Desormeaux, in his excellent article on this subject, ranges all the diseases of pregnancy under the following heads, viz., lesions of digestion, of circulation, of respiration, of the secretions and excretions, of locomotion, and of the sensorial and intellectual functions. And we propose to adopt the same order in our de- scription. ABTICLE I. lesions of digestion. § 1. Anorexia. The want of appetite, or the disgust for aliments, which pregnant women are so often affected with towards the end of gestation, and still more frequently at its commencement, may be referred to various causes, and consequently will pre- sent different indications for treatment. When it seems to result merely from the sympathetic relations existing between the uterus and the organs of digestion, there is little or nothing to be done, for it would be in vain to attempt removing the disgust which some patients have to certain articles of food. In general, 256 GENERATION. they dislike all meats, and this is an indication, or rather an obligation, to permit the use of vegetables in such cases. Again, if at an advanced stage, the anorexia be accompanied or preceded by the phenomena of general plethora, venesection, proportioned to the general condition of the female and the stage of pregnancy, may relieve it. Care, however, should be observed not to mistake the symptoms produced by anaemia for the indications of plethora; the former being far more effectually treated by ferruginous preparations. (See Disorders of the Circulation.) In those cases which exhibit evident signs of an overloaded condition of the alimentary canal, some purgative, such as rhubarb, or even the neutral salts, may be administered. Indeed, certain authors have recommended an emetic, when there is any gastric distress; but I think practitioners ought to be very reserved in the employment of this last measure, since the shock of vomiting has often produced abortion. § 2. Pica, or Malacia. Pica, or malacia, frequently accompanies the affection just described. Preg- nant women, like chlorotic girls, often have irregular and depraved longings for the most absurd or disgusting articles. For instance, I have known a young female to eat pepper grains almost continually. Another, at La Clinique, scraped the walls to appease her cravings for chalk ; and 31. Dubois often relates in his lectures, th\ history of a young pregnant woman whose greatest pleasure con- sisted in eating small bits of well-charred wood. Again, they have been observed eating greedily substances that are still more disgusting. Unfortunately, all our persuasions are useless with such monomaniacs in the majority of instances, and consequently we must, as a general rule, grant them an indulgence, and avoid too strong an opposition, unless the coveted articles would evidently be injurious to their health. I have but little to say of the acidity of stomach, of the spasmodic pains of that organ, and of the pyrosis and other symptoms of gastralgia, which are also quite frequent during pregnancy. The treatment of the symptom is here the same as under ordinary circumstances. Thus, for sour eructations and acidity of the priinae viae, magnesia and the absorbents, bicarbonate of soda, the water and pastilles of Vichy, may be administered. Pyrosis and cramps of the stomach are usually treated successfully by powdered columbo, and most of the antispasmodics, in connection with small doses of opiates. The latter may also be used after the endermic method. If, however, it be desired to attack the first cause of these gastralgic symp- toms, it is important to remember that this is different for the first and second half of gestation, and that the measures employed should vary accordingly. § 3. Vomiting. This symptom is so common that most females are affected with it; in fact, vomiting frequently commences in the very earliest stages : whence many women, taught by their former pregnancies, recognize it as an almost certain sign of a new gestation. At other times it does not appear until towards the third or fourth month, though seldom later than that; but it is not at all uncommon to see it reappear near the end of pregnancy in some who had been previously tor- DISEASES OF PREGNANCY. 257 mented in this way at its beginning. As an ordinary rule, the vomiting only lasts six weeks or two months; sometimes, however, it extends over four or five months, rarely persisting throughout the whole term. Some females have the unenviable privilege of vomiting every time they are pregnant; others, more for- tunate, pass through several gestations without feeling any digestive disorders whatever. It is a very remarkable fact, if we may rely on the testimony of numerous mothers, that the sex of the child is not wholly irrelevant to the pro- duction of this symptom; and, however ridiculous this may appear at first sight, I have heard it repeated by so many women, that I cannot refrain from believing that it, like most other popular prejudices, has some foundation. But what is the cause of such vomiting ? When they occur near term, we may justly attribute them to the pressure, to the mechanical constraint which the uterus, whose fundus reaches the epigastric region, exercises upon the stomach; but in the early stages it is much more difficult to explain this phenomenon, unless we content ourselves by referring it to the numerous sympathies existing between the uterus and the stomach : sympathies so intimate that they are mani- fested in certain women at every menstrual period, and even in nearly all those afflicted with a disease of the womb. Although the intimate nature of these sympathies is very obscure, we can admit, them more readily in the etiology of vomiting than the influence of most of the anatomical causes adduced by some authors. In endeavoring to trace a relation of causality between the vomiting and an inflammation of the uterus, placenta, and membranes, like Dance ; softening of the stomach and fatty dege- neration of the liver, like Chomel; or, finally, to the existence of organic lesions of parts in the neighborhood of the uterus, observers have merely noticed simple coincidences, without throwing the least light upon the question of etiology. How often, indeed, is nothing of the kind discoverable ! I am persuaded, says Dr. Bennett, that those gastric disorders and obstinate vomitings, which so often bring women to the portals of the tomb, are almost always caused by inflammatory ulcerations of the neck of the womb. For my own part, he adds, since my attention has been directed to this subject, I have almost invariably found ulceration of the neck in cases of this kind. I cannot receive this opinion of the English accoucheur, at least as relating to the majority of cases, for I have frequently examined with the speculum each of four primiparous women affected with incorrigible vomiting, and in whom I as- certained the cervix to be perfectly healthy. It has been said that primiparous women are more subject to vomiting than others, on account of the uterus yielding less readily to distension in first preg- nancies. Although this opinion is quite conformable to the theoretical views already given, the fact is, that it is liable to very frequent exceptions. Some multiparae, who suffered very slight disorders of the stomach in their first pregnancies, have vomited almost constantly in later ones. The rigidity of the uterus is not, there- fore, the only cause which is capable of sustaining an irritability of the organ which reacts sympathetically upon the stomach. I do not think that an epidemic influence can be admitted as a cause of these vomitings. 17 258 GENERATION. Some persons have been inclined to refer the vomitings and most of the other gastric disorders also, to albuminuria, or at least to the disease of which it is the symptom. I am not prepared to disprove this opinion, which I think few will be disposed to adopt, provided they remember that these disorders of the stomach are most frequent at the beginningof pregnancy, whilst albuminuria has hitherto hardly ever been observed before its latter stages. The vomitings vary much as regards their frequency, intensity, and the greater or less ease with which they are accomplished. Thus, some women vomit only upon awakening or rising in the morning. They then throw up some viscid or glairy matters, which are generally colored with a little bile, especially if the retchings have 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 unfortunate cases they continue even in the intervals of the repasts; 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 smell of it, are sufficient to provoke them. The vomiting is sometimes easy, and causes little pain; it is indeed not un- common to find ladies suddenly interrupted at their meals, who can return in a few minutes, and sit down and eat with a good appetite and pleasure. In other cases, however, the ingestion of food is productive of pain in the stomach or inexpressible uneasiness of variable duration, and it is only after five or six hours of suffering, that the food is vomited and then found to be almost unchanged, notwithstanding its long retention in the stomach. In such cases the vomiting is preceded by such prolonged and violent retchings as to reduce the patient to a state of extreme suffering and agitation. It is occasionally followed by considerable epigastric pain, which is increased by pressure, and might for a moment be taken as a sign of inflammation of the stomach ; it gradually diminishes, however, and disappears entirely after a time. The shocks and violent efforts sometimes extend their influence to the hypogas- trium, and give rise to abdominal pains and even uterine contractions, which may be active enough to produce abortion. But it must not be supposed that vomitings, even when prolonged and oft- repeated, are necessarily disastrous. No doubt many women waste away, but I have often satisfied myself that the leanness is not apt to be excessive, by examin- ing females, who, according to their own expression, could retain nothing at all; and hence it is exceedingly probable that all the food taken by them is not rejected. Burns states that he has never known vomiting dependent on pregnancy alone to have a fatal termination. I might cite, says Desormeaux, examples of emesis accompanied by cruel pains and violent general spasms, yet the gestation has happily gone on to full term. At this time, I have myself under care, a lady who has been vomiting throughout the whole period of gestation, and who has just been delivered of a daughter weighing seven pounds and three-quarters. Finally, it must not be forgotten that in some cases which even appear serious, the vomiting may cease abruptly, either spontaneously, or because the sympa- thetic irritation of the uterus has been translated to some other organ, or again, as a consequence of a violent mental emotion. A remarkable instance of the DISEASES OF PREGNANCY. 259 latter has quite recently come under my notice. A young lady, two months and a half advanced in her pregnancy, had been tormented for three weeks with such obstinate vomiting, that, according to her own statement, the smallest mouthful of fluid excited it, and that she was unable to retain anything whatever in her stomach. All the remedies employed against it had proved useless. At this juncture, her husband fell suddenly and dangerously ill with symptoms of strangulation of the bowels, and from this time her vomiting ceased, nor did she suffer the least disturbance of her digestive functions afterwards. I have been induced thus to hold forth from the outset a favorable prognosis, which indeed is true for the vast majority of cases, in order to relieve young practitioners from the anxiety which some recently published articles on the gravity of this affection are calculated to produce. The vomiting is not, generally, serious, but only painful and fatiguing to the mother; it must, however, be acknowledged that in some very rare cases, it is so violent and constant as to exhaust the strength of the patient in a few weeks, and after producing extreme emaciation terminate in death. The display of symptoms given by 31. Chomel in one of his clinical lessons, applies to these exceptional cases only. The disease, he says, is characterized by frequent bilious vomiting, an acid, foetid breath, and fever; then the brain becomes involved, and we have delirium, coma, and death. The views of 31. Dubois correspond closely with those of M. Chomel, and, like him, he describes three stages. In the first stage, the vomiting is very frequent, and occurs at all times of the day. It is very obstinate, and causes all, or nearly all of the food to be rejected, even liquids not being retained. This is soon followed by serious symptoms, arising from deficient nutrition, as debility, emaciation, and alteration of the features. To these symptoms I would add an extreme disgust and aversion for food of any kind,—a repugnance so invincible as to defy the entreaties of the family, and the repeated urgent solicitations of the physician. Shortly after, the symptoms peculiar to the second stage begin to appear. They are, frequency of pulse, great thirst, and a remarkably acid breath. The fcetidity and acidity of the breath, says M. Chomel, are so great as to strike the attention immediately upon entering the chamber. The smell is comparable to that of vinegar. In three cases, however, two of which proved fatal, I was unable to perceive this odor. This state, which is of variable duration, is generally followed in a short time by a third period, marked by cerebral symptoms. The patient suffers halluci- nations, intolerable neuralgic pains, and disordered vision. The vomiting lessens or stops, a comatose sleep comes on, and the scene soon ends in death. (La- borie, Lecons de M. Dubois.) In moderate cases, the diagnosis is quite easy. Here, the absence of acute symptoms, such as redness of the tongue, and pain upon pressure on the epigas- trium, would settle the question, even were pregnancy doubtful. But if, in the cases just spoken of, the nature of the epigastric pain be misunderstood, the practitioner would be more liable to error, therefore he should be very careful in his proceedings. For example, I have known a case of vomiting, which the autopsy proved to have been dependent upon tubercular peritonitis, attributed to 260 GENERATION. a pregnancy which did not exist. In the case of another female, who had actu- ally been pregnant for two months and a half, the examination after death dis- covered a serious disease of the stomach, amply sufficient to account for the vomiting. In the latter case, it is true, that an admixture of blood with the matters vomited, had, during life, excited suspicion of organic disease. This very case has, however, been quoted to me by some persons as one of incurable vomiting occasioned by pregnancy. Generally speaking, even when the vomiting is not so great as to compromise the life and health of the mother, it has but an indirect influence upon the life of the child, nor do I know of a single well-attested case of death of the foetus from inanition through defective nutrition of the mother. Still, we may understand how the violent efforts of the female may sometimes communicate such shocks to the uterus as to bring on premature contractions and even abortion. We can also comprehend how the same efforts may produce vas- cular congestion of the womb, giving rise to rupture of some of the utero-placental vessels and detachment of the placenta; such accidents are, however, rare. In grave cases, results of the kind are rather to be desired than deprecated, for vomiting generally ceases upon the death of the foetus, and the mother escapes the threatened danger. Treatment.—There are but few medicines that have not been proposed, at one time or another, for this affection of pregnant women; however, I shall merely bring forward those which appear to me the most efficacious. When the emesis is slight, and only occurring in the morning, we may recom- mend an aromatic infusion of the lime-tree, orange-flower, common tea, &c, etc. Where it comes on after a meal during the day, it is advisable to change the order of the repasts : for example, if it be generally more distressing after supper, the patient should sup sparingly and eat more breakfast. Cold aliments are sometimes retained when others are rejected. Iced drinks, mineral waters, and swallowing small pieces of ice, have arrested some cases of obstinate vomiting, that set at defiance the whole series of antispasmodics. The .subnitrate of bis- muth, in doses of from four to eight grains, before each meal, has appeared to me of late to be of some service. I have also directed two or three spoonfuls of kirsch to be taken after meals, and I think with some success. Should it persist, notwithstanding these measures, a resort may be had to a remedy, which has often succeded perfectly in my hands,—I allude to the narcotics. About an hour before the meal, let her take one-third or one-half a grain of the aqueous extract of opium made into a pill; but when she is constipated, it will be neces- sary to administer some mild purgative to counteract any action the opium may have on the large intestine. Whenever the emesis is attended with pain and stricture at the epigastrium, leeches have been recommended over this part, though I have rarely seen their application followed by any benefit. I should prefer laudanum lotions, or the application of a cataplasm well tinctured with this fluid. Sometimes I have successfully applied a small blister to the epigastrium, and subsequently sprinkled the sixth or the third of a grain of the muriate or acetate of morphia over it. If the vomiting occasions pains in the loins, or hypogastrium, in a word, if it DISEASES OF PREGNANCY. 261 threatens an abortion, or if the patient be plethoric, and this condition is mani- fested by local or general phenomena, venesection in the arm should be resorted to, as this is one of the best measures I am acquainted with, especially during the last half of gestation. Enemata containing laudanum are also very useful for the prevention of abortion, as well as for alleviating the vomiting, and calm- ing the irritability of the uterus. General bathing may be added to these measures with advantage. With regard to the regimen, doubtless a mild liquid diet, composed of aliments that are easily digested, seems at first to possess decided advantages over all others; but how many exceptions ! how many women reject the mildest articles— even liquids, and yet readily digest less suitable substances ! How often, indeed, have I not seen women eat ham, liver, pie, &c, who could not digest a piece of sole, or the white meat of fowl! Of course, we must respect these peculiarities of the stomach. Among the various measures recommended, but which I have rarely had occasion to resort to, may be mentioned the application of cups to the pit of the stomach (Mauriceau) ; of a plaster of theriaca (Sydenham); a few spoonfuls of sherry wine, or even some brandy, ether, peppermint-water, the potion of Riviere, and the Colombo root. In those cases in which there was some degree of regularity in the return of the pains, and febrile action, Desormeaux gave two or three grains of the dry extract of cinchona with success. Lastly, Walter and Blundell have highly extolled the use of hydrocyanic acid in the dose of one or two drops, in some mucilaginous drink, several times a day. With the same idea, I have success- fully given kirsch after meals, either undiluted or on a lump of sugar. The latter plan has seemed especially useful when the vomiting was preceded by un- comfortable sensations in the stomach or long continued nausea—a state of things resembling sea-sickness. To overcome the acidity of the primae viae, M. Chomel recommends the use of alkalies, as the water from the springs of Vichy and Bussang, also dilute solu- tions of potash and soda, magnesia with milk, but never milk alone, and an avoidance of acids. Alcoholic liquors, given to the extent of intoxication, have met with real success. M. Rayer tells me that be has used them with great advantage, and champagne wine, recommended by M. 31oreau in a case so obstinate as to cause great frequency of pulse and delirium, put an end at once to the symp- toms. M. Jacquemin, who related the case to me, considered the patient as lost, and had only called the professor in consultation, in order to obtain his opinion in regard to the propriety of producing abortion. Dance reports two cases, from which he feels authorized to conclude that these vomitings are often an evidence of a morbid activity in the uterine system, of an inflammation of the membranes; and consequently he advises direct antiphlo- gistic measures, especially in the neighborhood of the womb; but, as his opinion is founded on two cases only, which, after all, are not conclusive, it seems tome that it cannot be admitted as a rule of practice. M. Bretonneau, being induced to try belladonna, in the idea that possibly the vomiting might be occasioned by rigidity of the uterus, succeeded in quieting it, 262 GENERATION. even in very grave cases, by rubbing the abdomen with a concentrated solution of that medicament. In one very serious case, in which the vomiting had resisted every effort, even Bretonneau's measure, and in which the poor patient seemed doomed to a speedy death, I conceived the idea of applying the belladonna to the neck of the uterus; this was done by means of the speculum. A brush, laden with the soft extract, was introduced, and the neck, together with the inferior segment of the uterus and the walls of the vagina, were besmeared with it. From this moment, a marked change for the better was manifest, and after the same unctions had been repeated on four successive days, I had the satisfaction of finding my pa- tient cured. It is my duty to add, that in another case, the same means failed completely, though I think the failure due to the mode of application. When, as in this case, a brush is used, it is difficult to apply the ointment, and too little of it is sometimes left behind. I have, therefore, for a long time preferred covering a tampon of charpie or cotton with the extract of belladonna, and, after placing it in contact with the cervix by means of a speculum, leaving it there. This may be done morning and evening. The first symptoms of intoxication, such as, dilatation of the eyelids, a sense of heat in the throat and slight hal- lucinations, need occasion no alarm, inasmuch as the effects of the medicament are not felt until then. The patient ought, however, to be watched and the tampon removed if the symptoms become more serious. This method has been thrice successful in my hands. M. Stackler overcame the vomiting in two cases by the black oxide of mer- cury, in the dose of one grain daily. The prolonged use of the remedy was unaccompanied by salivation. The obstinate constipation which the patients suffer is very remarkable, and has not leceived the attention it deserves. The bowels sometimes remain un- moved for eight, ten, or even fifteen days. Strongly impressed with this fact, and supposing that the constipation might have some effect upon the continuance of the vomiting, I endeavored to overcome it; but, fearing the effect of emetics or drastic purgatives upon a weakened and pregnant female, my first efforts were too cautious to be successful. Encouraged since then by the experience of other practitioners, especially by 31. Forgue, of Etampes, I have had every reason to be satisfied with a bolder course. The above named physician addressed to the Academy of 3Iedicine a memoir, in which he lauded the effect of emetics and purgatives, but insisted much upon what he called a preparatory treatment, consisting in the administration to the patient for two or three days, a tisan of barley water, weakened with honey, to each quart of which he adds a drachm and a half of sulphate of potash ; giving also, morning and evening, an enema of a strong decoction of the mercurial is annua. When some stools have been thus obtained, he orders a bottle of Seidlitz water containing a grain and a half of tartar emetic, after which he continues the purgative for several days longer. M. Forgue claims to have treated five cases successfully by his method. In endeavoring to try this plan, I have always found it impossible to over- come the dislike of the patient to drinking enough of 31. Forgue's tisan (about two quarts in twenty-four hours). I am, therefore, in the habit of giving the DISEASES OF PREGNANCY. 263 emetic at once, when the saburral condition of the tongue seems to indicate it: which is not often the case. Generally, I order at once ten grains of scammony with fifteen grains of jalap. As the first dose is often rejected by vomiting, I order it to be followed immediately by another and sometimes even by a third, should the vomiting continue. The second or third dose is generally retained, and the purgative effect followed by a marked relief. In the case of a patient two months and a half advanced in pregnancy, to whom I was called in consultation by Dr. Briau, Professor Moreau discovered by the touch that the uterus was not only completely retroverted, but wedged, as it were, in the depths of the pelvic cavity. Suspecting that this displacement might have some effect to maintain the vomiting, he corrected it by lifting the uterus above the superior strait and bringing it into correspondence with its axis. Immediate relief followed, and the vomiting, which had proved intractable to a host of remedies, ceased on the same day, nor did it again return. M. Moreau said, that he had seen several similar cases; I had indeed myself, before this, observed the same accident, but not having acted upon the indica- tion, our Honorable master conferred a real service in making known the fortunate result which he had thus obtained. In future, therefore, the state of the uterus should be ascertained in all cases of incorrigible vomiting. Experience has, however, taught me, that although displacement of the uterus often coincides with gastric disorder, 31. Moreau's good fortune is not always to be expected. Three times since 31. Briau's case have I observed the coincidence indicated by my colleague. In three patients suffering from obstinate vomiting, I found the uterus not retroverted, as in 31. 3Ioreau's case, but so far anteverted that the anterior surface of the womb pro- jected considerably at the upper part of the cavity, its upper border resting against the posterior face of the pubis. The reduction, though easily accom- plished, could not be maintained, and the organ very soon resumed its primitive position. Several attempts at reduction were equally unsuccessful. Why, then, was I less fortunate than 31. 3Ioreau? I am inclined to think it was because of the different stages of pregnancy in our patients respectively. That of M. Moreau had reached three months or three months and a half; two of mine were only two months gone. Now, if at three months and a half the size of the uterus is sufficient to keep it above the superior strait after reduction, and that it can only, in some exceptional instances, fall back into the cavity, the case is very different at an earlier period. At two months, in fact, the uterus is so much smaller, and therefore so much more movable, that it yields readily to every cause of displacement brought to bear upon it, and, as though by the force of a bad habit, readily resumes its faulty position when the restoring effort is no longer made. We ought, therefore, in reference to 31. 3Ioreau's plan, to have great regard to the duration of the pregnancy; very efficient after the third month, it will generally be useless at six weeks or two months. Unfortunately it happens that incorrigible vomiting is more apt to occur at the latter period. All my efforts to remedy the difficulty by means devised for keeping the uterus in situ after reduction, have been fruitless. I had made an elongated 264 GENERATION. compress, which, when placed above the pubis, depressed strongly the wall of the hypogastrium, and at first seemed to keep the womb in place. Soon, how- ever, it slipped beneath the pad, fell back into the pelvic cavity, and as the bandage thenceforth did more harm than good, I was obliged to give it up. It was natural to think of Gariel's pessary, but I dared not keep so large a body in the vagina of a pregnant woman, lest it should have the effect on the uterus of a tampon which so often causes abortion or brings on premature labor. In short, 31. 31oreau's success in the case related by 31. Briau, is an en- couragement to make similar attempts, as, after all, they do no harm when pru- dently conducted; yet, they are not to be relied on when the patient has not advanced beyond the first two months of pregnancy. I have thus enumerated all these remedies, because they may be successively employed in this affection. In fact, the same medicine may act on one female and have no effect on another. And it must be confessed that sometimes all will fail, and we can scarcely succeed in moderating the patient's sufferings. The change of medicine is, however, useful, either by really calming her distress in a measure, or by sustaining her spirits, not seeming to abandon her, but holding out the idea that each new remedy may effect some amelioration. In this way she gradually approaches towards term, or at least to a period of gestation when the symptoms often disappear of themselves. But where the vomitings continue, notwithstanding all the rational measures resorted to, the woman absolutely throwing up everything she takes, and the pri- vation from food has reduced her to such a state of emaciation as to endanger life, and the symptoms which we have described as belonging to the second and third stages appear, some accoucheurs have advised (if her term is still remote) the production of premature labor. This operation has already been practised, in similar cases, by several English and German accoucheurs, with full success, both for the mother and child. (Merriman, Blundell, and Churchill.) It seems to me that it cannot be improper to resort to this measure after the seventh month of gestation, for it then appears to be fully justified both by the dangers to which the mother is exposed, and by the possibility of the child living after its expulsion. But is the case the same before the sixth month, when the sudden termina- tion of pregnancy must necessarily lead to the death of the foetus ? This is one of the gravest questions which can come up in practice. Although fully disposed to sacrifice the child whenever that sacrifice will surely save the life of the mother, as in cases of extreme narrowing of the pelvis, I make no hesitation in declaring myself against the production of abortion under the circumstances in question. I shall proceed to justify this proscription, as I know that several distinguished accoucheurs have boldly decided in the affirmative. 1. AVhen a woman having a contracted pelvis presents herself to a physician, he knows very well that if the pregnancy be allowed to go on until term, he will have to choose between embryotomy and the Caesarean operation; also, that in some cases the latter operation will be the only resource If, after mature con- sideration of the inevitable consequences of the one and the probable conse- quences of the other, he decides upon the mutilation of the child, it will doubt- DISEASES OF PREGNANCY. 265 less appear to him reasonable not to wait until the increased size of the fcetus at term shall add to the difficulties and dangers of embryotomy; therefore, the pro- duction of abortion within the first four months of gestation will seem to be fully justifiable. But the conditions are different when the life of the mother is compromised by vomiting, however severe it may be. In the first case, the danger is inevitable; and, unless abortion occurs spon- taneously, the Ccesarean operation is the only resource, and we are aware of the usual consequence of the latter. But however intense the vomitings may be, and notwithstanding the state of exhaustion to which they reduce the female, still they are not inevitably fatal. Patients, whose condition justly excited the greatest solicitude, have been known to resist until the latter months, and even until the term of their pregnancy, and then give birth to strong and healthy children. Others, whom the vomiting had reduced to a hopeless condition, have been suddenly restored to the most complete health. A case of this kind has fallen under my own notice, and the following was related to me (June, 1849,) by M. P. Dubois. A young German lady, two months and a half pregnant, had been troubled with the most obstinate vomiting from the first two weeks after conception. For the last six weeks, especially, she vomited almost without intermission; the smallest spoonful of fluid exciting violent contractions of the stomach. She was extremely emaciated and feeble, and her breath was disgustingly foetid; in short, her symptoms were so serious, that 31. Dubois, who was called in consultation, requested the additional advice of M. Chomel. Both of these gentlemen came to a most unfavorable prognosis, and left the patient, under the impression that she had but a few days to live. Some cold applications were the only remedies advised, but the attending physician, being alarmed at her extreme weakness, limited them to slight aspersions. On the second day after the consultation the patient was attacked with violent purging, and from that time the vomiting ceased and never returned. The poor sufferer was at once able to take and retain some nourishment, which, being gradually increased in amount, soon restored her strength. Now, this woman, who had been so greatly reduced that two eminent men regarded her fate as sealed, is in the enjoyment of perfect health, and has almost reached the middle of her pregnancy with every prospect of a happy termination. In two other cases, which the professor related with commendable frankness, he had deemed it his duty to propose the induction of premature labor. The women declined submitting to the operation, and reached the end of their preg- nancies in good health. 2. When abortion is produced in cases of extreme contraction of the pelvis, there is a certainty that when once accomplished, all the dangers which threat- ened the termination of the pregnancy are at an end, and that only the usual consequences of miscarriages can follow from the operation. Even supposing that the artificial means should add to the ordinary risks of spontaneous abor- tions, the object is nevertheless certainly attained in terminating a pregnancy whose progress so greatly endangered the mother's life. The conditions are very different in cases of spontaneous vomiting, for if all 266 GENERATION. m the instances on record be referred to, it will be found that the operation is far from removing the danger. I am well aware that four or five fortunate cases have been cited from the practice of English accoucheurs, but we are not told how often it has been followed by death. We have a personal knowledge of seven cases, in two of which we declined the operation, which was afterwards performed by skilful hands. Of these, but one woman survived; all the others perished, one of the latter dying only fifteen days after the first attempts, and ten days after the abortion was accomplished. The vomiting ceased, it is true, and she was able to take some food; but the fever continued, abscesses appeared in several parts of the body, and though no autopsy could be made, it is Very likely that they originated in a deep-seated suppuration of the genital organs. However this may be, the fact of the patient having lived for fifteen days after the first attempts to procure the abortion, makes it difficult to say that the operation had been postponed too long. The failure of the other operation was, nevertheless, accounted for in this manner. The operation was performed too late, say they, when the prolonged defective nutrition of the mother had exhausted the vital powers; and had the uterus been emptied sooner, the chances of success had certainly been greater. I believe this fully; but here it is that the most difficult question arises. When is the operation proper ? If you act too soon, may it not be said, whilst instancing the cases of spontaneous cessation of the vomiting, as in those which have been quoted, that you have destroyed the foetus without advantage? If you act too late, may you not be equally reproached, in view of the failure of all known operations, with an attempt which may have hastened the fatal termi- nation ? Where will the prudent practitioner place the limit of expectancy? If it be remembered that the ancient accoucheurs declared, as do Mauriceau and De- lamotte, that the vomitings may possibly produce abortion, yet are not dangerous for the mother; also that many moderns assert, with Burns and Desormeaux, that they have never known them to terminate fatally, there would certainly be small temptation to operate before all hope had been dissipated by the gravity of the symptoms. Our hopes, indeed! But does not nature sometimes mock at our expectations ? Did not the patient of 3131. Dubois and Chomel seem doomed to certain death? I know it may be answered that it must be left to the tact and skill of the practitioner to think deeply, and choose conscientiously, between the dangers of expectation and the chances of an operation; that the difficulties which I raise, present in a host of surgical cases; that there is barely an amputation which may not be authorized by affirming, dogmatically, that a spontaneous cure is impos- sible ; that the exceptional preservation of a limb proves nothing against the propriety of amputation in a majority of similar cases. All this is doubtless true; but let us not decide too quickly, for the comparison is far from being strictly just. When the surgeon has to deal with a serious traumatic lesion, he regards nothing but the interest of his patient; and after explaining to him the grounds of his conclusion, may, in cases of difficulty, consult his wishes, and then leave his life at his own disposal. The accoucheur has the serious interests of two DISEASES OF PREGNANCY. 267 beings to care for; and though the instinct of self-preservation may silence in the female the voice of maternal feeling, it is nevertheless his duty to protect the foetus, with whose welfare he is equally intrusted. In a given traumatic lesion, all experience shows that spontaneous recovery is a rare exception. On the other hand, the experience of all accoucheurs goes to prove that the spontaneous cessation of vomiting is of almost universal occurrence. Finally, when the surgeon decides upon a grave operation, he is not only con- vinced that he affords his patient a much greater chance than by expectation, but is emboldened by the results which it has already afforded. Hitherto, when abortion has been induced in order to stop the vomiting, it has not generally prolonged the mother's life to a sensible degree, though it has invariably destroyed the foetus; and even in the gravest cases, if the results of induced abortion be compared with those afforded by expectation, conjoined with the -use of rational therapeutic measures, the advantage will be found to remain with the latter. We thus see that the surgeon and the accoucheur stand on a different footing, and that the difficulty which I have suggested is not removed by the comparison which has been made between them with that object. The impossibility of deciding rationally upon the proper moment for producing abortion still continues, we observe, in its fullest extent. Therefore, so long as, in any given case, it is impossible to say that the patient presents an assemblage of symptoms, which, if left to themselves, will, in all probability, prove fatal, and these symptoms existing, it is probable that the procuring of abortion will put an end to them, and restore the patient,—I think that the operation should be rejected as irrational. § 4. Constipation. Diarrhoea. Constipation is a very common affection in pregnant women, and it is usually attributed to the pressure of the developed uterus on the upper part of the rec- tum, by which not only is the calibre diminished, but its action is also paralyzed. Would it not be more reasonable to attribute it in many cases to a commencing chlorosis? We know, indeed, that constipation is so common in the latter disease, that Hamilton regarded it as one of its causes. Some authors attribute it to diminished secretion of bile. WThen carried too far it often produces anorexia, and disordered digestion, and becomes a cause of agitation and loss of sleep. Whatever be its cause, the strainings necessary to expel the hardened faeces that have accumulated in the intestine, may give rise to hemorrhage and abortion. The best measures for preventing and remedying this state are nearly identical with those used at other periods of life. The same remarks apply to the diarrhoea with which women are often tor- mented. ARTICLE II. LESIONS OF RESPIRATION. Cough and dyspnoea are about the only affections claiming our examination under this title. 268 GENERATION. The dyspnoea that supervenes towards the end of pregnancy is evidently produced by the crowding of the lungs from the excessive uterine development, and the delivery alone can cure it; but sometimes it is sooner manifested in consequence of a pulmonary congestion, which must be remedied by general bloodletting, a light regimen, repose in a suitable position, and loose clothing. The same may be said of such palpitations as are not due to organic disease which existed before the pregnancy; but it must not be forgotten that though bleeding is useful when the dyspnoea or palpitations are very severe, by diminish- ing the local congestion for the time, the latter is much more frequently due to hydraemia than to a true plethora, and that the best means for preventing its return is to follow the bleeding by tonic remedies. (See the following article.) As to the cough, it is only dangerous as regards the pregnancy, by the violent jars sometimes given, which may produce an abortion. Indeed, all the observers who have written on the influenza, have carefully noted the frequency of -this accident in women who were affected with it. When the cough is the effect of pregnancy, it may sometimes be attributed to local plethora, and then we should bleed. But at other times it has a spasmodic character resembling hooping-cough, with the exception of the alteration of the voice. In such cases, I have derived much advantage from baths, repeated for several days in succession. When it is the symptom of a chronic malady, existing prior to gestation, the treatment will vary with the disease that produced the cough. Whatever may be its origin, the accoucheur should always resort to such demulcents and pecto- rals as are calculated to diminish its intensity. ARTICLE III. lesions of the circulation. § 1. Alterations of the Blood. Plethora and Hydremia. The general circulation is more active in pregnant women than in others, and this increased activity manifests itself by a greater frequency of pulse, which is often harder and fuller than in the non-gravid state. Though all this may be regarded as normal, it sometimes becomes exaggerated and gives rise to a slightly morbid condition. Thus, some women experience, at the same time, vertigo, dimness of vision, ringing of the ears, sudden flushings of the face, spontaneous heats over the body, but more especially of the head. If bleeding be practised under these circumstances, the blood will sometimes afford a large and consistent clot with but little serum; though much more frequently there is much serum, and a small clot, covered with a distinct whitish coat, resembling that observed in inflammatory diseases. The differences in the appearance of the blood drawn by venesection ought to have excited the suspicion that, notwithstanding their identity, these functional disturbances might be produced by different causes; and although some scattering therapeutic measures induce the supposition that the idea had suggested itself to some good minds, it is also evident that it was almost immediately stifled; for the majority of authors, even the most recent, do not hesitate to refer them to DISEASES OF PREGNANCY. 269 plethora, and making the treatment correspond with the etiology, recommend bloodletting as the best means of overcoming it. The little advantage which I had derived from this practice had, for several years, excited doubts in niy mind as to the value of the theory; which doubts were especially increased by reading the admirable investigations by M. Andral on the blood. Therefore, in treating, in 1844, in the second edition of this work, of the plethora of pregnant females, I wrote as follows : " After having read the curious statements just given (analysis of the blood by M. Andral), the reader will perhaps find them to disagree with the title of this paragraph, and possibly also with the therapeutic measures hereafter recommended; for how, indeed, can we reconcile this denomination of plethora, applied to the totality of the pheno- mena observed in most gravid females, with the evidences of anaemia furnished by the analysis of the blood ? Is it not probable that the profession has hereto- fore- been in error, in attributing to this cause what in fact is only due to an im- poverishment of the blood ? Because, if to these results we add the beating of the carotids, the caprices of the stomach, the digestive disorders, and the varied nervous phenomena that occur during pregnancy, and which closely resemble those so often observed in chlorotic patients, are we not irresistibly brought to the conclusion, that the chlorosis which produces them in the one case also does in the other ? and, consequently, that the bleeding generally recommended is more likely to augment than to diminish such disorders ? A sufficient number of facts are still wanting to decide the question satisfactorily; but, while presenting in this work the views most generally received, we cannot conceal the effects produced on our mind by the experiments of Andral and Gavarret." From that time, we have endeavored to test by facts, the inferences which we had drawn from the documents furnished by the experiments of these two learned professors; and we have to say, that the theory is confirmed by practice. There- fore, we now assert boldly, what we before expressed timidly in a simple note: That hydraemia is the most frequent cause of those functional disorders of preg- nant women which have hitherto been attributed to plethora. However strange this proposition may at first appear, it seems to us to be proved by the results of the chemical analysis of the blood, by the symptoms presented by the patients, and by the happy effects of a tonic treatment. 1. It is now well proved that the essential character of plethora is based upon a great increase in the proportion of the blood corpuscles, as their diminution is the distinctive fact in anaemia. Now, if we admit with M3I. Andral and Gavar- ret, that the mean normal proportion of corpuscles is 127, or with 3131. Bec- querel and Rodier, that it is 141 for men and 125 for women, it will be seen that all the analyses made up to the present time give a much lower mean for a woman at an advanced stage of her pregnancy. Thus, of 34 bleedings examined by Andral and Gavarret, but one specimen exhibited, at the end of the second month, a proportion of corpuscles greater than the physiological mean, namely, 145. In one only, pregnant between one and two months, did the corpuscles reach the physiological standard of 128. In all the remaining 32 cases the cor- puscles were below this point, ranging in 6 cases from 125 to 120, and in the other 20, from 120 to 95. The 34 bleedings gave different results as regards the fibrine, the mean physio- 270 GENERATION. logical proportion of which is 3, according to the period of pregnancy at which the blocd was drawn. Thus, from the first mouth to the end of the sixth, the amount of fibrine was always below the average; the mean being 2-5, the mini- mum 19, and the maximum only 2 9. During the last three months, on the contrary, the proportion of fibrine exceeded the physiological average; it was about 4, the maximum reaching 4-8. Toward the end of the last month, the average is 4-3. MM. Becquerel and Rodier analyzed the blood of nine pregnant women, two of whom were 20 years of age, two 22, one 25, one 27, one 29, one 34, and one 41. Five of these were of robust constitution, two were about the average in this respect, whilst the other two were weak and apparently lymphatic. Six enjoyed excellent health, two were not so well, and one was in the hospital on account of indefinite pains in the abdomen, and a cough of rather long stand- ing, though not serious in character. One was 4 months pregnant, four 5, one 5J, one 6, and two 7. None of them were bled except when they felt it to be necessary, and in pre- sence of an actual plethoric condition which positively indicated venesection. The carotid murmur was heard in three cases only, one of them being 5 months and the other 7 months pregnant. The following represents the average composition of the blood, at least, as re- gards its principal elements:— Average. Maximum. Minimum. Corpuscles, .... 111-8 127-1 87-V Fibrine,.....3-5 4- 2-5 Albumen,. .' 66-1 68-8 62-4 (•The average in non-pregnant women is 70-5.) Water,.....801-6 (The average in non-pregnant women is 791*1.) 3Iy colleague and friend, M. Regnauld, has the following table in his thesis, and I think it so important that I give it entire:— DISEASES OF PREGNANCY. 271 Table showing the Composition of 1000 Parts of Blood from 25 Women at various Stages of Pregnancy. STAGES OP PREGNANCY. CD to <1 .9 © a P ,0 < p a. O a" p ID g a IS ® m -a to o"-1 as FH a> a > a u a side, and from before backwards, as the left oblique, and the one passing from the right towards the left, and from in front posteriorly, as the right oblique diameter^) The posterior fontanelle is found to the left and in front, the anterior one is behind and to the right. The dorsal plane of the foetus looks forwards and towards the left side; while its anterior plane is directed backwards and to the right; the right shoulder is in front and to the right side; the left one is behind and towards the mother's left. Before the bag of waters is ruptured, the child's head is slightly flexed on the front of the chest, and the following are the relations of its diameter with those of the superior strait: the occipitofrontal corresponds to the left oblique of the strait, and the bi-parietal to the right oblique;1 and, of course, the occipitofrontal 1 We may remark, however, with M. Dubois, that this last relation is not absolutely exact. For instance, if the head of a foetus at term be found at the superior strait, so that MECHANISM OF LABOR. 405 circumference of the head is parallel with the periphery of the abdominal strait, and the axis of this strait corresponds with the trachelo-bregmatic diameter2 of the head. When the membranes are ruptured, a variable quantity of liquid escapes; then the uterus contracts and applies itself more directly to the foetal trunk; nevertheless, as but little fluid passes away in vertex positions at this time, there usually remains a sufficient quantity of it to render the pressure of the uterine walls on the child far from being immediate. After the rupture, the object of the contractions is to expel it from the womb; the foetus becomes more curved anteriorly, and its superior and inferior extre- mities more closely folded up; and, from that moment, properly speaking, the mechanical phenomena of labor began. These phenomena, or stages of the mechanism, are five in number, as follows: in the first, the head is more strongly flexed on the chest; in the second it tra- verses all the space betweon the superior and the inferior straits, and reaches the floor of the pelvis; there it experiences a movement of rotation which carries the occiput behind the symphysis pubis, thus constituting the third period; in the fourth, the head undergoes the process of extension, by which all the superior and anterior parts of the vertex and face become completely disengaged at the anterior commissure of the perineum; and then, after its perfect expulsion, the child's cephalic extremity performs a fifth and last movement, designated by Baudelocque as the period of restitution, but which M. Gerdy has proposed to name the exterior rotation. A. Stage of Flexion.—After the rupture of the membranes, the foetal trunk, being compressed on all sides, transmits to the head, through the spine, the im- the occipito-frontal diameter is parallel with the left oblique, the shape of the head will prevent the bi-parietal one from corresponding with the right oblique diameter. In fact, in this position the posterior extremity of the bi-parietal diameter is at the left sacro-iliac symphysis, but the anterior extremity, instead of terminating opposite the ilio-pectineal eminence, is found very near the middle of the horizontal branch of the pubis. 2 M. Nsegele and Professor Dubois (who adopts, afteast in part, the views of the Heidel- berg Professor) do not believe that the head presents at the superior strait, in the majority of cases, so regularly in all its relations, as we have just described, for they say the head does not offer perpendicularly to the plane of the strait, but, on the contrary, in an obhque direction; whence the right parietal protuberance, which is also the antenorone, would be lower, relatively to the plane than the left; and the bi-parietal suture, instead of being found in the direction of the axis of the head, would be a little behind it, according to M. Dubois, and would even look towards the second bone of the sacrum, agreeably to M Nsegele. But, notwithstanding these imposing authorities, we believe the occipito-frontal circum- ference is closely parallel to the plane of the strait in most cases, although the parietal boss is certainly one of the most dependent parts of the head, and the finger first strikes upon it in practising the vaginal examination. But those facts by which Naegele sustains his views prove just the contrary; because the plane of the abdominal strait, being directed very obliquely downwards and forwards, the portion of the head in contact with the ante- rior arch of the pelvis should be its most dependent part; and further, the finger first en- counters the anterior parietal protuberance, because the introduction takes place under the symphvsis pubis, that is to say, almost perpendicularly to the superior strait, and there- fore the index can only reach, in a very oblique direction, the anterior portion of the head, whose greatest circumference is parallel to the plane of the superior strait. 406 LABOR. pulse derived from the uterine contractions. The head, being forcibly pressed on. has a tendency to clear the uterine orifice, and to engage in the excavation. But it then encounter? resistances, either from the os uteri, which is not yet sufficiently dilated, or from the superior strait, or the walls of the excavation; and being thus placed between a power and a resistance, the head must naturally become still more flexed on the chest; in fact, the force of expulsion transmitted by the vertebral column, falling upon the occipital foramen, that is, on a point The head in the same position, though much nearer to the occiput than the chin, must necessarily (the resistance being equal at the two extremities of the occipito-mental diameter) act more powerfully on the occiput than on the chin; in other words, must press down the occiput into the excavation. But, by depressing this part, the chin is forced to ascend, thus producing the flexion of the head.1 The head being in this way forcibly flexed, its relations are changed: that is, the occipito-bregmatic diameter has taken the place of the occipito-frontal, and has become parallel to the left oblique of the strait; but the bi-parietal remains unaltered ; the occipito-bregmatic circumference is now on a level with the peri- phery of the strait, and the axis of the pelvis, which before corresponded with the trachelo-bregmatic diameter, now traverses the head very nearly in the direc- tion of the occipito-mental diameter. This movement of flexion, therefore, evidently places the child's head in the most favorable position for its passage, by constraining it to offer its smallest diameters to those of the pelvis. 1 In order to prove that the movement of flexion results from the position of the occipital foramen, relatively to the chin and occimt, which represent the two extremities of the lever whereon the spine is articulated, let us suppose, for a moment, that the vertebral column is attached to the occiput alone, when it is evident that the latter only will descend ; on the other hand, let it be made to the chin, which will then descend the first, and lastly let it be done at the centre of the interval between these two extremes, and an equilibrium will be produced, the same as results from equal weights or resistances placed in the dishes of a balance having equal arms. But where the articulation takes place nearer one extremity than the other, the descent will occur at this extremity, just as it would happen in the above-cited balance, if, without altering anything else, the arms were rendered unequal in their length. To conclude, lest the foregoing should not satisfactorily explain the phenomenon, I pro- pose the following rationale: the head, urged on by the uterine contraction, communicated to it by the spine, meets with resistance from the os uteri, which is not yet sufficiently di- lated. Let us change, for an instant, the order of forces, making the vertebral articulation a fulcrum, and the opposition on the part of the neck the power ; now, this power is evidently equal in all points of the periphery of the neck; but let us observe that, as the interval between the chin and the occipital foramen is greater than that betwixt the latter and the occiput, the resistance against the chin operates on a longer lever than that against the occiput, and consequently the first must be the more powerful of the two, and therefore it forces the chin to ascend. But raising the latter has the same effect as depressing the occiput: that is, still producing a flexion of the head. MECHANISM OF LABOR. 407 B. Stage of Descent.—The head, pressed on by the contractions, enters the excavation and reaches the floor of the pelvis. In making this descent, the occi- put presses in front against the internal and anterior face of the body of the ischium, the obturator internus muscle, and the external obturator vessels and nerves, which pass out through the upper part of the obturator foramen ; while the forehead or bregma presses behind on the internal border of the psoas and pyramidal muscles, the sciatic plexus of nerves, together with the gluteal and the internal pudic vessels and nerves. The left side of the head likewise comes into mediate relation with the same parts, and also glides over the anterior sur- face of the rectum. But the descent of the head is not completed until the occipito-bregmatic circumference is nearly parallel to the plane of the inferior Btrait: that is, when the two parietal protuberances have attained this level. Now, it is evident that, to reach this point, the left parietal boss (which is found behind) must traverse the whole anterior face of the sacrum, whilst the anterior one has only to clear a much shorter space; the first must therefore describe the arc of a much larger circle than the second. Perhaps a more exact idea of the actual movement of the head will be formed by imagining the anterior extremity of the bi-parietal diameter to remain nearly stationary in front and to the right, while its posterior extremity descends rapidly and traverses the whole posterior plane of the excavation. C. Stage of Rotation.—The head, being arrested by the floor of the pelvis, executes a movement of rotation, during which the occiput passes from left to right behind the symphysis pubis, or rather behind the left ischio-pubic ramus, and the bregma rotates into the concavity of the sacrum, though remaining a little towards the right. The posterior superior part of the right parietal bone then appears plainly under the pubic arch; the posterior fontanelle is behind the ischio-pubic ramus; and the sagittal suture erosses the coccy-pubal diameter very obliquely. Being forced on by the energetic contractions of the womb, the vertex then depresses the soft parts of the perineum, and by gradual^ distending them, succeeds in converting the pelvic floor into a part of a canal which prolongs the posterior wall of the pelvis downwards and backwards. It is during this time that the rotation is accomplished: that is, the sagittal suture becomes parallel with the antero-posterior diameter of the inferior strait, The occiput engages in the arch of the pubis, and projects beyond the lower part of the symphysis, until the back part of the neck comes into contact with it, when the anterior progression of the occiput is arrested. D. Stage of Extension.—Just at the moment when the occiput engages in this manner in the pubic arch, the shoulders and upper part of the body enter the excavation, and in engaging there, the foetal trunk, which is flexible, accommo- dates itself to the direction of the canal, and consequently, bends over a little on its posterior plane; this movement causes the chin to depart from the chest, and then the extension of the head begins. But, in order to understand how this last is completed, we must remember that the force of the uterine contraction, transmitted always by the spine, falls upon some part of the occipito-mental diameter, and that, in the beginning of the labor, this power operated both on the occiput and the chin, though up to 408 LABOR. Fig. 68. The head is seen in various degrees of extension, the nape of the neck rest- ing first behind, and then under, the symphysis pubis. the present moment the occiput had felt its influence the most: 1st, because, from the forced flexion of the head, it was more in the line of its direction; and, 2d, from the fact of its falling on the occipital foramen, the impulse was much nearer to the occiput than the chin; but the occiput having once engaged under the pubic arch, and the back of the neck being applied to the symphysis pubis, which, by its resistance, destroys all that por- tion of the uterine force that acted on the occi- put, there only remains that portion of the force which operated on the chin. Now this power continues to act, and under its influence the chin is pushed down, and consequently, by a continuance of the same movement, the oc- ciput ascends : that is to say, the whole head is turned up in front of the symphysis pubis. During this movement of extension, the fol- lowing points successively appear at the ante- rior commissure of the perineum, viz., the bi- parietal suture, the bregma (or fontanelle), the coronal suture, the nose, mouth, and, last of all, the chin. During this process, the head exactly represents a lever of the third kind, whose ful- crum is at the sub-occipital point, lying behind and under the symphysis pubis, the power at the occipital foramen, and the resistance at the chin, which is to be depressed, an opposition necessarily augmented by the resistance of the perineum. Further, the sub-occipito-bregmatic, the sub-occipito-frontal, and the sub-occipito-mental diameters successively pass the antero-posterior diameter of the inferior strait. As soon as the occipito-bregmatic circumference is beyond the vulva, the anterior border of the perineum, yielding to its natural elasticity, retracts strongly, slips over the face, and embraces the neck; and just at that moment, the head, which was before forcibly turned up in front of the mons veneris, falls back from its own specific weight, towards the anus. E. Stage of Exterior Rotation. (Restitution.)—The head remains for a few seconds in this position, and then it is seen to describe a fifth and last move- ment, namely, the occiput inclines towards the internal surface of the left thigh, and the face turns towards the right thigh. This process is usually denominated the restitution, for the following reason: Before the researches of M. Gerdy, it was generally supposed that when the head executed its movement of rotation within the pelvis, the trunk did not participate therein, and that the operation could only take place through the aid of a certain degree of torsion in the neck; and, further, that the head becoming completely disengaged, and only retained by the resistance of the soft parts, the neck then untwisted, and the head was restored to its natural relations with the trunk. M. Gerdy was the first to demonstrate the faultiness of this explanation; for, in fact, the trunk does participate in the head's rotation, in such a way that the shoulders, which, in the beginning of labor, corresponded to the oblique dia- meter, are nearly transverse after this movement (the right shoulder, neverthe- MECHANISM OF LABOR. 409 less, remaining always a little more in front than the left). The shoulders then reach the inferior strait in a transverse position, presenting, therefore, their great, or bis-acromial diameter, to the smallest one of this strait; but here they en- counter some resistance, under the influence of which the rotation is effected in the opposite direction to that of the head; the right shoulder, passing from the right side towards the left, approaches the apex of the pubic arch, while the left one gets into the perineal concavity, and the head, being free externally, neces- sarily follows the movement communicated to the shoulders. The rotation of the head is not therefore an isolated movement peculiar to itself, as Baudelocque supposed, but one secondary to the rotation of the shoulders. I must remark, however, that, in some cases, the head has appeared to me to execute a double movement; for, immediately after its expulsion, it turns very slightly; the occiput passing a little to the left, the forehead towards the right; after remaining some seconds in this position, it then undergoes the secondary movement just described, which is due to the rotation of the shoulders. The first of these movements has always seemed to me to result from the untwisting of the neck, and is the true movement of restitution of Baudelocque. The shoulders present at the inferior strait soon after the head, and, as we have just stated, nearly always in a transverse position. The right one gets under the right ischio-pubic ramus, while the left one lies in front of the left sacro-sciatic ligament. The bis-acromial diameter is rarely found in the direc- tion of the antero-posterior diameter of the inferior strait. The anterior or sub- pubic shoulder is the first to appear in the vulvar fissure; although, as a general rule, the posterior one, after having traversed the perineal curve, is first disen- gaged at the anterior commissure of the perineum, and the right one is subse- quently delivered.1 During the disengagement of the shoulders, the fcetus becomes flexed on its right lateral region so as to accommodate itself to the curvature in ths pelvic canal; and very soon after the remainder of the trunk is expelled, sometimes describing a very prolonged spiral course in its passage. 2. Mechanism of Natural Labor in the right Posterior Occipito-iliac Posi- tion. (The fourth of Baudelocque, and the third of M. Capuron.) In the vast majority of cases, the mechanism of labor in this position scarcely differs from that just described, and therefore we only need allude here to the 1 Contrary to the generally-received opinion, M. P. Dubois supposes that the anterior shoulder is the first delivered. That is certainly true in a great number of cases, but we have most usually observed the opposite fact; besides, there is a theoretical view which militates in favor of our opinion, that is, the left shoulder, being placed in contact with the posterior plane of the excavation, is situated, much more than the anterior one, in the direc- tion of the uterine axis, or the axis of the superior strait, and therefore being subjected to a more energetic uterine impulse, consequently must be delivered first; further, it was ne- cessary this should be so, as the posterior shoulder has much the longer course to traverse. Again, if I might refer to my own observations, I would say that in women who have be- fore borne children, more especially in those who have suffered from rupture of the peri- neum in former labors, the posterior shoulder is the first delivered ; and, on the contrary, in primiparae, the sub-pubic one has the precedence, the other being retained by the re- sistance from the soft parts. 410 LABOR. principal peculiar phenomena of the travail, without repeating all the preceding details. It, likewise, is composed of five periods, or stages; before the membranes are ruptured, the diameters of the head correspond with the same diameters of the pelvis, as in the foregoing case, and the only difference to be remarked is, that the occiput corresponds to the right sacro-iliac symphysis, and the forehead to the left ilio-pectineal eminence. The child's posterior plane looks backwards and towards the mother's right, while its anterior plane is in front and to her left— its left side is placed in front and on the right, its right side behind and to the mother's left. A. Period of Flexion.—The head is flexed by the same forces as in the pre- ceding case, and this flexion determines similar changes in the relations of its diameters with those of the pelvis. B. Period of Descent.—This stage presents nothing worthy of particular notice. c. Period of Rotation.—The head having reached the floor of the pelvis, undergoes a movement of rotation, in consequence of which the occiput traverses the whole right lateral moiety from behind forwards, in such a way that it passes successively towards the right extremity of the transverse diameter-, behind the cotyloid cavity and under the right ischio-pubic ramus, while the forehead, or bregma, revolving in an inverse direction, goes from before backwards towards the hollow of the sacrum; and thus, the position which was originally occipito- posterior, becomes converted into an occipito-pubic, or anterior one, and the labor then terminates just as it does in those cases where the occiput was primitively in front. In some instances, which are rare, however, this conversion does not take place, and the occiput remains behind until the termination of the labor. The delivery is then concluded in the following manner: the head is strongly flexed on the chest, and retains its oblique position ; the forehead, corresponding to the body of the left pubis, first reaches the inferior strait, and the left coronal boss then engages under the pubic arch, where we can sometimes distinguish the superciliary ridge just below the symphysis; and I even saw the upper eyelid in one case. But though the forehead first appears at the exterior, the occiput, urged on by the spine, which transmits the force of the uterine contrac- tion, traverses the whole curvature of the perineum (which is greatly distended in such instances), and becomes disengaged the first at the anterior com- missure. While the occiput is thus passing over the anterior surface of the sacrum and perineum, the coronal boss and eyebrow, that originally ap- peared at the vulva, reascend and become con- cealed behind the symphysis. The occiput is scarcely clear, when the peri- neum by gliding over the inclined plane formed by the nape of the neck, retracts strongly, and thus facilitates the subsequent delivery of the anterior Fig. 69. Disengagement of the head in the occipito-posteri or positions. MECHANISM OF LABOR. 411 portions of the head; therefore, the head may be observed to undergo the process of extension around the nape as a centre, and to appear below the symphysis in the following order : namely, the anterior fontanelle, the coronal suture, the fore- head, nose, mouth, and chin. Lastly, the head, placed in the right posterior occipito-iliac position, may, when once down in the excavation, depart from the chest, and the vertex pre- sentation be thus spontaneously converted into one of the face, at the inferior strait; we witnessed a case of this kind at the Clinique in 1838. This transmutation takes place, says M. Guillemot, in the following manner: the occiput being arrested by some point on the posterior part of the excavation, instead of advancing along the perineum towards the inferior strait, ascends in the curvature of the sacrum by executing the movement of rotation backwards, and being at the same time thrown back upon the posterior part of the chest. While this is going on, the forehead and face descend behind the pubis and pass downwards and backwards, until the chin engages under the arch, and then the head, which is completely turned back, traverses the perineal strait, as in a face presentation. The disposition which the inclined plane of the cervix uteri impresses on the vertex in this position, continues M. Guillemot, is a frequent cause of a similar transmutation above the abdominal strait. The slight backward inclination of the head, which always exists in these positions, may correct itself when the uterine contractions, by acting on the foetus, keep the chin applied to the neck; but, on the other hand, the reversion may be carried still further, or be entirely completed, if any obstacle impedes the descent of the occiput into the excavation; finally, in cases of uterine obliquity, where the inclination of the vertex is greater, the backward tendency, instead of disappearing, would be increased, and the occiput would then ascend and the forehead descend. Like the author quoted, I admit the fact, though I think it rare; but I cannot acknowledge, like him, the truth of the following proposition, i. e., that if the conditions of transmutation which then exist may be appreciated by a comparison of the face labors with those of the occipito-posterior positions, we should not depart far from the truth (Ibelieve it would be a wide departure) by announcing that, in every three occipito-posterior positions, one of them would give rise to a face presentation. Lastly, whatever may be the mode of the delivery of the head in the right posterior occipito-iliac position, the occiput always inclines towards the internal surface of the right thigh, and the face is directed to the left one; this external movement (restitution) results from the internal rotation of the shoulders, in con- sequence of which the left shoulder, which was originally the anterior, gets under the arch of the pubis, and the right one into the hollow of the sacrum, and then the shoulders and the remaining part of the trunk are expelled in the manner already stated. The great care we have taken in describing the natural labor in these two varieties of the two fundamental positions, will absolve us from repeating it anew in the other varieties. In fact, the left transverse occipito-iliac position does not differ from the ante- rior one; unless, perhaps, the movement of rotation, which brings the occiput in 412 LABOR. front, is somewhat more extended; and what we have stated concerning the two modes of termination in the right posterior occipito-iliac position applies equally well to the left posterior one ; but we must add that the movements of rotation will then take place from left to right, since the occiput is primitively turned towards the left side. Lastly, in the other two varieties, the right anterior and the right transverse occipito-iliac ones, the mechanism is still the same as in the corresponding varie- ties of the left occipito-lateral position. Remarks.—From the foregoing, the reader will see that, in order to study the mechanism of labor in the vertex positions, we have been obliged to consider each of the periods, or stages, composing it separately. Thus, we first examined the movement of flexion, then of descent, next the internal rotation, the exten- sion, and the external rotation; but it must not be supposed that these different movements occur successively, one after the other, in the order just described. 1. The forced flexion spoken of as happening before the descent, frequently only takes place simultaneously with the latter. Often, indeed, the head is not flexed until the descent is completed, and it encounters the resistance from the floor of the pelvis; and then only, in the majority of cases, is the flexion carried to its highest degree. We can imagine that this would nearly always be the case, since the head is engaged in the excavation in most women long before the com- mencement of labor; and even in those cases where it is still above the superior strait at the time of the membranes being ruptured, the presenting diameters will allow it to traverse the upper part-of the excavation without meeting any marked resistance. The movement of flexion likewise presents some irregularities : for instance, it is not at all unusual, more especially in the occipito-posterior positions, for the chin, instead of approaching the chest, to depart from it; and, consequently, for the head to become extended, and the anterior fontanelle gradually to get towards the centre of the excavation. However, this anomaly is usually tempo- rary, for the head is flexed anew when it reaches the pelvic floor. In some rare cases, the opposite of the preceding, the posterior fontanelle occu- pies the centre of the excavation, either because the flexion has gone beyond its usual limits, or else, because the trunk is inclined backwards; but here, also, the resistance from the perineum gradually brings back the head to its regular situa- tion. (P. Dubois.) 2. The rotation sometimes commences prior to the arrival of the head at the inferior strait, and before the descent is completed. So that, in such cases, the three first stages of the labor occur at the same time; thus the head is flexed, descends, and rotates all at once. Some curious varieties of rotation are occasionally met with, which should be known to the student. For instance, it may be incomplete, the head still retain- ing a great obliquity pending the whole duration of its disengagement; or it may not take place at all, which happens, as we have already seen, in certain occipito- posterior positions, or it may also occur in the transverse ones. In this latter variety, which is the rarest of all, the occiput and the forehead disengage along- side of the internal surface of the ischiatic tuberosities; the occiput escapes first, and then the forehead by a movement of extension analogous to the ordinary MECHANISM OF LABOR. 413 mechanism. Madame Lachapelle reports having observed three cases of this kind. In some exceptional instances, the rotation exceeds the ordinary limits : thus, for example, if the occiput is placed in relation with the right sacro-iliac symphysis at the begining of the labor, it may successively correspond with the right extremity of the transverse diameter, the posterior face of the right aceta- bulum, the symphysis pubis, and the left cotyloid cavity; and then, after a moment of repose, it retrogrades and places itself once more behind the sym- physis. M. P. Dubois originally pointed out this fact, and I have twice since had an opportunity of verifying its truth. Again, the rotation, by which the occiput is brought in front, sometimes only takes place just as the head is overcoming the final resistances from the soft parts; on one occasion, I observed and pointed out this fact, in a primiparous woman, to all the students then present at the Clinique; the child's head was in the right posterior occipito-iliac position, and it had descended to the pelvic floor and had cleared the inferior strait without rotation taking place; the perineum was forcibly distended, the vulva widely dilated, the parietal protuberances were engaged, and the occiput had but a few lines to pass over in order to escape at the anterior perineal commissure; when, under the influence of a new pain, the head rotated briskly, the occiput gained the front, the forehead simultaneously rolling into the perineal concavity, and the labor terminated almost immediately. The rotation within the excavation is certainly one of the most curious move- ments executed by the fcetal head during the whole process of a natural labor; indeed, from what we have hitherto stated, it must be evident that, whatever be the primitive relations of the occiput with the various points of the circumfer- ence of the superior strait, it finally succeeds in getting under the symphysis pubis.1 Now, the physical cause of this movement is nowhere given in the writings that have been published on the subject prior to M. P.Dubois, who has paid particular attention to this point, and who, after refuting the influence of the inclined planes, advanced by the older accoucheurs, as the cause of the move- ment, adds, " This cause evidently resides in the combination of a great number of elements, viz., on one hand, the size, form, and mobility of the parts which are expelled, and, on the other, the capacity, the shape, and the resistance of the canal traversed by them; and such is the influence of this association, that the foetal parts place themselves in the most favorable conditions for delivery; thus, if an active resistance is made to them at one point, they withdraw from that, and seek another where there is more space and liberty. The mobility of the traversing parts, and the extreme lubricity of those which are traversed, ren- der all this very simple and intelligible. In fact, every accoucheur must have remarked that, in those instances where the sacro-pubic diameter is contracted, the foetal head, if oblique before the labor, constantly places itself then in a trans- verse direction, that is, in the one offering the least possible dimension to the 1 M. Naegele has only known the occiput to disengage posteriorly seventeen times out of twelve hundred and forty-four occipito-posterior positions; and even in those cases it was always possible to appreciate the exceptional circumstances that had favored this irregu- larity : such as, an amplitude of the pelvis, or numerous former labors, lacerations of the perineum, or the softness, flexibility, reductibility, and want of consistence of the head, or an extreme smallness of the child, the presence of twins, &c, &c. 414 LABOR. shortened diameter; and this fact is nothing else than a very simple effect of those same causes, of which the rotation, when extensive, is a very complicated consequence." (Journal des Connaissances Medico-Chirurgicalcs.) M. P. Dubois further relates the following experiment in support of his explanation of the process of rotation : " The flaccid and voluminous uterus of a woman, who died soon after delivery, was freely opened near the os uteri, and her fcetus was placed in it near the soft, gaping orifice, in the right posterior occipito- iliac position of the vertex; then several midwife students, by pushing the child from above downwards, caused it to enter the excavation without difficulty; but it required a much greater effort to make the head traverse the perineum and clear the vulva; and it was not without some surprise that we noticed, in three different trials, that, as soon as the head passed the external genital parts, the occiput was in front and to the right, while the face turned backwards and to the left. Again, we repeated the experiment a fourth time; but now the head passed the vulva, with the occiput remaining posteriorly. We then took a stillborn child, delivered the preceding day, which was much larger than the other, and placed it in the same conditions as the first, and on two successive trials the head cleared the vulva after having performed the rotation; on the third and succeed- ing essays it was disengaged without executing this movement: that is, the process of rotation continued until the perineum and vulva had lost the power of resistance that produced it, or which, at least, had determined its accomplish- ment." (Loc. c.it.) I do not know whether the explanations and experiments of M. P. Dubois will render the cause of rotation very simple and intelligible to every reader; but, as to myself, I am constrained to admit that they describe and confirm the fact, but that they do not explain it. True, there can be no doubt that the cause of rota- tion is to be sought for in the form and direction of the canal, and in the shape and size of the fcetal head; but let us see if it would not be possible to ascertain the influence of those divers circumstances more precisely. The uterus is situated very nearly in the axis of the superior strait, and there- fore the sum of its expulsive forces, or, to speak more clearly, the sum of the contractions, may be represented as operating according to the direction of its axis. Now, supposing the head to be in the right posterior occipito-iliac posi- tion, the occiput, urged on by the uterine contraction transmitted by the spine, will descend in the line of its axis: that is, from above downwards, and from before backwards; and it will continue on until it is arrested by the resistance from the inferior and lateral parts of the pelvis, or from the soft parts constitu- ting the floor of the perineum. There it is arrested, provided the resistance be considerable, and thenceforth the occiput must necessarily change its direction. In fact, the resistance may be represented by a force operating in a direction perpendicular to the surface whereon the head strikes, and which is applied to the fcetal cranium at its point of contact with the posterior plane of the excava- tion. This point of contact, in the case before us, is evidently the right lateral and posterior part of the head, which strikes against some point in the hinder wall of the excavation; the child's head, or rather the occipital extremity of it, is from that time subjected to two different forces, one of which acts from above downwards, before backwards, and slightly from left to right (this is the uterine MECHANISM OF LABOR. 415 contraction); and the other from behind forwards, and a little from below upwards (this is the resistance, or force, represented by the perpendicular to the surface impinged upon by the head). By representing this force derived from the re- sistance, and that from the uterus communicated through the spine in the line of axis of the superior strait by a parallelogram, we obtain a diagonal or resultant from these two forces that points out the direction of the movement that is to take place. Now, by constructing such a parallelogram, we observe that the occiput must evidently pass forwards, downwards, and to the right; since the diagonal or resultant of the forces is directed from behind forwards, from above downwards, and from left to right.1 The extent of this downward progress, and the rapidity of its execution, are always proportionate to the energy and duration of the contraction, and to the resistance offered by the pnlvic floor. This also explains why the rotation, after being a long time delayed, is sometimes suddenly and completely effected during a violent pain; as also why, under other circumstances, and more particularly in those instances where the pains are feeble or short, this movement only takes place gradually, and requires for its entire completion a much longer period and more numerous contractions.3 Lastly, this theory enables us to explain those differences noticed in the rota- tion according to the part of the excavation where it commences; thus, it has been stated that usually the process only begins when the child's head reaches the pelvic floor; indeed, this could hardly be otherwise, since until that period the head, from being strongly flexed, and offering its smallest diameters to those of the strait, had encountered no resistance whatever from the osseous portion of the pelvic canal; but we can readily imagine that if the head be voluminous, the pelvis rather small, the superior strait too much inclined, or the uterus too oblique, the resistances might be felt much sooner, and the occiput hardly have entered the excavation, before it would strike against the posterior wall and be compelled to follow the new direction impressed upon it by the resultant (dia- gonal) of the forces. This explanation accounts readily for the absence of rotation, and the disen- gagement of the head in the posterior position. What, according to M. Naegele, are the kinds of cases in which this exception has been observed ? We have 1 In an article published in 1846, two years after the appearance of my first two editions, Prof. Simpson advanced nearly tho same theory, adding that no one had before given a satisfactory explanation of this movement of rotation. Though glad to find my theory confirmed by that of the learned Edinburgh Professor, I am sorry to have to remind him that my first edition was published in 1840. 2 This movement takes place gradually, says M. Naegele, in a slow spiral direction; for if the vaginal touch be resorted to during the pain, the small fontanelle. which was originally directed to the right and posteriorly, will then be found to place itself altogether to the right, towards the descending branch of the ischium; but, in proportion as the pain diminishes, it returns step by step to the place it occupied before. Again, if the finger be kept in contact with the head, the posterior fontanelle, which in the absence of a pain is wholly to the right, will be observed, during the latter, to turn forwards towards the obturator foramen, from whence it again departs as the pain goes off; and it keeps up these alternate movements for some time, until finally it becomes fixed opposite this foramen. 416 LABOR. already stated them : they are those in which the large size of the pelvis, the slight resistance of the soft parts, occasioned by previous labors or ruptures of the perineum, or else the small size of the fcetus, or the reductibility of its head, permit its passage through the canal without encountering resistance, and, con- sequently, without any alteration of the first direction of the uterine force by a new one. 3. The trunk participates, as we have elsewhere stated, in the rotation of the head; this, however, may not occur; at least two cases reported by M. P. Dubois would seem to prove as much. 4. The rotation of the shoulders after the head is delivered may also present two opposite conditions; that is, it may either take place in a partial manner or else not at all, the shoulders then disengaging transversely. This last circum- stance is not very unusual, and, in my opinion, clearly tends to confirm the views of M. Gerdy on the process of rotation; for when it does not occur the head undergoes no rotation. But the latter should always execute this movement, however great the immobility of the shoulders, if the process is a consequence, as Baudelocque supposed, of the untwisting of the neck. Sometimes, on the contrary, the same movement that rendered the shoulders transverse before the delivery of the head continues after the expulsion of this latter in such a way, that the shoulder which was originally anterior instead of retrogading towards the pubic arch passes behind, while the other that was primitively posterior gains the apex of this arch, and the face then turns towards the internal surface of the right thigh in the right occipito-iliac, and to the left thigh in the left occipito-iliac positions. § 4. Inclined, or Irregular Vertex Presentations. Under the name of inclined, or irregular presentations of the vertex, we have designated those (page 399) in which the sagittal suture, instead of being placed very nearly in the axis of the superior strait, looks either to the fore or hinder part of the pelvis, as well as those in which the forehead or the occiput is placed at the centre of the strait, in consequence of the incomplete or exaggerated flexion of the head. Baudelocque and his school have considered these as so many distinct presentations, which they have accordingly denominated the pre- sentations of the side of the head, or ear, forehead, and occiput; but we shall follow the example of Lachapelle, Naegele, Stoltz, and P. Dubois, by including them all in the general term of vertex presentations. In fact, they scarcely ever impede the course of the labor, and seldom modify its mechanism. For example, let us take the first position (the left anterior occipito-iliac), and suppose it to be inclined on its anterior (right) parietal region; then the right parietal protuberance corresponds to the centre of the strait, and the sagittal suture looks towards the first bone of the sacrum. When the contractions take place, the head will descend just as in a natural position, excepting that, upon its entrance into the excavation, or during the first half of the descent, it will undergo a movement of correction, in consequence of which the posterior parie- tal protuberance will describe an arc of a circle around the anterior one as a centre, and both will soon appear on the same plane, and the labor terminate as usual. Of course, this process of correction would operate in the opposite direc- MECHANISM OF LABOR. 417 tion if the inclination were on the posterior parietal region instead of the anterior; however, the rectification is then much more difficult, owing to the direction of the expulsive force, which has a continual tendency to augment the inclination. In those cases where the flexion of the head is incomplete, as in the forehead presentations of Baudelocque, it will become perfected during the descent, and the same will occur when it is exaggerated (the presentation of the occiput of Baudelocque); the forehead becoming lower and lower. § 5. Prognosis. The vertex presentations are the most favorable of all, and this statement will be more fully verified when we study the prognosis of the other presentations. But the vertex positions are not all equally advantageous; and we may lay it down as a general proposition that those in which the occiput is turned towards some point of the anterior half of the pelvis, at the beginning of the labor, are more favorable than those in which it looks posteriorly. In occipito-posterior positions, the head, in the early part of the labor, gene- rally remains quite high and less flexed than when the occiput is in front, a fact shown by the difficulty then experienced in reaching the posterior fontanelle. The descent, also, is very slow, and barely complete until rotation has brought the occiput in front. In the latter case, as hitherto demonstrated, the labor may terminate by two varieties of mechanism which are altogether different from each other: that is, the occiput either comes in front, so as to get behind the symphysis pubis, or else it remains posteriorly throughout the labor. Whenever the posterior position converts itself into an occipito-pubic one, the very considerable extent of the rotation then demands a rather more energetic contraction on the part of the womb than where the occiput was originally nearer to the anterior arch of the pelvis, and the labor is, therefore, somewhat more painful, though in general it is not serious. But the expulsion becomes particularly difficult when the head maintains its primitive position, and does not rotate, as we shall endeavor to prove; though first, let us establish as an axiom, the evidence of which no one can deny, that whenever a straight and an inflexible trunk has to pass through a curved canal, it will do so the more readily as the canal is shorter and less curved, or the trunk itself is the more diminutive. Now, in the folded condition exhibited by the child's body in vertex pre- sentations, the trunk, which represents the great longitudinal axis, may be divided into two portions; one of which, constituted by the spine and the infe- rior extremities, is flexible, and can accommodate itself to the pelvic curvature, and, therefore, its expulsion should offer no difficulty; while the other, corre- sponding to all the space between the vertex and the atloido-axord articulation, forms a straight, inflexible stem. Now, it is evident that in the primitive occi- pito-anterior positions, or in the posterior ones, which afterwards become con- verted into anterior, that portion of the straight inflexible stem which the long axis of the foetus represents, is reduced to its smallest possible dimensions, and it only has to traverse the shortest and least curved part of the canal, I mean 27 418 LABOR. the symphysis pubis; whence one extremity is clear at the inferior, while the other is scarcely engaged at the superior strait. But does the same thing occur in those occipito-posterior positions that remain posterior until the end of the labor? We know the occiput, in this latter ease, is the first to escape at the anterior perineal commissure, and it therefore has to traverse all the front surface of the sacrum and of the greatly distended perineum. But as the child's neck is not long enough to thus measure the whole posterior wall of the pelvic canal, the chest must engage in the excavation soon after the head, and the latter, as a necessary consequence, must be forcibly flexed on the breast. Owing to this forced flexion, the straight inflexible stem extends not only from the vertex to the atloido-axoid articulation, but even to the first dorsal vertebra), and it is, therefore, much longer than usual; yet more, it has to traverse the whole ante- rior face of the sacrum prolonged by the perineum, that is to say, the longest and the most curved part of the pelvic walls. Whence it is evident that the expulsion of the foetus in this case must be much more tedious and painful than in the others; however, we cannot admit that the delivery is absolutely impossible. M. Capuron, who still professes this latter belief, supposes (the occiput remaining posteriorly) that the labor can only take place when the foetal head is unusually small, or the pelvis very large; but this opinion is opposed at the present day by too great a number of facts, to require us to refute the theoretical proofs upon which he relies. There is yet another reason for the occipito-posterior positions being more diffi- cult than the anterior ones; a reason to which sufficient importance has not, in my estimation, been attached: I allude to the mode in which the uterine contrac- tions are transmitted. Observe, in fact, when the occiput is in front, that these are communicated to it by the spine, nearly in a direct line, whilst they only reach it when this part is posterior at the close of labor, by describing a well- marked curve, owing to the extreme flexion of the head on the chest. Hence, there would be, as everyone knows, a great loss of force; and observe further, that such loss coincides precisely with an occipito-posterior position, which, for the reasons before stated, occasions, of itself, still greater difficulties in the delivery. Now, to have demonstrated that the labor is longer and more difficult in those cases in which the occiput remains posteriorly, is, in effect, to prove that it was at the same time more dangerous both to the mother and child. In fact, it is in such instances, especially, that a rupture of the perineum is to be feared; it being very difficult indeed to prevent such an accident; it is then, also, those central lacerations of the perineum are apt to take place, in which the posterior commissure of the vulva and the sphincter ani remain intact, while the foetus forces a way for itself through the distended perineum. Such, indeed, is the effect of the length of the straight stem represented by the foetus, and of the length of the curve represented by the canal, that in order for expulsion to be effected, it becomes necessary either: 1. That the straight stem should break, or bend, so as to accommodate itself to the curvature of the canal, which is impossible; 2. That the curved canal should be straightened out; 3. That the walls of the canal should be ruptured; 4, or finally, that the deli- very should become impossible. MECHANISM OF LABOR. 419 Happily, in the majority of cases, the soft parts which form the continuation of the posterior wall, allow themselves to be straightened out; but when they resist, nothing but their rupture can allow of a spontaneous delivery, their con- siderable thickness affording the only explanation of the rarity of this accident.1 The head, by remaining a long time in the excavation, compresses the neigh- boring parts, thereby giving rise to retention of the urine, to eschars, and to urinary or stercoral fistulae. And apart from all these inconveniences, it is well known that the labor cannot be prolonged without danger; that the woman becomes fatigued and exhausted, and that the child remains compressed and painfully flexed. It has always seemed to me that in occipito-posterior positions, the left one is attended with much greater trouble than the right, the engagement of the head being generally more difficult, and its rotation much slower. Quite often, indeed, the occiput remains behind, preventing, in first labors, a spontaneous delivery, besides rendering much more difficult the application of the forceps, which then becomes necessary. Whenever a fcetal head is examined just after its delivery in a vertex position, there is always to be found a more or less considerable tumefaction on some point of the vertex, provided the labor has lasted long after the membranes were rup- tured; and the size of this tumor bears a direct proportion to the more or less rapid progress of the labor. Its seat is so constant that it is easy to determine in what position the child was born by a simple inspection. For instance, when the occiput escapes under the pubic arch, the tumor is always located on the superior posterior angle of one of the parietal bones, i. e., on the right parietal in the left occipito-iliac, and on the left one on the right occipito-iliac positions; and in those rare cases, where the occiput is disengaged posteriorly, it is usually situated about the centre of the vertex, often indeed on the anterior fontanelle; in a.word, it is mostly developed at the point which corresponded originally with the os uteri, and subsequently, with the void under the pubic arch. The mechanism of its production is very easily understood, for the whole circumference of the head is strongly compressed, leaving only a single point corresponding to the void in the pelvis or arch, which is not subjected to that pressure, and which must, therefore, become the seat of a sero-sanguinolent infiltration, just in the same way as the skin does, when, by the application of a cupping-glass and the creation of a vacuum, it is thereby protected from the atmospheric pressure that operates on every other part of the body. This tumor, when large, is the result of a slow and painful labor; it is al- ways single; and may be distinguished from the cephalasmatoma, with which it was for a long time confounded, by the following characters: the former (or the tumefaction caused by labor) is irregularly circumscribed, whilst the limits of the latter are very distinct; in the former, the hairy scalp is of a well-marked violet color, the tumefaction has an oedematous consistence, retaining the im- pression of the finger, and is not fluctuating, whilst the skin of the cephalsema- toma is colorless, presenting a well-marked fluctuation, occasionally even some 1 For an idea of the resistance sometimes presented by the perineum, see the article in the fifth part of the book on The Application of the Forceps in Occipito-posterior Positions. 420 LABOR. pulsations, and its base is limited by a prominent osseous border;1 in some in- stances, however, this border is not developed for several days after the com- mencement of the disease; but the pulsations and the border are never met with in the other variety. Lastly, the semi-sanguineous oedema of the cranium in new-born children ap- pears immediately after birth, and disappears in from twelve to forty-eight hours; but the cephalaematoma, on the contrary, though it may exist at the moment of birth, scarcely ever appears until some hours after the delivery, and then lasts for several weeks. Dr. Fortin relates that he was able, in one instance, to detect the presence of a cephalaematoma as large as a pigeon's egg, before the labor was terminated; and a similar statement has been made by several authors. The sanguineous tumor just spoken of does not exist when the foetus dies prior to or during the labor, and before the membranes are ruptured; the infer- ences which the medical jurist can draw from this fact, in cases where it is de- sirable to fix the period of death of a new-born child, are clearly obvious. ARTICLE III. ON THE PRESENTATION OF THE FACE. It may happen when the cephalic extremity presents at the superior strait, that the head is not only extended, but also turned back towards the posterior plane of the child, which situation constitutes a face presentation. This presentation is very rare; thus, it has been ascertained, from the most numerous statistics, that the foetus presents by the face, on an average, once in two hundred and fifty to three hundred labors. We have admitted two fundamental positions for this presentation; in one of which, the chin looked towards some point on the right lateral half of the pelvis, the right mento-iliac; and in the other, it was directed to one of the points on the left lateral half, the left mento-iliac position; and we may repeat for the face what was said concerning the vertex presentations, namely, that there is no por- tion of the circumference of the superior strait with which the chin may not be in relation at the commencement of the labor; nevertheless, we shall include all these shades of position in the three principal varieties for each side; that is, for each fundamental one, we have the anterior, the transverse, and the poste- rior varieties. The right mento-iliac positions are somewhat more frequent than the left; about in the • proportion of thirty-one to forty-one, if we may judge from the statements of Madame Lachapelle. The transverse variety is rather more fre- quent than the right posterior one, which has been considered erroneously as the most common. The face presentations are either classed as primitive or secondary, according to whether they existed before the commencement of labor, or were the result of ill-directed contractions. In fact, the latter have generally been considered 1 This border is not always present at the beginning of the disease, sometimes not making its appearance until after several days. MECHANISM OF LABOR. 421 as the more frequent of the two; but we shall have occasion to show the value of this supposition hereafter. § 1. Causes. The obliquity of the womb, according to most authors, is the cause of face presentations, though all of them do not interpret its influence in the same man- ner. According to Deventer, if the womb be inclined to the right side, and the vertex be placed in the left occipito-iliac position, the contractions, taking place in the direction of the uterine axis after the membranes are ruptured, will force the fcetus from above downwards, and from right to left, so that the vertex will strike against the left border of the superior strait, and the head, being thus arrested, will be thrown back upon the posterior plane of the child. Bau- delocque, though admitting the right uterine obliquity, supposes that a right occipito-iliac position of the vertex exists at the same time; for, says he, a face presentation is scarcely ever observed, without the obliquity of the womb being on the side which corresponds to the occiput. In this instance, the foetus is lying on the right lateral wall of the womb before the labor sets in, and the head, obedient to its own specific weight, departs slightly from the chest; but when the contractions manifest themselves after the rupture of the membranes and the discharge of the waters, the direction of the forces transmitted to the head is such that, instead of falling on the occiput, as they would were the head flexed, they are spent on the forehead, and tend to force it down; but a depres- sion of the latter compels the occiput to ascend: that is, causes an extension of the head. The reader will perceive that all these explanations suppose that the face pre- sentations are uniformly the consequence of deviations from a vertex position; but this, however, is not always the case, for the face may often present directly at the superior strait, even before the commencement of the labor or the rupture of the amniotic sac. For instance, Madame Lachapelle, when making an autop- sical examination of two women who died at full term, found the foetus present- ing by the face; moreover, of the eighty-five face presentations collected by the authors of the Dictionnaire de Medecine, forty-nine had been clearly made out, and announced as such before the membranes were ruptured; and further, of those eighty-five women, there were but three in whom the uterus was in a state of well-marked obliquity, and only one where the quantity of the amniotic liquid was so great as to attract attention. Whence the conclusion is evident from these and many other facts, that the face presentations, in the great majority of cases, are not determined by a previous inclination of the foetus, nor by a wrong direction of the uterine contractions, but that they are primitive^and produced by causes which are beyond our knowledge. The reason for the greater frequency of the right mento-iliac position must evidently be owing, when secondary, to the greater frequency of the right lateral obliquity that produces it. There are several causes, according to Madame Lachapelle, which contribute to render the transverse positions more common than the others: as 1, the form of the superior strait and the length of its diameters,'which correspond better in this -direction with those of the face; 2, the frequency of oblique or transverse positions, which, when the head falls back, 422 LABOR. evidently give rise to transverse positions of the face; 3, the frequency of lateral obliquities of the uterus, or partial ones of the child, if, as Gardieu admits, the fcetus can be oblique independently of the womb. § 2. Diagnosis. The diagnosis of face presentations is made out more or less easily, according to the period of labor at which the examination is made. Before the membranes are ruptured, the head in general is high, and difficult of access, so that it is almost impossible to reach the presenting portion, provided the membranes are the least tense. Again, the reversion of the head not being yet completed, the forehead is the lowest part, and the one the finger encounters in performing the touch; whence, by feeling a hard, rounded body furrowed by a membranous interval (the coronal suture), we might very readily mistake it for a vertex pre- sentation. But if the flaccid and folded membranes can be depressed without difficulty, or, still better, if they have been recently ruptured, the diagnosis be- comes easier. Then we find towards one side of the pelvis a rounded, solid sur- face, the forehead, traversed by a suture leading to a transverse depression ; next a triangular elevation whose base, looking in an opposite direction from the fore- head, exhibits two openings, the nares, and beyond this, a transverse fissure bounded by the superior and inferior maxillary arches. Sometimes, the finger, when introduced into the mouth of the child, has been clearly sensible of an effort at suction. On the sides of the median protuberance, two little soft tumors (the eyes) are felt, surrounded by an osseous circle; and lastly, when the head is low down, an ear may be detected behind the pubis. When the presentation is once determined, the position is easily made out, for the opening of the nostrils must evidently look towards that part of the pelvis which corresponds with the chin. When a long time has elapsed after the rupture of the membranes, new causes of difficulty are met with. Thus, the face, which now corresponds to the open space in the pelvis, becomes the seat of a considerable tumefaction, due to the same cause which produces the tumor of the scalp in vertex presentations. The cheeks, being greatly swollen, and at the same time compressed on the sides, project, and lie close to each other in front, thus leaving a deep fissure between them, in the bottom of which the distinctive characters of the face are entirely concealed; this fissure might very readily be mistaken for the one between the nates, which are then confounded with the tumefied cheeks. Further, the lips are also swelled, wrinkled, and everted, in such a manner as to offer a rounded orifice instead of the usual transverse fissure, and this orifice has been mistaken, in some instances, for the anus; hence, in such cases, a careful examination seems to be necessary to avoid an error which, according to authors, has not un- frequently been committed. § 3. Mechanism. As those varieties, in which the chin looks towards one extremity of the trans- verse diameter, are found to be the most frequent of all, we shall follow the example of Naegele, Dubois, and Lachapelle, by taking one of them as the type in our description of the mechanism of natural labor by the face, and shall com- mence with the right mento-iliac, as being the more common of the two. MECHANISM OF LABOR. 423 1. Mechanism of Natural Labor in the right Transverse Mento-iliac Position. Before the membranes are ruptured, the head, as a general rule, is but mode- rately extended, whence the forehead is nearly always placed at the centre of the superior strait; the chin corresponding to the right, and the bregma to the left extremity of the transverse diameter. The diameters of the head hold the fol- lowing relations to those of the pelvis: the mento-bregmatic corresponds to the transverse diameter of the pelvis; the bi-temporal to the antero-posterior one, and the mento-bregmatic circumference is parallel to the periphery of the supe- rior strait; and, therefore, the pelvic axis traverses the head in the direction of the occipito-frontal diameter. The posterior plane of the fcetus looks directly to the mother's left, and its anterior plane to her right; its right side is in front, and the left one behind. Early in the labor, the bag of waters projects into the upper part of the exca- vation, to an extent proportionate to the dilatation of the orifice; and its rupture generally takes place suddenly during a contraction, with considerable noise. The rupture is followed by the escape of a large amount of amniotic fluid, and the fcetus, which was before so high as to be felt with great difficulty, descends, and renders the diagnosis more easy. As soon as the membranes are ruptured, the mechanism of the expulsion begins, and here, as in the case of the vertex, it is composed of five stages : /. e., the forced extension, the descent, the rotation, the flexion or disengagement, and the external rotation; these comprise the movements which the head under- goes in face positions. A. Forced Extension.—The head being already moderately extended on the' back, its extension will be completed during the first uterine contractions that take place after the discharge of the waters, owing to the resistance it will then meet with. This forced extension of the head changes but very little the rela- tions of its diameters to those of the pelvis (Fig. 70); for instance, the fronto- Fig. TO. Fig- ?!■ Fig. 70. The face in the right transverse mento-iliac position, after the forced extension. Fig. 71. The face in the same position, though more fully engaged. mental has taken the place of the mento-bregmatic, and is now parallel to the transverse diameter of the strait; the bi-temporal has not changed at all; the 424 LABOR. facial, or fronto-mental circumference, corresponds with the periphery of the superior strait,1 and the pelvic axis traverses the head in the direction of a line passing from the posterior fontanelle to the child's upper lip. b. Descent.—As soon as the head is freely extended, it engages in the exca- vation, and descends as far as the length of the neck will permit. This last sentence requires a short explanation. In the vertex positions, we have already seen that the head descended to the floor of the pelvis in such a way as to tra- verse all the space between the superior and inferior straits, without changing its position. But in the transverse position before us, it is clearly evident that the face can only reach the pelvic floor under one of the following conditions: that is, either the chest will engage along with the head in the excavation, or else it will remain above the superior strait; the face descending alone as far as the inferior one; that is to say, the forehead reaching the level of the left, and the chin that of the right tuber ischii; but then the neck must necessarily elon- gate enough to measure the whole length of the pelvis at its lateral portion, which is three inches and three-quarters. But as neither of these two conditions can be realized, the head will not be able to reach the pelvic floor; and it is for this reason that we say the face only descends as far as the length of the neck will permit; whereby the descent is interrupted. c. Rotation.—The head then undergoes a movement of rotation, during which the chin rolls from right to left, so as to get behind the symphysis pubis, while the forehead rotates from left to right, and from before backwards, in order to place itself in the concavity of the sacrum. When this movement is effected, the descent becomes completed; for the shortness of the neck, or the too great extent of the ischium, formed heretofore the sole obstacle; if, therefore, by the process of rotation, the neck, which can be no further stretched, is brought into apposition with a part of the pelvic wall short enough for it to span its whole length, the descent may evidently be completed : that is, the breast still remain- ing above the superior strait, the chin may descend as low as the inferior one, and this is precisely what does take place; for, as the trunk participates in the rotation of the head, the neck gets behind the symphysis pubis at the same time that the chin reaches the lower edge of this symphysis, which is short enough to allow the neck to subtend its whole length. D. Flexion.—The process of flexion begins as soon as the descent is achieved; indeed, we may remark that, when the chin passes behind the symphysis pubis, the forehead goes into the hollow of the sacrum, and it therefore has to traverse, in order to arrive at the inferior strait simultaneously with the chin, the whole anterior face of the sacrum, that is, about five and a quarter inches, whilst the chin only descends the length of the symphysis, or one and a half inches; in a word, this is found just in the same condition as the posterior extremity of the bi-parietal diameter in vertex presentations; and, like it, the forehead has to describe an arc of a circle around the chin as a centre. Now, this arc cannot be described without a certain degree of flexion of the head. Whence it appears 1 M. Na?gele further supposes that the face is inclined relatively to the superior strait, and that the anterior cheek is the most dependent part, &c. The reasons upon which our objections were founded to such an inclination in the vertex presentations, oblige us also to reject it in the positions of the face, for we believe that the facial circumference is most usually parallel to the plane, as stated in the text. MECHANISM OF LABOR. 425 that, in this transverse position of the face, the descent is completed at the same time that the rotation is taking place, and the process of flexion beginning. If the relations of the diameters of the head to the inferior strait be then ex- amined, we shall find that the same ones are concerned as at the beginning of the labor, before the complete extension had occurred; thus, the mento-bregmatic corresponds to the antero-posterior diameter, the bi-temporal to the transverse, and'the axis of this strait passes through the occipito-frontal diameter; and thus it should be; since, by the commencement of flexion, the head is replaced in the state of semi-extension it had when the labor began. The chin, under the influence of the uterine contractions, next engages beneath, and continues passing under the inferior part of the symphysis, until the forepart of the neck, by coming into apposition with the posterior surface of the pubis, has its forward progression arrested; but, from that time forth, the expulsive force is exerted on the other extremity of the occipito-mental diameter, owing to its action on the chin being destroyed by this resistance; the occiput is pushed down, and the head thereby compelled to complete its flexion or dis- engagement. Of course, the perineum becomes greatly distended, and the fore- head, the bregma, the vertex, and the occiput, successively appear before its anterior commissure. During the process of flexion, the head resembles a lever of the third kind, the fulcrum being at the prse-tracheloid region, placed directly under the symphysis pubis, the power at the occipital foramen, and the Fig. 72. resistance at the occiput; wherefore, pending this movement, the prae-trachelo-frontal, the prae-tra- chelo-bregmatic, and the prae-trachelo-occipital diameters, clear in turn the antero-posterior one of the inferior strait. E. Restitution.—This differs in nowise from the external rotation described by the head in the vertex presentations; for here, also, it is a conse- quence of the movement executed by the shoulders, in order to place themselves in the direction of the antero-posterior diameter of the strait. In addition to the above, the mechanism of face labors sometimes presents a variety, which we pur- r . , i Various degrees of the disengagement posely omitted for fear of interrupting the regular of the head (in the same position), the description ; thus, we Stated, that the head Com- occiput departing more and more from pleted its extension and descended, but that this movement of descent was interrupted by the rotation; after which the descent was completed, and at the same time the flexion begun. Now all the difference rests on this last point; for in practice a considerable number of cases, more par- ticularly of the mento-posterior positions, are met with, in which the following phenomena are observed : the second movement, or the descent, actually com- mences, but is checked by the shortness of the child's neck. Then a certain degree of flexion takes place before the rotation occurs, in consequence of which the forehead descends to the pelvic floor, and the mento-bregmatic diameter places itself anew parallel to the transverse diameter of the excavation ; then the 426 LABOR. process of rotation occurs, which carries the chin behind the symphysis, and the labor terminates in the manner just indicated. 2. Mechanism of Natural Labor in the left Transverse Mento-iliac Position. In this position, the expulsion of the foetus takes place in absolutely the same manner as in the preceding case. Only the chin, as well as the anterior plane of the child, is to the left; and hence the movement of rotation occurs from left to right instead of right to left, but all the rest is precisely similar. The same is also true of the two varieties denominated the right and the left anterior mento-iliac positions. The two other varieties (the right posterior, and the left posterior mento-sacro-iliac) exhibit an identity of mechanism in a vast majority of cases : that is to say, the head, having reached a certain depth in the excavation, then undergoes the process of rotation, which converts the posi- tion into a mento-pubic one; indeed, the necessity for this movement is far more evident here than in the mento-transverse positions, since the depth of the pelvis is much greater behind than on the sides. It may, therefore, be laid down as a general, nay, as an almost absolute rule, that, in the face positions, whatever may have been the relations of the chin with the circumference of the superior strait at the commencement of the labor, there must be a process of rotation, whereby the chin is brought under the sym- physis pubis, before the labor can terminate spontaneously. The necessity for this rotary movement may be readily understood. In order that delivery may be accomplished with the face presenting, it is absolutely necessary that the chin should reach the inferior strait; now, in the extended condition of the head, the chin cannot reach this strait, except the neck be capable of measuring the depth of that portion of the wall of the pelvis to which it corresponds. If, therefore, the symphysis pubis be the only part of the pelvis which is short enough to allow the neck to measure its depth, it becomes indispensable that the chin should be turned forward. In the numerous varieties of this position before admitted, the mechanism of the labor only differs in the greater or the less extent of the process of rotation; an extent evidently varying according to the point with which the chin was primitively in relation to the upper strait. Remarks.—Nevertheless, the mechanism of the face positions occasionally offers some anomalies, that require a more special notice. 1. The rotation just described, whose object is to bring the chin constantly towards the symphysis pubis, and which has been spoken of as absolutely essential to the spontaneous termination of the labor, may not be executed. But such very rare exceptions do not in the least discredit the general principle before laid down, for they may all be referred to those instances where the dimensions of the head are small relatively to those of the pelvis; or else to those cases in which the position of the face has been spontaneously converted into one of the vertex. True, Madame Lachapelle has known the face to escape from the vulva in a transverse direction, or nearly so, in two or three instances; but she carefully adds that they were very rare exceptions. Now, to understand this movement of rotation, it is only necessary to recall our remarks concerning the mechanism of labor; thus, it has been shown that the descent could not be completed in the transverse positions, until the chin MECHANISM OF LABOR. 427 has turned towards the pubic symphysis; and further, that when the head is extended, the resultant of the forces transmitted by the spine falls very nearly on the chin, and tends to engage it still more. Well, in this situation, the ex- pulsive force is either perpendicular or oblique to the plane of the resistance; if the former, the uterine efforts are lost, since they do not contribute in any wise to the progress of the labor; but, if the force is oblique to the resistance, it is so either from before backwards, or from behind forwards. In the former case, it will have a tendency to carry the chin backwards; but a movement of this kind will not aid in the engagement of the chin, since the pelvic wall is much higher nearer the median line; and hence the efforts are still lost. In the latter, on the contrary, the oblique force, by operating from behind for- wards, tends to carry the chin in front: that is, towards a portion of the pelvic wall, which becomes shorter and shorter as it advances anteriorly, and thus faci- litates the descent. But, after all, what is the direction of the uterine force ? Everybody knows that it changes at each instant; according to the woman's position, or the power of the contractions, the womb may be successively found in all three of the direc- tions above indicated, relatively to the resistant plane. If it is perpendicular to that plane, the efforts are lost; or, if oblique, from before backwards, the con- tractions are useless; they can only be fully efficacious when acting on the chin from above downwards, and from behind forwards. But far be it from me to attribute an intelligent force to the uterus; for it is only by groping along, so to speak, that the womb finally acquires a proper direction, though, when the im- pulsion is once given, the force becomes more and more oblique, and consequently more active. And it is those gropings (excuse the term) which at times render the rotation so difficult and so tedious. It has been asserted, of late, that the process of rotation is quite as easy in the mento-posterior as in the mento-anterior positions. Now, if I have succeeded in making my views of the cause and mechanism of this movement understood, the reader will readily comprehend that, in proportion as the chin is turned backward, and more especially if towards the right at the same time, the greater will be the difficulty of its accomplishment. 2. As regards those varieties in which the chin looks backwards, we have already stated that it is necessary this part should come round in front, though some cases of mento-posterior positions, that terminated spontaneously, are found in the books, where the chin did not get under the pubic arch; writers differ in their explanations of this anomaly. M. Velpeau takes as an illustration the mento-sacral variety, or the second position of Baudelocque, in which the chin is turned toward the anterior face of the sacrum (though we may observe, in passing, that this position is scarcely admissible); and he remarks that, as the chin does not rotate in front, the following phenomena may then take place: the forehead engages behind the body or the symphysis of the pubis, while at the same time the chin gets below the sacro-vertebral angle. The whole head de- scends into the excavation beyond the anterior fontanelle for the anterior plane, and the face drags after it the front surface of the neck, and even the upper part of the chest behind. The occipito-mental diameter, which still represents the axis of the strait very nearly, now begins to perform a see-saw movement from 428 LABOR. above downwards, and from behind forwards. The chin, penetrating further and further towards the bottom of the excavation, though at the same time retained by the thorax, which cannot advance, forces the sagittal suture to slip down behind the pubis, and the forehead to gain the upper part of the inferior strait. The frontal protuberances soon find a point of resistance on the perineum, and the posterior fontanelle descends in turn, and ultimately appears at the summit of the arch, when the head finally escapes from the vulva as it would in an occipito-anterior position; whence it follows, adds M. Velpeau, that the occipito- frontal is the greatest diameter which can present at the planes of the straits. But we cannot admit the truth of this last proposition; for if, as he says, the chin is in relation with the anterior surface of the sacrum, and it descends more and more, while the occiput slips behind the pubis, it is evident that the occipito- mental diameter must, at a given moment, traverse the antero-posterior one of the excavation. Now, as this is clearly impossible, we have to reject M. Velpeau's explanation altogether. Besides, the cases observed by Smellie and Delamotte, which he cites in support of his theory, prove nothing at all; for, in both of those instances, the foetuses were small and dead, and the women had, on former occasions, been delivered of voluminous children. M. Guillemot has explained the spontaneous termination of the labor in these cases somewhat differently; for when the chin does not rotate in front, the labor, according to his idea, may terminate in two ways, namely: lst. The forehead continues to descend and to engage under the branch of the pubis until the anterior fontanelle appears at the vulva, which progression permits the chin to advance forward and reach the border of the perineum; then the process of flexion commences, &c. But we cannot conceive how, in the forced extension of the head on the thorax, it is possible for the chin to arrive at the anterior perineal commissure by traversing the whole posterior plane of the excavation, because, from all evidence, the breast must engage extensively along with the head, which is wholly impossible, unless it be a case of abortion. 2d. The labor by the face may be converted into one by the vertex; and this always takes place, he continues, in the following manner: the face being forcibly pressed on, and unable to escape through the perineal strait, has a natural ten- dency to pass towards those points that offer the least resistance. Here, this condition is found above and behind, whence the chin leaves the perineum and approaches the fcetal chest by ascending along the hollow of the sacrum towards the sacro-vertebral angle, and the forehead following this movement corresponds to the sacrum in turn; the vertex is depressed and slips behind the pubis, and, just at the moment when the chin applies itself to the child's breast, the occiput engages under the pubic arch. He further supposes the face to be sufficiently engaged for the chin to come in contact with the perineum; but, as we have already stated, this is impossible, on account of the extent of the conjoint diameters of the head and breast, both of which would be deeply engaged in the excavation. But, even admitting the chin should descend so low, where is the power to make it subsequently rise up in the hollow of the sacrum, the cavity of which is occupied, whatever M. Guillemot may say to the contrary, by the deeply-engaged breast? For the uterine contraction, which is always transmitted by the spine, MECHANISM OF LABOR. 429 acts at first on the chin as a consequence of the reverted position of the head (as M. Velpeau clearly recognized), and it is only because its power is inadequate to make the latter descend any further, that its action is transferred to the other extremity of the fronto-mental diameter, that is, to the forehead, which it then depresses, according to the theory of Guillemot. Again, even supposing that the chin may remount, it is scarcely possible to believe that it gets above the sacro-vertebral angle; it must therefore constantly remain in contact with the anterior surface of the sacrum; and, consequently, at a given moment, the occi- pito-mental diameter must traverse the antero-posterior one of the excavation. In my estimation, therefore, we are not to understand this as the true mode by which the mento-posterior positions of the face are converted into occipito- pubic ones; indeed, among all the cases I have been able to consult, I have only found three in which the chin was in direct relation with the anterior face of the sacrum, viz., those of Smellie, Delamotte, and Meza (reported by Guillemot). Now, in the one furnished by Smellie, it is positively stated that the child was small, that the woman had a large pelvis, and that she was usually delivered very promptly; Delamotte says nothing about the head and the dimensions of the pelvis, in his case; and, lastly, Meza was obliged to apply the forceps, in the one reported by him; so, of course, that was no longer a spontaneous termina- tion, for it would be an easy matter to demonstrate that the application of the forceps may act in an altogether different manner, and even more advantageously, than the uterine contraction in this instance; besides, the reader will not forget that, in the first two cases, the children came away dead. All the other observations may be referred either to the right or the left mento- sacro-iliac positions; and, in these latter, it appears to me that a spontaneous ter- mination of the labor might occur without a simultaneous engagement of the chest and head; for instance, let us suppose that the child is in a right mento- sacro-iliac position; then, after the complete extension of the head, the face will descend into the excavation as far as the length of the neck permits, and conse- quently the chin will reach the level of the great sciatic notch, the more so, as the form of this portion of the ilium, which is shaped like a cone, will favor the movement of downward progression. Having arrived at this notch, the chin will there encounter soft parts, which it can very readily depress, and this depression will be quite sufficient to augment the length of the oblique diameter of the excavation from a quarter to half an inch, thereby permitting the occipito-mental diameter to clear it, and the head to undergo the process'of flexion, that will gradually bring the occiput under the pubic symphysis. § 4. Inclined or Irregular Face Presentations. The face does not always present so regularly at the superior strait, as to have its fronto-mental circumference parallel to the opening in the pelvis, since the same causes that determine the inclination in vertex presentations, may also render those of the face irregular; and here, likewise, we may invoke the uterine obliquities, the partial obliquity of the child, or an incomplete or an exaggerated extension of its head, to explain how we sometimes find one of the cheeks, and at others the forehead or the chin, at the centre of the upper strait. But still, these are not to be considered as distinct presentations, but rather as 430 LABOR. varieties or shades of the face presentations, which scarcely ever render the labor more difficult. In fact, the following is the only modification they are likely to cause in the mechanism of parturition; in the malar positions of Baudelocque, or those inclined towards the side,' where one cheek is at the centre, the head undergoes a movement of correction whilst engaging, similar to what it does in the parietal inclinations of the vertex, whereby the face gradually regains its normal horizontal direction. In the so-called presentations of the forehead or chin, the most elevated part becomes depressed, and ultimately gains the same level as the other. § 5. Prognosis. It was for a long time thought, and still is, by some persons, that a delivery by the face cannot take place by the powers of nature alone, and it is only since the labors of Boer, of Chevreul, and of Madame Lachapelle, that the expulsion of the child in the- face positions has been admitted to be spontaneous nearly as often as it is in the vertex positions. Nevertheless, we must remark that, as a general rule, the labor is more tedious, more painful, and more dangerous, both to the mother and the child, and that it much oftener demands the intervention of art. Besides, the reflections above presented would naturally lead us to anticipate that the mento-posterior positions are much more unfavorable than the anterior ones. Now, this unusual delay is not because the greatest diameters of the head then present to those of the pelvis, as Capuron and many others supposed; for it is only necessary to bear in mind the relations before indicated, to understand that it is the mento-bregmatic, and the bi-temporal diameters (the one three inches, and the other three inches aud three-quarters in length), which are then found to correspond with the diameters of the straits; but because the dilatation of the os uteri takes place more slowly, and because the expulsive forces, especially in the process of flexion and of dis- engagement, act, like the arm of a lever which is bent, nearly at a right angle. Moreover, it has already been stated that, in all other than vertex positions, a very large quantity of the amniotic liquid usually existed between the presenting part and the inferior segment of the uterus. We have also remarked (see the Physiological Phenomena of Labor), that this circumstance singularly influenced the rapidity of the dilatation of the os uteri. On the other hand, it is also evi- dent that, when the chin is actually engaged under the symphysis, and the pro- cess of flexion has already commenced, the force of the contraction transmitted through the spine can only determine the successive disengagement of the fore- head, the bregma, and the occiput, by describing a well-marked flexure, and, consequently, thereby losing a large proportion of its force.1 1 This is so true, that, during the process of extension, the uterine contraction is not transmitted by the spine alone; for I believe that, in certain cases at least, the thorax, by being subjected to forcible pressure, and therefore flexed on itself, just above the head, rests by its posterior-superior part directly upon the occiput, and hence may immediately transmit the uterine force to the latter, as I believe occurred in the following case. In August, 1839, I was summoned to a grocer's wife, in the Rue du Bac, in whom the child presented in the left transverse mento-iliac position ; the membranes had been ruptured at eight o'clock in the morning; it was then five in the afternoon, and an application of MECHANISM OF LABOR. 431 Certain authors, says Gardien, have incorrectly supposed that those labors in which the child presents by the forehead are more unfavorable than those where it offers by the face; for, if attention be directed to this point, the head will then be found to present in reality by its favorable diameters; and, further, as M. Stoltz remarks, in the face positions, the forehead is already the lowest part, and, the more it descends when the head engages, the more easy will be the labor. Again, the chin presentations are less favorable than those of the forehead, because the child's head is then in the most perfect state of reversion, and, if the shoulders engage at the same time with the vertical diameter of the cranium, a wedging in must inevitably take place in the excavation. But even these, also, soon transform themselves into true face presentations. As regards the fcetus, the labor, if tedious, may prove very disastrous; since apoplexy, or at least a cerebral plethora, and a disposition to convulsions, are but too often, says Madame Lachapelle, its unfortunate result. The repeated and prolonged compression of the child's neck, a compression which occurs just at the moment when the head is clearing the cervix uteri, or the superior strait, or, still more probably, when the front of the neck is placed under the symphysis pubis, satisfactorily accounts for the difficulty in the return of the venous blood, and the cerebral congestion which it occasions. Consequently, a particular attention should be given to the constrained position; for a case that might be abandoned to nature, were the mother alone regarded, would require the inter- vention of our art, to relieve the fcetus from its painful situation. In cases of this kind, where the face had descended enough to be in full view at the vulva, Madame Lachapelle was in the habit of judging by the movements of the infant's tongue and lips; though it must not be forgotten that these motions are not con- stant; but, when they do exist, and are found to grow weaker, and finally to dis- appear, they constitute a bad sign, and claim our immediate attention. Further- more, the child often exhibits certain peculiarities in face deliveries, which ought to be known, in order that the family may be advised of them beforehand. The face corresponds to the open space in the excavation, as also for a long time to the void under the pubic arch; and hence, it becomes affected with the ecchymosis and the sero-sanguineous infiltration before spoken of as happening in vertex presentations. Consequently, when the labor has been somewhat tedious, the infant's face at birth is nearly black, its cheeks swollen, its lips turned in, and the nose scarcely visible, and nothing frightens the parents so much as such an object, if they are not previously advised of the possibility of such an occurrence. However, this condition is generally dissipated in the course of a few days, and its resolution may be hastened by lotions composed of a little wine, or vegeto- mineral water, or brandy, freely diluted with water. No alarm need be felt about the tendency observed in the head to fall backwards, as soon as the support is withdrawn; for, it only regains the attitude it had temporarily in the pelvis. This feebleness of the muscles of the neck is evidently due to the prolonged the forceps had already been attempted. However, in about three-quarters of an hour after my arrival, the labor terminated spontaneously. The infant soon revived ; but, in examining its head, I detected, near the posterior fontanelle, what appeared to be small splinters of bone, which crepitated under the finger, and there were also evident traces of a considerable depression on its dorsal region. 432 LABOR. extension they have undergone, and which has momentarily paralyzed a part of their contractile force : it ordinarily disappears in the course of two or three days. ARTICLE IV. PRESENTATION OF THE PELVIC EXTREMITY. We have already had occasion to state that most accoucheurs describe three distinct presentations of the pelvic extremity of the foetus, to wit, the presenta- tions of the breech, of the feet, and of the knees, according as the breech, the feet, or the knees, are the first to engage in the excavation and clear the external parts of generation. We have also explained why (following the example of Madame Lachapelle, Ant. Dubois, P. Dubois, and others) we consider these three as being only slight modifications of the true pelvic presentation ; for modi- fications that do not in anywise change the mechanism of the natural labor ought certainly to be included under one and the same title. Thus, it may happen, in presentations of the pelvic extremity, that this extre- mity, composed of all its elements, that is to say, of the thighs flexed on the abdomen and the legs on the thighs, may engage in the excavation and inferior strait; or that the lower extremities, carried along when the membranes are ruptured, by the gush of the waters, may be completely or partially unfolded; the feet in the former case, and the knees in the latter, appearing first externally; or that, the inferior members being stretched out and applied to the child's anterior plane, the breech alone may descend;1 or, lastly, that one of the lower limbs may be extended up along the abdomen while the other remains down, and then one foot or one knee, as the case may be, will present at the vulva. We shall in- clude all these varieties under the general name of the presentation of the pelvic extremity; and we again repeat that, in the presentations of this extremity, the points of departure, taken on the foetus, are, the posterior face of the sacrum for the breech; the anterior face of the tibias for the knees; and the heels in the footling cases. With regard to the pelvis, the sacrum, or the back of the child, may be found in relation with any one of the various parts of its superior strait; but still, all these shades of position are included in two principal ones, namely, a first, or left sacro-iliac, and a second, or right sacro-iliac position; and, further, each of these exhibits its anterior, transverse, and posterior varieties. The presentations of the pelvic extremity are less frequent than those of the vertex, though much more common than those of the face. Thus, in thirty- seven thousand eight hundred and ninety-five labors, Madame Lachapelle has noted one thousand three hundred and ninety of this class; in twenty thousand five hundred and seventeen, Madame Boivin observed six hundred and eleven; and in two thousand and twenty, M. P. Dubois met with eighty-five. In order 1 This position of the lower extremities may be primitive ; that is, it may exist before the rupture of the membranes (indeed, according to M. P. Dubois, this most frequently occurs), or may be consecutive to the engagement of the breech. In this latter case, the feet may have been arrested either by the periphery of the cervix uteri, or by the superior strait at the time when the breech was passing into the excavation, and hence the inferior members would be necessarily pressed up along the child's anterior plane. MECHANISM OF LABOR. 433 to give an idea of the relative frequency of the cases in which the nates the knees, or the feet are first expelled, we will add that, in those eighty-five labors the nates appeared first at the vulva fifty-four times, and the feet twenty-six times. The presentation of the knees, so called, was not observed in a single instance. In fact, this is a very uncommon variety; for, in the thirty-seven thousand eight hundred and ninety-five cases of Madame Lachapelle, the knees came down first only eleven times, or one in three thousand four hundred and forty-five. In a sum total of sixteen thousand six hundred and fifty-four labors, Dr. Col- lins has observed the pelvic extremity to offer once in thirty times; and Rams- botham, Jr., from calculations founded on twenty-seven thousand seven hundred and thirty-nine labors, and twenty-eight thousand and forty-three births, occur- ring at the Maternity Hospital of London, has arrived at the conclusion that breech presentations are to the others as one to thirty-five.1 The left sacro-iliac positions are far more frequent than the right; thus, in thirteen hundred and ninety instances, the back looked towards the left side seven hundred and fifty- six times, and to the right, four hundred and ninety-four times; but thirteen times in front, and twenty-six times directly backwards (Lachapelle). In the eighty-five positions of M. P. Dubois, the back was forty-one times towards the mother's left, and forty-four to her right. As to the varieties exhibited by these two positions, the left anterior is a little more frequent than the right posterior one, but each of them is far more common than all the others put together. For instance, in one hundred and sixty-three pelvic presentations, says M. Naegele, the back was in front and to the left one hundred and twenty-one times, whilst it was only forty times behind and to the right. § 1. Causes. It is wholly impossible, in the present state of the science, to say why the breech should sometimes present at the superior strait; true, numerous explana- tions have been offered, and the following, proposed by Madame Lachapelle and reiterated by Velpeau, is perhaps the least objectionable of any. The child, they say, floats comparatively free in the uterus, until near the eighth month; then its head, during certain movements on the part of the mother, the act of lying down in particular, is carried towards the fundus uteri; and, if the infant has then acquired a considerable volume, perhaps its great occipito-coccygeal diameter cannot repass through the small diameters of the uterine ovoid, without undergoing as forcible a movement as that which changed its position; and if this latter does not occur, the foetus will retain its new attitude, and at the time of the labor the pelvic extremity will present at the passage. This explanation, I repeat, although liable to many objections, still appears the most probable. 1 By a table in the revised edition, Dr. Ramsbotham furnishes a record of 35,743 deliveries that occurred between January lst, 1828, and December 31st, 1843, in which there were 930 presentations of the breech, or lower extremities, thus showing the proportion to be 2-6 per cent., or 1 in 38-8.—Translator. 28 434 LABOR. § 2. Diagnosis. Even before the commencement of the labor, a breech presentation may be almost positively diagnosticated by the following signs, namely, in thin women, in whom the abdomen, from being previously distended by numerous pregnan- cies, retains a certain degree of softness and flaccidity (and the womb containing only a moderate quantity of liquid), we may more or less readily detect the head occupying the upper part of the uterus, and inclined towards one or the other side. No part, however, can be made out by the internal exploration, since the hard, rounded tumor felt in the vertex presentations is always absent. Some- times, as has often happened to myself, a little tumor (the foot, or a knee) can be detected and balloted ; and, further, the heart's movements are revealed by auscultation at an elevated point of the abdomen, on a level with, or possibly above, the umbilicus. The shape of the distended uterus differs in no respect from that which it has in vertex positions, though in some cases it is rather more oval. To the foregoing signs may be added the following as distinguishable during labor. The bag of waters is very large, and projects considerably into the upper part of the vagina; sometimes assuming the form of an elongated tumor,1 which may descend, even to within a short distance of the vulva. When the membranes are ruptured, a very considerable quantity of water escapes, for the presenting part fills up the neck but very imperfectly, and hence, all the amniotic liquid flows out; and if the rupture should occur during a strong pain, it would probably be accompanied by a loud report. Stein described the uterine orifice as being oval after the rupture, and Madame Lachapelle confirmed this sign; but I must confess that I have found great diffi- culty in verifying it. A momentary suspension or a diminution of the pains often results from a too copious or a too rapid discharge of the waters; and, further, a flow of meconium most generally takes place soon after the membranes give way.3 But the only characteristic signs are those furnished by the touch; and they will vary with the presenting part. Therefore, although we have included, so far as the mechanism is concerned, all the cases in which either the nates, the feet, or the knees present, under one general term; yet, in the diagnosis, we must carefully distinguish them from each other. 1. When the breech alone presents, the finger first encounters a soft, rounded tumor, upon some portion of whose anterior surface a hard, resistant part, formed 1 Certain writers have evidently been in error in giving this particular form of the am- niotic sac as a positive sign of a presentation of the pelvic extremity, since it may be met with iu other cases. I have twice observed it myself in clear vertex presentations that were engaged, even then, as far as the middle of the excavation. I can only explain this last circumstance by supposing an extreme laxity of the membranes. 2 However, a discharge of meconium may take place in other than pelvic presentations ; but then it is an alarming sign, and one that should receive the accoucheur's immediate attention. In fact, it always indicates the death, or at least a suffering condition, of the child; and, therefore, will most generally require the intervention of art, since it is par- ticularly apt to come on when the labor has continued a long time after the rupture, and the fcetus is suffering from the protracted delay; or possibly it may announce the com- pression of the umbilical cord (see Prolapsus of the Cord). MECHANISM OF LABOR. 435 by the great trochanter of the thigh bone, is detected. Thus far, it might be mistaken for a vertex presentation; but if the finger be next carried upwards and backwards, so as to reach, as it were, the sagittal suture, it will penetrate into the fissure between the nates, at the bottom of which the most important diagnostic signs are discovered; for the point of the coccyx is felt towards one side, surmounted by an irregular osseous surface, constituted by the posterior face of the sacrum; then the anus, a small, rounded, and wrinkled orifice, into which the finger cannot be introduced without resorting to considerable force, whatever authors may say to the contrary; lastly, the external genital organs can be easily distinguished, and thereby the sex of the child may be announced in advance.1 The prominence of the coccyx is not only a certain sign of the presentation, but it may also serve to determine the position; because its point is always di- rected towards the side not corresponding with the child's back. 2. Where the two feet present together in the vagina, it is impossible to con- found them with any other part, and the direction of the heels then clearly indi- cates the child's position. But where a single foot only is detected, and that very high up, it might be mistaken for a hand. However, a little attention will serve to distinguish them; thus the toes are arranged in the same line, are shorter, and less movable; while the fingers are longer and the thumb separated from the others; the internal border of the foot is much thicker than the exter- nal; but the two margins of the haud are very nearly of the same thickness; again, the foot articulates with the leg at a right angle, while the hand continues • out the line of the arm. The diagnosis is very difficult when the feet present along with the nates, and they alone are accessible. Sometimes even only one foot can be felt, which ren- ders the case still more obscure; then we have first to ascertain which is the foot touched; though, for that purpose, it is only necessary to pay attention to the relation existing between its internal border and the heel. For instance, let us suppose that the latter is turned towards the symphysis pubis, and its internal border to the right side of the mother; this is evidently the right foot; if, on the contrary, the heel be directed towards the sacro-vertebral angle, and the in- ternal border to the right, this would be the left foot, &c.; now, the right foot being once distinguished from the left, it only remains to determine towards what part of the superior strait the points of the toes are directed (bearing in mind that we always suppose the inferior extremities to be flexed on the abdomen, and the feet crossed and turned inward). In this position of the child, if the toes of the right foot are turned towards any point of the anterior half of the pelvis, the back will be directed to some part of the left lateral half; but if the 1 The accoucheur ought to be exceedingly careful not to deceive himself on this point; and, in case of any doubt, it would be much better to abstain from all predictions, than to expose himself to an error that would most certainly be retorted upon him afterwards. It is also prudent, where the child is ascertained, by the touch, to be of a sex different from what the family, and more especially from what the mother desires, not to commu- nicate the result of his diagnosis, lest the disappointment she would experience might, like any other acute moral emotion, exercise an unfavorable influence over the progress of her labor. 436 LABOR. toes on the left foot point towards the anterior half of the pelvis, the child's back will look to some point on the right lateral half, and vice versa. 3. The knees very rarely present first; besides, they have such well-marked characteristics in their form, their roundness, their hardness, the size of the limbs attached, and the fold of the ham which surmounts them, a fold present- ing a transverse concavity instead of the convexity exhibited at the elbow and instep, that we consider it useless to dilate further upon their diagnosis. § 3. Mechanism. As the left anterior and the right posterior are the most frequent of the three varieties admitted for both the left and the right sacro-iliac positions, we shall select them as the type of our description. 1. Mechanism of Natural Labor in the Left Anterior Sacro-iliac Position. (The first, of authors.) Before the rupture of the membranes, all the parts of the child are folded up along its anterior plane; the head is slightly flexed on the chest, the arms are applied to the sides of the thorax, the forearms are bent on the breast, and the inferior members flexed on the front of the abdomen. In the position before us, the back of the fcetus looks forward and to the mother's left; its anterior plane behind and to her right; its left side is in front and to the right, and the right side behind and towards the left; the greater or bis-iliac diameter of its hips corresponds to the right oblique, and its sacro-pubic or antero-posterior one to the left oblique diameter. Prior to the rupture, the presenting part is very high up; but, at the moment of its occurrence, a large quantity of the waters escapes, and the part then becomes more easily accessible. Then, also, the pre- sentation becomes fixed, and one of the varie- ties of it before studied is thereby established. As an example, we will suppose that the inferior members are stretched out, and ex- tended upwards along the anterior plane of the fcetus. If the os uteri be freely dilated when the rupture takes place, the nates im- mediately engage by traversing the cervix, and descend rapidly into the excavation; though, in the contrary case, they remain high up for a long time. In proportion as the contractions acquire more force and energy the buttocks gradually descend; the left slid- ing on the internal surface of the obturator foramen and the obturator internus muscle, and the right along in front of the parts that are situated in the left posterior quarter of the pelvis. Having arrived at the inferior strait, the child's pelvis undergoes a movement of rotation that carries the left hip behind the right ischio-pubic ramus, and the right hip in front of the inner half of the sacro sciatic ligament. The left or anterior hip next engages under the aforesaid ramus, and is the first to show itself through The presentation of the breech in the left anterior sacro-iliac position. MECHANISM OF LABOR. 437 the vulva; but it is generally the right or posterior hip, which, advancing step by step, and describing an arc of a circle around the anterior one as a centre, and Fig. 74. Fig. 75. The same position after the internal The delivery of the breech. rotation is accomplished. traversing the whole anterior surface of the perineum, first succeeds in disen- gaging itself at the anterior commissure, while the other remains nearly immov- able at the summit of the arch. During the delivery of the breech, the body of the child, by becoming strongly engaged in the excavation, is flexed laterally on its anterior (left) side in such a way as to accommodate itself to the curvature of the pelvis. As the right buttock approaches the posterior commissure of the labia externa, and engages in this opening, the breech, or rather the bis-iliac line of the fcetus, which had already cleared the lower strait in a somewhat dia- gonal position, now assumes an exactly antero-posterior direction, so as to corre- spond with that of the longitudinal diameter of the vulva. However, this is not constant, as the breech sometimes retains its diagonal position throughout; the thighs closely applied on the belly already begin to appear, and, pending the disengagement, the fcetal trunk, by accommodating itself, as above stated, to the direction of the pelvic axis, is strongly flexed on its anterior (left) side. The rotation executed by the hips, when they reach the inferior strait, may either be a partial movement, or else one in which the whole trunk participates. In the former case, it can only take place by the aid of a certain degree of torsion in the lumbar vertebral column, and then the pelvis, immediately after its delivery, undergoes the process of restitution, whereby it once more regains its primitive diagonal position. As soon as the hips are clear, the breast engages in the excavation, the arms always remaining applied against the anterior-lateral parts of the thorax, and the shoulders soon arrive at the inferior strait in an oblique position, supposing they have not previously participated in the rotation performed by the pelvis of the child. The shoulders observe the same mechanism in disengaging as the hips; that is, they turn in such a manner as to place the anterior one, here the left, behind the right ischio-pubic ramus, and the posterior one just in advance of the left 438 LABOR. sacro-sciatic ligament, whence they both clear this strait diagonally; but when this is passed, and there is no other resistance than that of the soft parts to over- come, they complete the rotation and become placed, the one, directly in front; the other behind. As to the other parts, the sub-pubic shoulder and elbow are the first to appear externally; but it is still the posterior ones that are first delivered.1 Prof. Dubois contends that, in breech deliveries, the anterior hip and the front shoulder, in the disengagement of the upper part of the trunk, are expelled before the corresponding part in the rear; but I may be permitted to repeat again, that, although matters often do occur in the way described by the pro- fessor, still, it has seemed to me that the view above given holds true in the majority of cases. Whilst the shoulders are traversing the pelvis in the manner just indicated, the head, being flexed on the breast, clears the upper strait in the direction of its left oblique diameter; that is, the forehead is turned towards the right sacro-iliac symphysis, and it retains that position until it reaches the inferior strait. The diameters of the head which are then found in relation with those of the inferior strait, will necessarily vary according to the greater or less degree of the flexion of the head. For instance, when it is only moderately flexed, which is generally the case, the occipito-frontal diameter corresponds to the left oblique one, the bi-parietal to the right oblique, and the axis of the inferior strait traverses the head very nearly in the direction of its trachelo-bregmatic diameter. If we suppose the head to be more strongly flexed on the chest, the sub-occi- pito-bregmatic diameter takes the place of the occipito-frontal, and the occipito- mental corresponds very nearly to the axis of the inferior strait. In a word, we find the same relations as in a vertex presentation, only the head presents by its base instead of its summit. It then performs a movement of rotation, whereby the face is carried into the hollow of the sacrum, while the occiput gets behind and the neck under the symphysis pubis; whence the sub-occipito-bregmatic diameter approaches the antero-posterior one very closely, still retaining, however, a certain obliquity. At that time, the womb can act but very feebly on the head (see Prognosis), which is altogether down in the vagina, or nearly so; but the tenesmus, says Velpeau, occasioned by its pressure on the rectum and the bladder, constrains the woman to collect all her powers, and to redouble her courage, and then the contrac- tions of the abdominal muscles soon come to the aid of the powerless womb; these forces, acting conjointly, flex the head more and more, and whilst this process of flexion is going on around the neck or the sub-occipital region as a centre, the 1 Many books, on the subject of shoulder-delivery, assert that the arms are retained by the borders of the excavation, and thereby get up alongside of the head; though, as Desormeaux very justly remarked, this scarcely ever happens when the delivery i3 left entirely to nature, and no traction whatever is made on the pelvic extremity; consequently, when the labor progresses regularly, the accoucheur should overcome the temptation to aid nature a little by drawing on the parts, for such imprudent traction must certainly straighten out the arms, since there is no counteracting power in these cases to press them outwardly; for, being retained by the friction, they remain above the excavation, and the head de- scends between them, rather than that they mount up on its lateral parts; and fortunate indeed will it be if extension of the head is not produced by these tractions ! MECHANISM OF LABOR. 439 chin, the forehead, the bregma, and occiput will be found to appear successively in front of the anterior commissure of the perineum. During the flexion, the head represents a lever of the first kind, whose power is at the occiput, the fulcrum at the sub-occipital point, or that portion of the neck situated under the arch, and the resistance at the chin, or rather at the forehead, which, being arrested by the perineum, must distend the latter and render it thinner. Hence, if radii be drawn from the sub-occipital point of the head, situated beneath the symphysis, as a centre, and terminating at the median line of the face and vault of the cranium, those radii will exactly represent the diameters which successively clear the antero-posterior one of the inferior strait; the principal of which are the sub-occipito-mental, the sub-occipito-frontal, and the sub-occipito-bregmatic. 2. Mechanism of Natural Labor in the right Posterior Sacro-iliac Position. (Fourth of Baudelocque and third of Capuron.)—In this position, the child's sacrum is turned towards the right sacro-iliac symphysis, its back is behind and to the mother's right, and its anterior plane is to the left, in front; the right side looks forward and to the mother's right, while the left side is behind and towards her left; and the great or bis-iliac diameter of the child's pelvis corresponds to the right oblique diameter. Let us suppose, when the membranes are ruptured, that the lower extremities, swept along by the gush of liquid, are completely unfolded, and that the feet present first at the vulva. In this case, the limbs are soon delivered, under the influence of the uterine contractions, without offering any peculiarity, and the hips easily reach the inferior strait, where they engage, sometimes preserving their primitive diagonal position, while at others the anterior one gets slightly in advance towards the symphysis pubis, and the other or posterior goes behind to the median line of the sacrum. The arms and shoulders present in turn, and their disengagement is nearly the same as in the preceding case. After the delivery of the shoulders, the head alone remains in the excavation, and its expulsion may take place in several different ways; sometimes, indeed, the occiput remains posteriorly throughout the whole delivery, though at others, and indeed iu the great majority of cases, it comes round in front so as to place itself behind the symphysis pubis. A. The Occiput comes in front.—This conversion may begin as soon as the hips have cleared the inferior strait; thus, it often happens, as before stated, that the whole foetal trunk participates in the rotation of the haunches, whence the posterior plane of the child, which was primitively situated behind, is brought in front by describing a kind of a spiral, that commences in the hips and termi- nates at the occiput. The head also has participated in the rotation of the trunk, so that, when the former descends into the excavation, the occiput be- comes placed behind the symphysis pubis. But when the occiput retains its posterior position, after the delivery of the trunk, this rotation of the head may even take place in the pelvis or at the in- ferior strait. In such cases, after the shoulders are born, the back of the child resumes its posterior direction by a sort of restitution, and the head, remaining alone in the excavation, becomes placed in the direction of the left oblique dia- 440 LABOR. Fig. 76. meter, the occiput being behind and to the right, and the forehead or bregma towards the mother's left, in front. It then performs a movement of rotation, by which the occiput, after having traversed the whole right lateral half from behind forwards, locates itself behind the symphysis, and the forehead, by roll- ing from front to rear, is carried into the hollow of the sacrum.....Though, whatever may have been the mode by which this mutation is effected, the labor terminates, just as in the preceding case, as soon as the occiput gets behind the pubic symphysis. B. The Occiput remains behind.—When the occiput remains behind until the end of labor, the delivery of the head may take place in two ways : thus, in the majority of cases, this part engages in the excavation in a state of flexion, where it soon undergoes a very slight movement of rotation, which carries the occiput towards the concavity of the sacrum, and the forehead or bregma behind the symphysis pubis; then, as the uterine contractions and the abdominal muscles force the head to become more and more flexed, the following parts are found to appear in succession below the symphysis and through the vulva; first the whole face, then the forehead, the bregma, the vertex, and last of all the occiput. The head is therefore delivered by a process of flexion, hav- ing the neck, as a centre, resting against the anterior commissure of the perineum. Finally, it may happen that, instead of remaining applied on the chest, the chin is arrested, and continues above the pubis, while the occiput is carried more and more backwards by a well-marked movement of exten- sion. The head engages in the strait by its occipital extremity, which then traverses the whole posterior part of the excavation by a see-saw movement, and is born first at the perineal commissure; after it come, succes- sively, the vertex, the anterior fontanelle, the forehead, and the entire face. Consequently, the head disengages by a process of extension, having the prae-tracheloid region as a centre, which is placed at first behind, and then under the symphysis pubis. Cases of this kind are reported by Leroux, Michaelis, and Asdrubali. The mechanism of labor in the left transverse, and in the right anterior, and right transverse sacro-iliac positions, is absolutely the same as that just described for the left anterior one; and again, the mechanism of the left posterior is an exact counterpart of that of the right posterior sacro-iliac position. § 4. Prognosis. Breech presentations are not, usually, much more dangerous than those of the head; still, in order to arrive at an intelligent prognosis, the labor should be studied in reference to its effect upon the mother and upon the child respectively. Though, from the manner of its expulsion alone, the life of the child is seriously endangered, the parturition is certainly less exhausting and less painful for the mother. Delivery of the head in the sacroposterior positions. MECHANISM OF LABOR. 441 1. As regards the Mother.—As a whole, the labor is somewhat longer in breech presentations; though, fortunately, the delay is experienced almost exclusively during the first stage, and is the cause of but little additional suffering to the mother. The slowness of the process of dilatation is readily explained by the conditions which have been already pointed out. Before the membranes are ruptured, the presenting part, having neither the form, roundness, nor regularity of the top of the head, cannot adapt itself to the regular concavity of the inferior segment of the uterus, and being separated from the neck by a considerable amount of amniotic fluid, is therefore incapable of hastening its dilatation. Should the membranes happen to rupture long before the dilatation is completed, the size or irregularity of the breech prevents its engaging readily, and the neck, not being supported as it is by the top of the head in vertex presentations, col- lapses, and contracts, so to speak, the opening which it had just before presented. In cephalic presentations, on the contrary, the head engages like a wedge, and each expulsive effort tends to increase the dilatation. When the neck is once thoroughly dilated, the expulsion has always seemed to me to be effected more rapidly than in vertex presentations. The breech, the trunk, and the shoulders, are generally delivered with ease, but the head some- times meets with obstruction, and may be arrested at the superior strait. Gene- rally, however, it is detained for but a short time, for if the efforts of the female are not capable of expelling it, it becomes the duty of the accoucheur to inter- fere promptly, in order to remove the child from the danger which threatens it. The course to be pursued under these circumstances, exposes the mother to no danger whatever, the entire risk falling upon the fcetus. As regards the mother, therefore, the breech presentation is perhaps even more favorable than that of the vertex; I would add, that it is certainly more so for her than a face presentation. It is important to observe, that all the varieties of breech presentation are not equally favorable. Some authors think that the labor is usually longer when the foetus presents by the breech, than when the feet are the first to descend into the excavation. The size of the parts that constitute the pelvic extremity, it has been said, do not permit it to engage so readily; and hence, the uterine contractions must operate a longer time in order to adapt those parts to the diameter of the pelvis. This is true; but, as Madame Lachapelle has observed, their softness is such that, when once engaged, they easily conform to the passage ; and besides, as M. P. Dubois declares, the greater their volume is, the more will the labor resemble that of the vertex presentations. Consequently, the professor teaches, contrary to the opinion generally adopted, that a delivery by the breech is far preferable to that in which the feet come down first; the truth of which proposition will be better understood when we shall have pointed out the inconveniences attending this latter circumstance. As the footling presentation does not exhibit the same unfavorable appearances in respect to volume, it is preferred by some persons; for then the foetus, pre- senting by its smallest extremity, will, in their estimation, be more easily ex- pelled, since the dilatation of the parts, from being slow and gradual, will be much shorter and less painful. If you wish, they say, to drive a cork into the neck of 442 LABOR. a bottle, you would present its smallest extremity, and then it would enter more readily, and the same is true of the child in the foot presentations; for the foetal ovoid may be considered as a cone, whose base is at the cephalic, and whose summit is at the pelvic extremity. In the case of the bottle this is true, but only so, because the efforts you use to make it penetrate will be redoubled as the larger extremity approaches the neck of the bottle; that is, the force will in- crease with the difficulties to be overcome; but this last condition does not hold good in the delivery by the feet. Because, as the inferior parts of the child become successively disengaged, there is less left remaining in the uterine cavity, and there is even a period when the head, having reached the excavation, is almost entirely out of the cavity of the cervix; but the uterus, during its evacua- tion, retracts, and, like all contractile muscles, loses a great portion of its power by this retraction; and it is therefore just at the moment when the great extre- mity of the cone, represented by the foetus, has to overcome the resistance of the soft parts, that the uterine contractions are the most enfeebled, and often, indeed, they cannot aid at all in the expulsion of the fcetal head; consequently, the powers here diminish in an inverse ratio to the obstacles in the delivery. If the reader now recalls what takes place in vertex presentations, he will readily com- prehend the difference between the two; no doubt, the largest part of the child then presents the first, and its expulsion requires violent and long-continued efforts; but remark that, up to the moment when the head clears the vulva, the uterus yet contains in its cavity a considerable quantity of amniotic liquid, and also the largest part of the fcetal trunk; wherefore, it is still sufficiently distended not to have lost its power of contracting, a power that can be exercised over a large surface, and upon which it is forcibly applied until the end of labor. Again, the head having once reached the exterior, the parts which have been freely dilated by its passage offer but a feeble resistance to the expulsion of the trunk and lower extremities; and hence, the retraction of the womb may dimi- nish its expulsive forces without this diminution having any unfavorable influence over the termination of the labor. 2. As regards the Child.—The delivery by the pelvic extremity is very dan- gerous to the child; thus, the statistical results furnished by Madame Lachapelle prove that, in eight hundred and four presentations of this class, one hundred and two children are born feeble, and one hundred and fifteen are stillborn: the proportion of deaths to the whole being rather more than one-seventh; whilst, in twenty-six thousand six hundred and ninety-eight vertex positions, there were only six hundred and sixty-eight stillborn children, which gives one in thirty, or about one-thirtieth. As to the particular prognosis in each of the three varie- ties of this presentation, it has been remarked that, when the buttocks advance first, the number of deaths is about one in eight and a half, or a little less than an eighth; for footling presentations, one in six and a half, rather less than one- sixth; and for the knees, one in four and a half, or not quite one-fourth. But M. P. Dubois has justly remarked that this proportion is not perfectly correct, since all the children born by the pelvic extremity are included in the registers of the Maternity, without making any allowance for circumstances foreign to the position, but which nevertheless may have produced the child's death. There- fore, by laying aside all the cases where the children seemed to have been lost MECHANISM OF LABOR. 443 under the influence of causes that evidently did not attach to the presentation itself, he has arrived at the conclusion that, in delivery by the pelvic extremity, about one child in eleven dies; whilst, in vertex presentations, only one in every fifty proved fatal. The difference still, as here shown, is frightful. Other things being equal, the labor is much more dangerous for the foetus in primiparae, than in those who have previously borne children; because the re- sistance of the perineum, which is sometimes sufficient in the former to arrest the labor, even in vertex presentations, has here a still greater tendency to arrest the head, the uterine contractions, as just demonstrated, being weaker. But what is the cause of the child's death ? For a long time it was supposed that, when the foetus presented its smallest extremity, each part, as it came down, being more voluminous than the one which preceded it, had to overcome new resistances; that it underwent, in consequence, a certain amount of com- pression, and this compression, being exercised from below upwards, would neces- sarily drive back the fluids, and thus give rise to a cerebral congestion, the anatomical signs of which are detected at the autopsy of the little corpse. But this supposed pressing back of the fluids is altogether inadmissible: lst. Because the uterine neck is alternately in a state of relaxation and constriction, whilst such an explanation would require it to be permanently contracted; 2d. Because, however great the contraction, it would not be sufficient to compress the large vessels situated deep in the extremities, and in the centre of the great cavities; od. Besides, by recalling what takes place in the vertex and face presentations, we shall see that it is not in the parts which are still contained in, and com- pressed by, the uterine cavity, that a more considerable afflux of fluid would be likely to occur, but rather in those which, from being already free, are thereby relieved from all further compression. We think this mortal congestion can be explained in a much more satisfactory manner by a compression of the cord; for, after the breech is disengaged, the cord is stretched from the umbilicus to its placental insertion, and is placed, both in the excavation and uterine cavity, be- tween the pelvic wall and the trunk, or even, a little later, betwixt this wall and the child's head. Hence, we can easily understand how liable it is to be com- pressed ; and as the delivery of the upper parts, and more especially of the head, often takes place with difficulty, how this pressure may exist for a long time, and thus necessarily interrupt the circulation in the cord. Indeed, it is now gene- rally admitted that the placenta is the seat of the child's respiration; or, rather, that the blood of the foetus comes there directly into contact with that of the mother, whereby it experiences certain modifications closely analogous to those which the blood of the adult undergoes in the lungs, by its contact with the atmospheric air; the circulation being interrupted in the cord, the foetus then finds itself in the condition of an adult deprived of respirable air, and it dies asphyxiated; now it is well known that cerebral congestion is one of the most constant anatomical phenomena of this state.1 I am of the opinion that asphyxia 1 Most of the older writers have explained the child's death somewhat differently, in these cases; thus, according to some, the pressure interrupts the circulation in the umbilical arteries, but leaves the calibre of the vein entirely free, whence the foetus continues to re- ceive blood through the latter, without being able to send it back again by the former ; and it then dies from a superabundance of this fluid, from apoplexy. Others, on the con- 444 LABOR. of the fcetus might take place in still another manner, and yet without the cord being necessarily compressed. It was stated above, that, when the head gets down into the excavation, no portion of the child is left in the uterine cavity, and the empty womb then retracts of its own accord; which retraction deter- mines, as is well known, the separation of the placenta, whereby the utero- placental vessels are inevitably torn, and the fcetus placed in the same condition as if the cord was compressed, and, should the expulsion of the head be at all delayed, it might die asphyxiated. It is not necessary, however, that the placenta should be separated in order to produce this effect; for, as Van-Huevel remarks, if the head be retained for some time in the cavity of the pelvis, the retraction of the womb would of itself ob- struct, or even stop the utero-placental circulation, and destroy the fcetus by asphyxia. ARTICLE V. PRESENTATION OF THE TRUNK. At the commencement of this chapter, we gave the reasons that induced us, like Madame Lachapelle, Naegele, and Dubois, to admit but two presentations for the trunk, and therefore shall not now repeat them; for, doubtless, the reader will bear in mind that all the varieties of the trunk presentations may be referred to the two following, namely, one of the right and one of the left lateral plane. When the former presents at the superior strait, the child's head, which, in these cases, is taken as the point of recognition, may be found placed over some portion of the left lateral half of the pelvis, and this constitutes the first position of the right lateral plane (or of the right shoulder, Lachapelle); or, the head may be situated over some point of the right lateral half, and this is the second position. We have, therefore, two positions of the right shoulder, or right lateral plane; and, in the same way, there are two for the left shoulder, or left lateral plane; in the one, the head is to the mother's left (the left cephalo-iliac), and in the other it is at her right (the right cephalo-iliac). It is a very common circumstance in trunk presentations, to find the arm and hand hanging down in the vagina, or even the latter appearing at the vulva. This, although regarded for a long while as a much more serious affair than a proper shoulder presentation, should be considered as very nearly similar in its character to the deflection of the lower extremities in certain cases of pelvic pre- sentation ; the older accoucheurs have therefore erred in describing it as a dis- tinct variety, under the title of the presentation of the arm and hand, it being merely an additional phenomenon associated with the presentation of the child's trary, supposed that the stricture acted more particularly upon the vein, leaving the arte- ries free, and therefore that the infant died of anemia or syncope. Neither of these theories will bear the slightest examination, since it is all-sufficient to examine the cord, and the intertwining of its vessels, to be convinced that this partial compression cannot exist, except under peculiar circumstances ; that such pressure must interrupt the circu- lation, both in the arteries and veins, and that it neither augments nor diminishes the quantity of the child's blood. Death by asphyxia, therefore, is the only possible mode. MECHANISM OF LABOR. 445 lateral region, and scarcely deserving consideration as a variety of these posi- tions ; we shall see, further on, wherein they were mistaken on this point of doctrine. The trunk presentations are comparatively rare, being a little less so, however, than those of the face; thus, Madame Lachapelle met with sixty-eight cases in fifteen thousand six hundred and fifty-two labors, or one in about two hundred and thirty; and, in the two thousand two hundred deliveries reported by M. P. Dubois, there were thirteen trunk presentations. Dr. Bland observed it in the proportion of one to two hundred and ten; Dr. Joseph Clark, one in two hun- dred and twelve; Merriman, one in two hundred and fifty-five, in his private practice; M. Naegele, one in one hundred and eighty; and Dr. Collins, one in four hundred and sixteen. As to the relative frequency of the presentations and positions, it would ap- pear, from the statistical tables of Madame Lachapelle, that the right shoulder, or the right lateral plane, presents a little more frequently than the left; and that the dorso-anterior positions, that is, the first one of the right shoulder, and the second of the left, in which the back corresponds to the anterior part of the uterus, are more frequent than the dorso-posterior positions, or the first one of the left and the second one of the right shoulder, where the child's back is directed towards the mother's loins. (Naegele.) § 1. Causes. We have but little to say concerning the cause of trunk presentations, except- ing that the smallness and mobility of the child, a rounded form of the uterus produced by a large amount of amniotic fluid, obliquity of the womb, or of the straits of the pelvis, and distortions of the superior strait, are generally regarded as predisposing thereto. We can readily understand that, in the latter case, the contraction of the pelvic entrance might render the engagement of the head im- possible, and by causing it to glide toward one of the iliac fossae, favor a presen- tation of the shoulder. The insertion of the placenta upon the neck of the uterus, also, seems to predispose to presentations of the trunk, inasmuch as out of ninety cases of this character, there were twenty-one in which the shoulder presented. M. Danyau thinks that a more plausible explanation may be found in the shape of the uterus, whose transverse diameters he supposes to be greater under those circumstances than usual. In support of his view, he alleges the following case of Dr. Lecluyse. A woman had her children to present the shoulder in three successive labors, and on the third occasion, the latter physician discovered that the womb, so far from being pyriform in the vertical direction, was shaped, so to speak, like an ellipsoid, whose major axis was transverse, whilst the fundus of the organ was but slightly elevated above the pubis. The same explanation was proposed long ago by Wigand. How is it possible, says he, for a well-formed child, whose body represents an oval, to assume, with- out being compressed or incommoded, an oblique or transverse position, in a womb of an ovoid shape ? Supposing that, impelled by certain causes, it should assume these defective positions for a moment, what magical power could keep there a fcetus, whose mobility is so highly favored both by the fluid in which it swims, and the polish of the internal surface of the ovum ? What is there to 446 LABOR. prevent it, in obedience to physical laws, from changing its inconvenient posi- tion by bringing its long diameter to coincide with the longitudinal one of the uterus? No better reply, he adds, can be given to these questions, than by ad- mitting that these defective positions are due to an irregular shape of the womb, rather than to the movements which it may have performed. Remembering the unfortunate perseverance with which defective positions recur in the cases of certain females, there is a strong disposition to seek for the cause in a peculiar shape of the uterus; and had a peculiar conformation of the organ been discovered before the first gestation, it might, perhaps, be admitted, that notwithstanding the development undergone during pregnancy, the irregu- larity of shape would be preserved. Still, we may be allowed to ask whether the increase in size transversely, near the end of gestation and at the beginning of labor, may not be the effect rather than the cause of the unfavorable position of the foetus. As to the determining causes, the only ones recognizable are fortuitous and accidental; thus, any violent commotion, any trifling shocks, kept up for a long time, such as those produced by carriage riding, or by exercise on horseback, the perturbation from the upsetting of a coach, and even sudden fright, may change, according to authors, the child's position in certain cases, and convert sponta- neously a vertex presentation into one of the shoulder. Indeed, many accou- cheurs have supposed that irregular or partial contractions might convert, during labor, a favorable position into one of the trunk; this is barely possible. But I cannot as readily admit the supposed influence which, according to some others, those uterine contractions may have, that torment the woman during the last few days, or sometimes even weeks of her gestation, and which have before been con- sidered as the preludes of labor. The following is a case in point: A patient, in whom the foetus presented by the shoulder five times successively, had always suffered from these pains during the last few days of her pregnancies; Professor Nyjgele, under whose care she came on the sixth occasion, endeavored this time to calm the pains, which again appeared with the same energy as in the pre- ceding gestations. After the ineffectual administration of various remedies, he finally ordered opiate injections, when, to his great satisfaction, the spasms ceased almost immediately, and were not again renewed, and the woman was de- livered at full term of a living child, which presented in a favorable position. But what does this prove ? simply that, whatever may be the child's position, these pains, the preludes of labor, may appear, and that vicious positions may be reproduced in the same woman with a most deplorable perseverance. It must be evident that such contractions are too feeble to change the child's position in any way, especially when we remember that the integrity of the amniotic sac, and the presence of the waters, likewise protect it from any influence they might have. § 2. Diagnosis. There is sometimes reason to suspect a trunk presentation, even before the commencement of labor, from the following signs: the abdomen is much larger in its transverse diameter than usual, and when its walls are soft and flabby, they can often be depressed enough to detect the fcetal head in one of the iliac fossae, MECHANISM OF LABOR. 447 presenting there as a hard, rounded, and resistant tumor; then, by placing the hands opposite each other in the lumbar regions, a greater and firmer resistance offered by the two extremities of the foetal ovoid will be felt at these points, and the solid body, formed by the child, may be readily moved from side to side, thus proving that its long axis lies transversely above the superior strait. Finally, the tumor formed by the head, in the vertex presentations, is no longer detected by the vaginal touch, and it is almost impossible to reach the present- ing part; in some rare instances, the elbow, or the little hand of the child, may be recognized and balloted, and this sign, accompanied by the first two, renders the diagnosis quite probable. The form of the abdomen is then very irregular, especially if the uterus should contain but a small quantity of amniotic fluid. It has, however, been observed, that after the discharge of the waters, the longitudinal diameter gradually becomes greater than the other; because, as M. Hergott remarks, the transverse position has no longer a real existence, for the body of the fcetus is so curved upon itself that one of its extremities is lodged in the fundus of the uterus, although the other does not correspond to its orifice. Notwithstanding what has been said on the subject of late, we do not believe that auscultation alone is capable of throwing any light upon the diagnosis. Sometimes, however, it may prove a useful auxiliary. If, for example, a small member of the foetus be detected by the touch, and the pulsations of the heart are heard in the hypogastric region, we may conclude almost certainly that the member belongs to the upper extremity. Should the heart be heard on a level with the umbilicus, it would most probably prove a pelvic extremity. Before the membranes are ruptured, the elevation of the part renders the vaginal touch very difficult; and so, of course, the form of the bag of waters, or that of the uterine orifice, can be of but little service. According to Madame Boivin, the os uteri dilates more slowly, but as this slowness of dilatation is met with in ail presentations, excepting those of the vertex, it forms a sign of minor importance; the touch, therefore, can only give a positive certainty after the rupture of the membranes. When the side is the presenting part, the shoulder (Lachapelle) is very frequently found at the centre of the superior strait, as also the elbow, or the side of the chest (P. Dubois), and hence will be the first encountered by the finger in making an examination; and we therefore have to point out the characters, successively, whereby these several parts may be re- cognized. 1. When the shoulder presents, the finger first detects the rounded tumor formed by its summit, upon the surface of which a small osseous projection, con- stituted by the acromion, is distinguished; then, behind or in front, according to the position, the clavicle and the spine of the scapula are felt, and below the clavicle the intercostal spaces are easily made out, whilst under the spine of the scapula there is only a plane surface, terminated by the acute inferior angle of this bone, which is movable and permits the finger to slip under it; lastly, on the sides of the tumor formed by the shoulder, the axillary space can always be distinguished, and sometimes also (though on the opposite side) the depression in the neck can be felt. The shoulder being once recognized, we must next determine which one it is, 448 LABOR. and what is its position. I will remark, in advance, that we have admitted but four positions of the trunk, namely, two for the right shoulder and two for the left, and that the relation existing between the situation of the head and that of the child's posterior plane is different in each of these four. Thus, there are two positions where the head is to the left, namely, the first position of the right and the first of the left shoulder; and remark that, in the latter, the child's back is turned towards the mother's loins; in the former, on the contrary, it is in front; and, therefore, whenever the head is to the left and the child's back is behind, we have to treat with a first position of the left shoulder. In the same way, there are two positions in which the head is to the right, to wit, the second of the right and the second of the left shoulder; but again ob- serve, that in the latter the back looks forwards, while in the former, on the contrary, it is directed posteriorly. Hence, to recognize a second position of the left shoulder, it will only be necessary to ascertain that the child's head is turned towards the mother's right side, and that its back looks anteriorly. In a word, to satisfy ourselves which is the presenting shoulder and what is its position, we only have to find out where the head lies, and the position of the posterior plane of the child. The shoulder presenting and being recognized, it is evident that if the axillary space looks towards the mother's right, the head will be to her left, and vice versa; consequently, the situation of the head is readily known by the direction of this space, and, as regards the child's dorsal plane, the omoplate will clearly indicate its position. 2. When the elbow alone is accessible to the finger, it may be recognized by the three osseous projections (the olecranon and the two condyles), which it pre- sents, by the transverse concavity in the bend of the elbow, and by the vicinity of the chest and intercostal spaces. The elbow having been distinguished, it will be necessary to make out the position to ascertain where the fcetal head and its dorsal plane lie, but this is now comparatively easy, since the elbow is always directed towards the side opposite to that where the head is found, and the forearm is always placed on the anterior plane. Again, as above stated, it happens at times that the forearm is not doubled up, but that, on the contrary, the hand hangs down in the vagina, or even appears at the vulva. Now, to determine which is the presenting hand in those cases, it is necessary to turn it in such a way as to place its palmar surface in front and above, for, in this position, if the thumb be directed to the mother's right thigh, it is the right hand, but if to the left thigh, it is the left hand; and then, to find out where the head is, the accoucheur must slip his finger up to the axillary space. When the hand comes out at the vulva, a careful inspection of it will most generally be sufficient to establish the diagnosis. Thus, if its dorsal surface is turned towards the patient's right thigh, the head is at the right, and if to the left thigh, the head is at the left. The little finger, directed towards the coccyx, indicates that the child's dorsal plane corresponds to the mother's loins, and the same finger pointing to the pubis, is an evidence of this plane being in front. We have been thus particular in the diagnosis, because it is all-important in trunk presentations to understand clearly which side presents at the strait, since the accoucheur must always endeavor to turn; and if the details just given MECHANISM OF LABOR. 449 prove difficult of comprehension from a single reading, we hope they will become clearer by practising on a mannikin. § 3. Mechanism. When the trunk presents at the superioi^strait, the labor nearly always requires the intervention of art; though, in some rare cases, which may be considered as altogether exceptional, nature alone is adequate to accomplish the delivery, which may then take place in one of two ways; for either the presenting shoulder is driven from the superior strait under the influence of the uterine contractions alone, to make room for one of the child's extremities, thereby producing a change in position, and giving rise to what is designated as spontaneous version, or else the presenting shoulder descends into the excavation and engages at the inferior strait; notwithstanding which, the breech sweeps along the whole anterior sur- face of the sacrum and of the perineum, and is delivered the first at the posterior vulvar commissure; this latter mechanism is called spontaneous evolution. 1. Spontaneous Version.—Where the membranes are not ruptured, though the labor has actually commenced, the fcetus sometimes enjoys a great latitude of motion in the amniotic cavity, in consequence of which it might, in such cases, readily change its position before the discharge of the waters took place; and it has been known to present, in this way, different points of its surface during the first period of the labor. Sometimes the head ascends in the womb while the breech descends; at others, on the contrary, the nates mount up towards the fundus uteri, and the head becomes located at the superior strait. Consequently, two varieties of spontaneous version have been admitted, i. e., the cephalic and the pelvic. This phenomenon usually occurs either just before or else soon after the mem- branes are ruptured; in some instances, however, it takes place a long time after the waters are discharged. The following case, reported by M. Velpeau, will give a very correct idea of what occurs under such circumstances: " A young woman, pregnant for the second time, came into the hospital at ten o'clock in the morn- ing. The os uteri was very little dilated; nevertheless,«I could recognize a second position of the left shoulder. The waters did not escape until three in the afternoon, and I did not wish to go after the feet, as the pains were neither very strong nor very frequent, and I had some confidence in the assertions of Denman on this subject. At eight o'clock in the evening, the shoulder had sen- sibly moved towards the left iliac fossa, and I could then readily detect the ear at the right. At eleven, the temple had almost gained the centre of the orifice; the contractions were augmented in energy; and the cervix was entirely effaced. At midnight, the vertex had become lower; the head engaged; and, in the course of an hour, the vertex was delivered in the right occipito-cotyloid position."1 1 With regard to the case in the text, I may say briefly, that the course of M. Velpeau was legitimized by the desire he had of testing the opinions at that time (1825) in dispute; but young practitioners should be very cautious how they make such experiments; for although, in the hands of a man like Velpeau, the version, at an advanced period of labor, would have been comparatively easy, yet it must never be forgotten that, in trunk pre- sentations, the soonest possible period after the rupture of the membranes is the most favorable for the artificial version. 29 450 LABOR. This case, in which the progress of the labor has been followed and described, step by step, is well suited for explaining the mechanism of spontaneous cephalic version. The reader will easily comprehend that the same phenomena would take place, if the breech, instead of the head, descended towards the superior strait; and, in the above instance, for example, the shoulder, instead of being driven towards the left iliac fossa, would be forced to the mother's right, and then the side of the chest, the loins, the left hip and thigh, would successively appear at the upper strait, and the breech finally engage in the excavation. In a shoulder presentation, the arm and hand may hang down in the vagina, or even protrude beyond the vulva; but this last circumstance does not preclude the possibility of a spontaneous version, only it is well to bear in mind that the arm may then ascend again into the uterine cavity, and this will almost certainly happen if the pelvic extremity descends into the excavation, but it may also lodge on one side of the pelvis, and thus permit the head to descend alongside of it; the presentation of the cephalic extremity being then complicated by a procidentia of the arm and hand. In the present state of our science, it would be a very difficult matter indeed to point out the various causes, under the influ- ence of which it is sometimes the head, and sometimes the breech, which thus, in cases of spontaneous version, take the place previously occupied by the shoulder, at the superior strait. Nevertheless, I am inclined to believe that irregu- larity of the uterine contractions is not wholly foreign to such an effect. In fact, when we shall speak hereafter of what the German accoucheurs have de- scribed under the name of Partial Contraction of the Womb, it will be seen that, in some cases, the organ appears to contract in but a limited part of its extent, the remainder contracting with much less force, or even perhaps remaining entirely inert. Now, without being able to cite a single instance in support of my opinion, I am strongly inclined to believe, that it is in such a condition of the uterine walls that spontaneous version would be the most likely to take place. Let us suppose, for example, that when the child is placed in a left cephalo-iliac posi- tion of the right shoulder, the left side of the uterus alone contracts, the right remaining passive; k is manifest that the whole expulsory effort, being then exercised on the head, would necessarily depress it towards the centre of the superior strait; and this movement of the cephalic extremity will be easy, in proportion as the inertia of the right lateral wall of the womb shall oppose no obstacle to the elevation of the pelvic extremity. But if, on the contrary (in the same position of the child), the right side of the womb only contracted, it is evident the breech alone would receive the impulse from the uterine efforts, and then a spontaneous podalic version would be observed to take place.1 2. Spontaneous Evolution.—The mechanism of spontaneous evolution is much better understood, and we shall find embraced in its description all the divisions of the mechanism of natural labor in the vertex and face presentations. Here, also, M. Velpeau has admitted two varieties, that is, a spontaneous cephalic, and a spontaneous pelvic evolution. But we cannot conceive how a spontaneous cephalic one can take place, unless it be in cases of abortion, or in those where the child is completely putrefied; hence we shall treat of the pelvic variety alone, 1 It is proper for me to acknowledge, that "Wigaud had already given a similar explanation. MECHANISM OF LABOR. 451 a taking, as an example, the first or left cephalo-iliac position of the right shoulder in which the child's head is placed in the left iliac fossa, the breech in the right iliac fossa; the dorsal plane being in front, and the sternal one behind, and the long axis situated very nearly in the direction of the transverse diameter of the upper strait. Under such circumstances nearly all the waters escape immediately after the membranes are ruptured; then the uterus contracts forcibly, and, by compressing the foetal trunk on all sides, has a tendency to make the presenting part engage in the excavation. A. Under the influence of the uterine contractions, the child is strongly bent in the direction of its long axis towards the side opposite to the presenting one • for instance, in the case before us, the head is bent to the left side, and the breech towards the hip of the same side; whence we might designate this first modification effected in the situation of the child as the movement of lateral flexion. B. A second stage, the period of descent, then sets in; that is to say, in pro- portion as the contractions are renewed, the shoulder approaches more and more towards the inferior strait, and the foetal trunk, being bent double, engages deeply Fig. 77. _ Fig. 78. First position of the right shoulder with The same position during the descent. the arm hanging down. in the excavation. But the same difficulty is here met with as in the face pre- sentations (see Positions of the Face); that is, the body being thus placed trans- versely, it is impossible for the shoulder to reach the lower strait unless the head engages simultaneously with it in the excavation; or, indeed, unless the neck should be long enough to subtend the height of the lateral wall of the latter, which we have already seen is impossible (see Mechanism of Face Positions). The descent of the shoulder is therefore limited to the length of the neck. c A movement of rotation next occurs, by which the long axis of the child, that was originally placed transversely, is brought very nearly into an antero- posterior direction, so that its cephalic extremity is placed above the horizontal branch of the pubis close to the spine of that bone, and the breech above, or rather in front of the sacro-iliac symphysis. This process of rotation being once 452 LABOR. effected, the descent may now be completed, since the side of the neck is placed behind the symphysis pubis, whose whole length it can subtend; consequently, the forearm and arm are found to appear at the vulva, and the shoulder to get under the arch of the pubis. D. The trunk, being now bent double, is forced en masse into the excavation, under the influence of the powerful uterine contractions, but the shoulder can descend no further, because it is arrested by the shortness of the neck; hence, the expulsive force acts on the pelvic extremity, which is pressed more and more towards the floor of the pelvis, and traverses the whole anterior face of the sacrum. It then rests against, depresses, and forcibly distends the perineum; the vulva socn dilates, and the acromion remaining always fixed under the symphysis, the following parts are observed to appear successively at the anterior perineal commissure: first, the superior lateral parts of the chest; next, its infe- rior part, the loins, the hip, the thighs, and lastly, the whole length of the inferior extremities; and there remain only the head and the left shoulder in the excavation, which are soon after extracted or expelled without difficulty. This last movement may be considered as the fourth stage of the labor, and it is Fig. 79. Fig. 80. Fig. 79. Position of the child after the rotation, and just at the moment when the process of disengage- ment begins. Fig. SO. The same position with the delivery more advanced. therefore named the period of deflexion or disengagement. It takes place around the shoulder, situated under the symphysis as a centre, and therefore, if lines be drawn from this centre, terminating at the various points on the child's side, we shall have all the radii, or the foetal diameters, which clear the antero-posterior . one of the inferior strait. Such is the exact mechanism of the spontaneous evolution in those cases where the child's posterior plane was originally in front; or, in other words, in a first position of the right or a second of the left shoulder, for there is no differ- ence in this last, excepting that the movement of rotation must take place in the opposite direction, that is, the head must pass from right to left and from behind forward, and the breech from left to right and from before backwards. But when the sternal plane of the fcetus is primitively directed towards the mother's MECHANISM OF LABOR. 453 front, as in the first position of the left, and the second one of the right shoul- der, the process takes place somewhat differently. M. P. Dubois, who had an opportunity of seeing two cases of this nature, informed me that, at the moment when the breech disengaged at the anterior perineal commissure, the child's whole trunk underwent a movement of torsion that again brought its dorsal plane forwards and upwards, which plane, without this process of torsion, would still have been directed towards the anus; whence we find, even here, remarkable as it may seem, the influence of that general law which was observed to regulate all natural labors, namely, that, whatever may have been the original relations of the child's posterior plane, it ultimately comes into correspondence with the anterior parts of the pelvis. As observed in the commencement of this article, the mechanism of sponta- neous evolution may be subjected without impropriety to the same divisions as the delivery by the face. In fact, we have a first period of flexion of the child's trunk towards the side opposite to the presenting one; a. second, of descent, interrupted by the third movement, or period of rot a tion; a fourth, of deflexion, or disengagement, and even, according to the observations of M. P. Dubois, we might add, for the dorso-posterior positions a fifth, the period of external rotation. § 4. Prognosis. We again repeat, for it seems highly important that this should be firmly im- pressed on the mind, that in trunk presentations a spontaneous expulsion of the child is wholly an exception to the general rule, and one upon which no reliance can be placed, unless in a case of abortion; and that the resources of our art are demanded in every case just as soon as the necessary conditions exist for such intervention. (See Version.) In fact, by consulting the published cases, or indeed by simply reflecting on the mechanism by which the delivery is effected, we realize how this must expose the woman to a very long and painful labor, and the fcetus to so violent a com- pression that its death must often result in consequence. According to the statistics furnished by M. Velpeau, one hundred and twenty-five children, in one hundred and thirty-seven, were stillborn. It must not be supposed, however, as some persons appear to have done, that this mode of delivery is only possible in cases of abortion ; for facts too numerous militate against this opinion for it to be any longer tenable. Burns justly remarks, in endeavoring to demonstrate the physical possibility, that the greatest diameter measures five inches and a half; sometimes the dis- tance is barely five inches, and continued force may make it less; hence, pro- vided the dimensions of the pelvis are slightly greater than in their normal condition, there is nothing here physically impossible, as has been affirmed and reaffirmed, doubtless without mature reflection. The favoring circumstances which render a spontaneous evolution easier and more likely to take place are: a premature labor, the smallness of the child, a large pelvis, strong contractions, diminished resistance from the soft parts, numerous antecedent labors, and the readiness with which the woman has heretofore been delivered of large-sized children. The opposite circumstances would render it exceedingly difficult, if not wholly impossible. 454 LABOR. CHAPTER IV. OF THE NECESSARY ATTENTIONS TO THE WOMAN DURING AND AFTER LABOR. ARTICLE I. OF THE ATTENTIONS DURING LABOR. When the accoucheur is summoned to a woman in labor, he should always provide himself with lancets, a female catheter, and the forceps; and, if in the country, he should have besides some ergot, either in grain or else freshly pow- dered, and one or two drachms of Sydenham's laudanum. His arrival ought always to be announced before entering the patient's chamber, for the emotion caused by a sudden entrance often proves sufficient to suspend the pains for a considerable time. Then, after having made the usual inquiries as to the time at which the pains began, their frequency, their duration and intensity, he might, if he supposes from this account the labor to be somewhat advanced, proceed at once to the vaginal exploration; in the contrary case, he may wait a few minutes, as well to satisfy himself of the value of the communications made by the atten- dants, as to give the woman time to prepare for the examination. When he finally judges this is necessary, he is to proceed with all possible dec'ency, and always during the interval between the pains. The object of this is to endeavor to ascertain: 1, whether the woman is pregnant; 2, if she is in labor; 3, if she is at full term; 4, whether the membranes are ruptured; 5, whether the labor is far advanced; 6, what is the condition of the cervix, vagina, and perineum, and their degree of suppleness or resistance; 7, what is the conformation of the pelvis; 8, lastly, what part of the child presents. At first sight, it may seem a ridiculous precaution to attempt to verify the existence of the pregnancy in a woman who declares she is actually suffering from the pains of childbirth; but, to say the least, this is not altogether useless, since it has unfortunately happened that some over-confident accoucheurs have been imposed upon by women who were themselves deceived as to the nature of the pains they felt; and we might quote many instances where, after having waited for the delivery to take place for several days, they have ultimately been constrained to acknowledge their mistake. Besides, this error is easily avoided by bearing in mind the diagnostic signs pointed out in the article on Pregnancy. After observing the progress of the pains for some instants, he should next endeavor to ascertain their cause and nature, in order to favor those which have a bearing on the labor, and to combat any that are foreign thereto. Women are not unfrequently tormented by pains during the latter stages of gestation, which are dependent on some sympathetic disorder of the intestines, or abdominal organs, and which even a physician might mistake for the commencement of labor; these have been denominated the false pains, by way of distinguishing them from those produced by the contraction of the womb. The true and the ATTENTIONS TO THE "WOMAN. 455 false pains may be recognized by the following characters: the latter are ordi- narily seated in the region occupied by the diseased organ, while those occasioned by the commencement of the travail usually begin about the umbilicus and loins, and die away at the perineum, the anus, or the sexual parts; the false are almost continuous, and their intensity is nearly uniform; the others, on the contrary, are intermittent. If the irregularity in the return and progression of the pains be such as to leave any doubt as to their character, he should interrogate the neighboring organs, and by a little attention he will succeed in determining their seat and nature. There are, however, certain pains which have their seat in the uterus ifself, affect a certain degree of regularity, and stimulate a true labor, which are dependent on a plethoric condition of the organ, that may be calmed by rest, a restricted diet, and bloodletting. Further, the epoch at which they occur, and the absence of the other phenomena of labor, will serve to lessen the difficulties in determining the diagnosis; nevertheless, it is the touch alone that can dispel all doubts; for the hardness that comes on in the uterine globe, the rigidity in the circumference of the os uteri, the tension and protrusion of the membranes during the pain itself, together with the retreat and relaxation of all these parts in proportion as it diminishes, characterize the pains of childbirth in an infallible manner. "By examining," says Wigand, "the course of the true contractions, it will be found that they commence at the cervix, and pass to the fibres of the fundus, which are then thrown into action; and hence all contractions that begin in this latter pajft of the womb are anomalous, and result either from some disorder having occurred in the uterine forces, or else they are produced by an inflamma- tion, or a disturbance in the functions of a neighboring organ." When the true pain is manifested, the head, which reposed during the interval on the cervix, sometimes mounts up even beyond the reach of the finger, but the membranes engage more or less in the orifice. In the course of a few seconds, the contrac- tion extends all over the uterus, and more particularly to the fibres of the fundus; and the head, which was at first elevated, is forcibly pressed down on the neck, thus assuming the office of a wedge for hastening its dilatation; and, as a general rule, it is only when the fundus contracts in this manner, that the woman com- plains of pain. We may, therefore, consider the true pain as constituted of a series of phenomena, which succeed each other in the following order: first, the periphery of the cervix becomes tense; then, the presenting part ascends, and the membranes bulge out; next, the remainder of the uterus, the fundus espe- cially, becomes hard, during which the patient complains of a sharp pain; and, lastly, the part that presented endeavors anew to engage. It is unnecessary to add, that the rapidity with which these phenomena succeed each other, necessa- rily varies according to the individual, to the irregularities to which the process is subject (which we shall hereafter study), and according to the stage of the labor. Other things being equal, the contractions will effect the dilatation so much the sooner, in proportion as the cervix shall correspond more directly to the fundus of the organ, and the uterine axis shall be the more parallel to that of the pelvis. After having learned the true character of the pains, the accoucheur next en- deavors to ascertain whether the woman is really at term, so as not to encourage 456 LABOR. a premature labor, which might often be prevented if he knew its cause. He ought, therefore, to recall the various signs, by means of which we have attempted to characterize the different periods of pregnancy. Thus, should he find that the cervix is not yet entirely effaced, that it still retains a certain degree of length, that it is hard and resistant even during the interval of the contractions; that the latter are much less regular in their course, duration, and return, than in parturition at full term; and the belly not yet sunk down; he may justly conclude that the patient has not yet reached the end of the ninth month; also, that such a premature labor is owing either to some acute moral emotion, or some antecedent external violence. In all cases, he ought to attempt the arrest of this premature or false labor, by rest, both of body and mind, by venesection, if the woman's general condition will admit of it, and, more especially, by the administration of laudanum in full doses, taking care to empty the bladder when necessary, and to keep the bowels free by mild laxatives. The use of means to stop the premature labor ought not to be given up, even though the cervix be entirely effaced, the orifice somewhat dilated, and a certain amount of waters discharged; inasmuch as the escaped fluid might proceed from a hydrorrhoea and not from within the amnios, whilst premature pains can some- times be calmed and the pregnancy enabled to proceed to full term. Very conclusive observations upon this point were published in 1857 by Dr. Charrier: he cited cases in which the dilatation equalled a quarter of a dollar in size, and in which the pains were suspended notwithstanding the membranes were engaged in and projected from the orifice. The cervix afterwa^s closed in such a way as to reproduce its external orifice, and to present the conical shape which it has in the eight month of gestation. This phenomenon, styled by M. Charrier, retrocession of labor, though doubtless rare, need only be possible in order to encourage the practitioner to suspend the labor whenever he is sure the membranes are intact, the child alive, and the woman not at term. However, there is one phenomenon, sometimes manifested in the latter weeks of gestation, which may place the most skilful practitioners at fault. I allude to what has been designated as the false labor, in which certain women, after having nearly reached their full term, experience the true contractions; the pains are regular, the membranes bulge out, aud the os uteri dilates; at times, these pains last from four to six hours, but then they disappear all at once, and everything goes on as usual. In others, the false labor is kept up at first during several hours, and then it passes off, returning in this manner every day, particularly towards the evening, and lasting one or two weeks. (See Uterine Rheumatism.) Where he is very sure that the woman is really in labor, his attention must be directed to the frequency and the intensity of the pains, and to the dilatation, the hardness, and thinness of the cervix, in order to judge of its probable dura- tion. During the same exploration, he should ascertain the conformation of the pelvis, particularly if the woman happens to be in her first confinement, and if any apparent deformities exist; he should also learn the situation of the orifice, the obliquity of the body and neck of the womb, and the child's presenting part. (See Mechanism of Labor.) If this latter is so high up as to render the diag- nosis of the presentation difficult, its examination should be deferred until a more ATTENTIONS TO THE WOMAN. 457 advanced period of the labor; but the bag of waters is never to be ruptured, in any case, for the mere purpose of rendering this examination more easy, before the entire dilatation of the neck; for such an untimely rupture of the membrane would be attended by very great inconveniences, if the position were at all defec- tive ; for, all the waters escaping, the foetus might suffer from the pressure exer- cised directly upon it by the uterine walls; the umbilical cord would be com- pressed ; and the womb, irritated by the prolonged contact of the foetal inequalities, miaht be affected with spasmodic contractions; and, finally, the intervention of art becoming necessary, long after the evacuation of the waters, the necessary manipulations would be attended with much greater difficulties. The accoucheur should next ascertain whether the child is living or dead, as it is highly important to determine this point, in order to diminish his own re- sponsibility, by advising the family of the fact. Before the membranes are ruptured, the diagnosis may be easily made out by ascertaining through auscultation the existence or absence of the pulsations of the fcetal heart, as also the continuance or complete cessation of the active movements, in regard to which, the woman can always give sufficiently accurate information. After the rupture of the membranes, the active movements are feeble, and sometimes entirely absent; in which case, however, the pulsations are still detected by auscultation. The touch also reveals certain signs which may shed still further light upon the question. Thus, when the child is alive and the head presenting, it often becomes affected with a sanguineous swelling, the size of which depends upon the length of time which has elapsed since the discharge of the waters. This tumor does not form when the child has ceased to live; and if its death dates back for several days, the resisting tumor formed by the sero-sanguineous infil- tration will be replaced by a soft, flaccid, and wrinkled condition of the hairy scalp. Besides this, the bones of the cranium will be more movable, and the overriding of their edges greater than usual; a sort of crepitation is also pro- duced by their rubbing against each other. A more embarrassing case is that in which the child dies some time after the rupture of the membranes, but not before the sanguineous tumor has had time to be developed. Even here the uncertainty will be of short duration, for, provided the labor should continue beyond three or four hours, the tumor will lose its consistency, and its softness and flaccidity render a mistake a matter of difficulty. Finally, when the pelvis is rather contracted, the wrinkling of the scalp may simulate a swelling, whose diagnostic importance it is well to appreciate. In this case, says Merriman, the best means of judging of the life or death of the child by the tumor of the scalp is as follows: when living, it is observed that, at the moment when the head is strongly urged down by the contraction of the womb, the bones overlap each other, and, as a consequence, the scalp becomes folded, and thus constitutes a temporary tumor; but immediately after the pain is over, the head regains its primitive form, by the expansion of the cranial bones, and the folds and tumefaction previously exhibited by the skin disappear, or, at least, considerably diminish. On the contrary, however, if it be dead, the expansibility of the bones is destroyed, and the head does not reassume its primi- tive form and volume after the contraction has passed off; wherefore the tumor 458 LABOR. formed by the doubling of the hairy scalp still persists, in a great measure. Now, in this condition of affairs, the swelling is sometimes greatly augmented by the liquids forced in by the pressure from above, and whenever, in such cases, a perforation of the cranium has to be resorted to, practitioners well know there is half an inch at least of soft parts to be traversed before reaching the bone. (Merriman's Synopsis.) If the face should present, the softness of the lips, and the flaccidity and im- mobility of the tongue, should lead us to suspect that the child is dead; since, when living, the firmness of all its parts, and the motions of the tongue, are often felt with ease. In breech presentations, the introduction of the finger into the anus will detect a resistance and contractile power on the part of the sphincter if the child be living, which will be absent if the child be dead. Lastly, in shoulder and arm presentations, the swelling of the member, and its violet hue, will afford an indication in favor of its life. Should the cord hang in the vagina, its softness, withered condition, and the absence of pulsation in the umbilical arteries, would justify a belief that the child was dead. A thick and fetid condition of the amniotic fluid, and a discharge of meco- nium, have been regarded as indicating the death of the child. The importance of the latter sign has been discussed already. The altered condition of the waters is of no great importance, since it has sometimes been found to coincide with perfect integrity of the foetal life. Of all these signs, the best, doubtless, is that furnished by the auscultation of the pulsations of the heart, which are always perceptible when the foetus is living. It may indeed happen that the pulsations of the cord are imperceptible, without our being able to conclude therefrom that the child has ceased to live. It some- times happens that they stop during the pain, only to reappear again in the interval of the contractions. Consequently, to render the diagnosis more certain, the cessation in the pulsation should last for some time, at least for ten or fifteen minutes. But it is not always so easy a matter as one might imagine to ascertain whether the membranes are ruptured or are still intact; for instance, where the vaginal examination is resorted to between the pains, in a vertex presentation, they are often applied so directly to the scalp that it is impossible to distinguish them. A pain should then be waited for, because, as soon as the uterus con- tracts, it drives the waters towards the lower parts, and the finger is observed to be raised up by a small quantity of this fluid that insinuates itself between the head and the amniotic sac, the integrity of which latter is thereby easily verified; but where the head is more deeply engaged, this afflux of liquid is very incon- siderable, and the tension of the membranes can scarcely be distinguished. Con- sequently, attention should be given to the state of the tumor both during and after the contraction. Where the waters have escaped, and the finger comes directly upon the child's cranium, it will detect the hairy scalp puckering up while the pain lasts, and becoming smooth and even as soon as it shall have ceased; though the contrary will take place when the membranes are intact, for they are never more smooth or more tense than during the contraction itself. ATTENTIONS TO THE WOMAN. 459 It is difficult at times to reach the cervix uteri in the commencement of the labor, because it is then carried so far backwards, that the plane of its orifice actually looks towards the anterior face of the sacrum. I have often seen young practitioners who were unable to get at it at all, and others, who, not finding the os uteri, and distinctly feeling the child's head through the anterior inferior part of the womb, which is then rendered very thin by the distension it has under- gone, have imagined that the dilatation was already completed, whereas it had hardly commenced; the disastrous consequences to which such an error might lead, can be readily imagined. In fact, it is very often necessary to pass the finger around the convex tumor which fills the excavation, in order to get the index far enough upwards and backwards, where the uterine orifice is to be found. All these questions being determined, the accoucheur's attention should be directed early in the progress of the confinement to having the woman moved into the most suitable place. The chamber intended for her lying-in should be spacious, airy, well-lighted, and retired; the air she respires ought to be pure and of a moderate temperature, and all strong odors, whether good or bad, should be excluded. A temperature too elevated will predispose her to nervous agita- tion, and to hemorrhagic accidents; and, on the other hand, the impression of cold is a very frequent cause of acute inflammation, or of chronic engorgements, such as those that often come on after delivery, which have for so long a time been attributed to lacteal metastases. But few persons are to be admitted in the chamber, and all those, especially, whose presence is at all unpleasant to her, ought to be rigidly excluded. This latter point demands the greatest care on the part of the physician, for it is he alone who has authority thus to dismiss such as he may think useless or injurious, and he must judge, from the reception given to each, of the pleasure or otherwise the patient experiences from their presence. Some women are almost ashamed of being delivered in the presence of the husband; with others, on the contrary, it is one of the greatest consola- tions to have him near them, and the accoucheur must endeavor to. discover all the little shades of delicacy and feeling, to sound, by discreet and artful ques- tions, a wish that the woman herself at times fears to express, and, after having once learned it, he should religiously comply with it. As a general rule, the mother and sister, or two intimate friends of the patient, besides the nurse, are the only ones that are to be allowed to stay in the room. With regard to dress, her garments should be full, sufficiently so, as neither to incommode her move- ments nor her respiration. If some time has elapsed since she has had a passage from the bowels, a simple injection must be given; and where this does not prove sufficient to procure a stool, a second is to be immediately administered with the addition of one or two ounces of the miel mercuriale.1 The evacuation of the matters contained in the rectum is the more necessary, as its distension might subsequently retard the escape of the head, and likewise prevent that of the intestinal gases, whose accumulation might bring on colic and gripings; besides, this precaution has the advantage of sparing the woman the shame and disgust which an invo- 1 This preparation is only used as an injection; it is prepared by taking equal parts of clarified honey and the juice of the mercurialis annua, a plant belonging to the tribe of the Euphorbiaceas, and reducing them to the consistence of a syrup.—Translator. 460 LABOR. luntary expulsion of the faeces during the last moments of labor would necessarily cause, as also of preventing the accoucheur's hand from being soiled, while it supports the perineum. Her bladder likewise requires attention, and the catheter should be resorted to when the emission of urine does not take place. He should also attend early to having everything prepared that may be wanted somewhat later; thus, the thread intended for the ligature of the cord is to be laid out, and the bands and linen for covering the child's navel are to be cut; for the mother, he ought to procure some cold iced water, vinegars, and smelling salts, agents that will probably be unnecessary, but which, notwithstanding, he ought always to have at hand; and, lastly, he must direct the preparation of the bed upon which the woman is to be delivered. This bed (called the lying-in bed, the bed of misery, or the little bed) is arranged in the following manner: one with a sacking-bottom is procured, of a moderate height, and about two feet to two and a half in width, and one end of it is placed against the wall, being careful to keep it clear on both sides, so that one can pass freely all around it. A first mattress is placed on the bottom, and upon this a second, which covers its upper part, and is folded double towards its superior third, in such a way as to leave the first one uncovered about the foot. An oil cloth, then a sheet, some pillows, and a coverlet, complete the furniture of the bed. A solid bar is placed transversely across the foot of the bed, so as to give the woman's feet a solid point of resistance in the last moments of labor. In France, the patient is so placed that the upper part of her back rests on the inclined plane formed by the second mattress, and her breech at the margin of the same mattress; the inferior extremities are slightly flexed, and the feet press against the trans- verse bar placed at the foot of the bed. In England, women are delivered on the edge of their beds; they lie on the left side, having their legs and thighs flexed, and their knees separated by pillows. In Germany, the lying-in chair of the ancients is used; the patient is placed on an inclined plane, which can be modified at will, by lowering or raising the back, by means of a rack; the woman then draws on the arms of the chair, and presses her feet against the rounds with which it is supplied, and, as she gives way to the throes of labor, the sexual parts are uncovered, and correspond to the opening made in the edge of the seat. But, on the whole, the bed, furnished as we have described, ap- pears preferable, the more so, because it is always at hand; and, as suggested by Desormeaux, it is particularly suitable where the woman must remain recumbent during the whole progress of labor, as is necessary whenever she is affected with hernia, or is threatened with hemorrhage, prolapsus, or a displacement of the womb. In case of necessity, its place might be supplied by a table and a few chairs placed against the wall. It would be much better, say Desormeaux and M. P. Dubois, where the family are in easy circumstances, to make use of an ordinary bed, taking care, however, to supply it with a rather hard mattress, and a hard cushion near the buttocks, to prevent the pelvic region from sinking down into the substance of the mattress, and the borders of the hole thereby produced, from forming an obstacle to the extension of the coccyx, or the escape of the child's head. On this bed, the woman is more at ease; she can lie on her side, or take the most convenient attitudes, and even sleep during the intervals of the pains; and then, after the delivery, she may remain there some time before being transported to another. ATTENTIONS TO THE WOMAN. 461 Ought the accoucheur to remain constantly with the patient? This is a ques- tion whose solution varies according to the character of the female herself, and the greater or less intimacy existing between her and her physician, for there are some timid women who desire to have him always close at hand, and others again, who are impatient and annoyed by his continual presence. But in all cases, he should bear in mind that, during parturition, the patient very often wishes to urinate or to empty her bowels, and he ought, therefore, to go from time to time into an adjoining chamber, in order to give her the desired opportunity. Again, during the labor, a wife is frequently cheered up by the caresses and consola- tions bestowed by her husband;' the physician will understand that his presence at such times must act as a restraint, and he should discreetly withdraw, or, at least, not observe what is going on. Further, he may absent himself more frequently during the period of the dilatation; for instance, after having made the examination, and ascertained that the child's presentation and position are both favorable, he might, if the cervix was just beginning to dilate, attend to his other occupations, and return again in the course of a couple of hours; but if the diagnosis of the position had been impossible, or if the latter had proved to be an unfavorable one, he must not quit her under any pretext, in order to be always ready to ward off any accidents which might subsequently demand his interven- tion. When the stage of expulsion commences, the accoucheur places himself at the right of the bed, on a chair of a suitable height. The part he has to per- form consists, in a natural labor, in ascertaining its progress, from time to time, by the touch, in directing properly the bearing-down efforts of the patient, and in sustaining the perineum with his hand while the child's head is passing through the vulva. During the first stage, the woman may lie down, sit down, or walk about, at her pleasure; indeed, this frequent change of position renders the slowness and fatigues of childbirth more supportable; but, at the end of this stage, when the dilatation is completed, and the amniotic sac projects strongly and is on the point of yielding, she must then resume her bed; and this precaution is particularly indispensable in those who have already borne several children; because, in them, the expulsion of the foetus sometimes follows so promptly after the rupture of the membranes, that the patient has not always the time to regain her bed, and is liable to be delivered standing. But when, after the rupture, the progress of the labor is slow, and the head is more or less engaged in the excavation, or has already descended as low as the perineum, but does not advance, and the pains seem to become more and more feeble and distant, it is advisable to recommend her to get up and walk about, having her supported by assistants, if her own strength does not permit her to walk alone, for it is found by experience that bodily motion seems to give more activity to the uterine contractions. In the contrary case, she must not leave the bed without some special indication. Where the patient is tormented by pains in the loins, we may relieve them by stretching a folded napkin under the small of the back, and directing two per- sons placed at the opposite sides of the bed to pull on the extremities of the towel during the pain. Attempts should also be made to assuage the cramps, so often experienced in the thighs and calves of the legs, by frictions over the suf- fering parts. 462 L A B 0 R. Some nervous women are troubled with tremblings and chills, in the very com- mencement of their labor, which are at times sufficiently marked to cause much disquietude. Dewees observed that they often coincide with an unusual rapidity in the dilatation of the cervix, and he says, " A lady, who every moment expected her labor to commence, was awakened suddenly in the night by a violent chill. The nurse became alarmed, and I was immediately sent for. AVlien I arrived, I found her still trembling very severely, but she had not experienced any symptoms of labor; she assured me that nothing was the matter with her except what I was witnessing, namely, an agitation of the whole body, which she could not, by any effort, control. In about five minutes, she cried out she believed her labor was coming on ; and this really was the case, and so rapidly, as not to give me time to place her in a proper situation for delivery; she was delivered in less than five minutes from the time she first called my attention to her. Tbese shiverings are sometimes renewed during or immediately after the labor; but, in no case, do they merit a serious attention. Patients are often frightened at the time the bag of waters is torn, and it is, therefore, a good plan to advise them of it beforehand; and the precaution should also be taken of placing a sponge or some old linen near the genital parts, so as to receive the liquids as they escape. Immediately after the discharge of the waters, it is advisable for the practitioner to assure himself anew of the pre- sentation and position, lest he might have been deceived in the first examination. The rupture of the membranes generally takes place spontaneously, but this is not always the case, and the accoucheur must sometimes interfere. It is very certain that, when the uterine orifice is entirely dilated, when the membranes are forced into the vagina by a large quantity of fluid, and the head is movable, but still the contractions do not produce a spontaneous rupture of the membranes,—it is evident, we repeat, that they, by their resistance, prolong the labor. Although this obstacle is never insurmountable, by the efforts of nature alone, yet the delay in the delivery and the dragging on the membranes may be attended with some inconveniences, and it is, therefore, better to lacerate them. This is done by taking advantage of a strong contraction, and, while they are greatly distended, forcibly pressing the index finger against the centre of the tumor. When this rough pressure is not sufficient, we scratch the membranes with the finger-nail; and, by gradually weakening the three tunics, succeed in rupturing them. Sometimes, however, they still resist, and then some instrument, such as a blunt probe, or, still better, the end of a quill cut down, is directed up to them along the finger. Where the waters are flat, that is, when but little liquid inter- venes between the membranes and the head, some care is requisite, in using the little instrument, to direct it obliquely, so as not to wound the foetus with its point. Rupturing the membranes is, therefore, a trifling, simple operation; still, excepting in some rather rare cases to be spoken of hereafter, it ought not to be performed until after the orifice is thoroughly dilated. Whatever the presenting part may be, there is always an advantage in retaining a large amount of fluid in the uterus. Some peculiar circumstances may, however, demand the artificial rupture before the dilatation is completely effected. In a case reported by Baudelocque, the child was so movable, that it succes- ATTENTIONS TO THE WOMAN. 463 sively presented every part of the surface of its body at the os uteri. In a woman whose belly was distended by a great quantity of water, M. Martin, of Lyons, had recognized the feet and one hand through the membranes. " I then felt disposed," says he, " to terminate the labor, when, at the request of her hus- band, I called a friend in consultation; but, on touching her again, before his arrival, I detected the head where I had previously found the feet and hand, when I immediately punctured the membranes, whereby the head was fixed at the superior strait and the delivery rendered natural." (Comptes Rendus, p. 155.) Should a case of this nature be met with, the rule we have just given might be laid aside, and the membranes be ruptured, however inconsiderable the dilatation. It is scarcely necessary to add that an artificial rupture is only to be resorted to when the foetus shall be detected presenting by its cephalic extremity ; for then the discharge of a certain quantity of the amniotic liquid, and the re- traction of the uterus, will irrevocably fix this part at the upper strait. Again, according to the majority of writers, the membranes may be lacerated before the entire dilatation of the cervix, where there is reason to suppose that the waters, from their too great abundance, distend beyond measure, and thus weaken the contraction of the uterine walls; but, even here, Gardien recom- mends the greatest circumspection, and advises the previous employment of all the measures calculated to stimulate the* contraction of the womb. Finally, we shall learn hereafter that the puncture of the ovum at an early period of labor, is one of the most effectual means of arresting certain dangerous hemorrhages which may supervene during its progress. The finger ought to be introduced into the vagina several times in the course of the last stage of the labor, both during the pains and in the interval between them, to ascertain the progress of the head in the excavation. Nevertheless, this exploration is to be resorted to as rarely as possible, and only when the in- terest of the mother seems to demand it. Most women, supposing that they can materially hasten the termination of the labor by making the most of their pains, contract their muscles, bear down violently, and make extraordinary efforts at the beginning; but these uselessly exhaust their strength; for, so long as the neck is ineffaced, and the bag of waters unbroken, all bearing-down effort is fruitless. But, in the second stage, where the head descends into the excavation and rests on the perineum, she should be encouraged to aid the uterine forces by a voluntary contraction of the muscles of the trunk and limbs; though, as soon as the pain has passed off, all the auxiliary efforts should be at once suspended. Again, in the latter moments of the travail, just when the head is about to clear the vulva, the pains are so sharp that the woman naturally gives way to incredible exertions, which may possibly occasion serious accidents; hence all the powers of persuasion should then be employed to induce her to moderate her strainings. During the last moments of childbirth, the pressure of the head on the lower part of the rectum creates an urgent desire of emptying the bowels; and many women, yielding to a misunderstood modesty, then wish to rise and retire to the closet; but it would be exceedingly imprudent to comply with their demand, and they must not leave the bed under any pretext whatever. In the first place, this desire is often illusory, more especially where the precaution has been taken 464 LABOR. to empty the intestine at the commencement of labor; and then it may happen, as I once witnessed, that the patient, surprised by a violent pain, is delivered on the close-stool, without the physician being able in any way to render her the necessary attentions. It is in these last moments that the accoucheur must give all his attention to supporting the perineum, which is done by pressing the whole perineal surface equally, and with a moderate degree of force, by the palmar face of the hand. The latter is applied in siach a way as to make the radial border of the index finger cover the anterior margin of the perineum, the ends of the fingers corre- sponding to the left side, and the thenar eminence of the palm to the right side of this partition, while the thumb is held to the right of the labia externa. The pressure should be somewhat greater near the anus, so as to give the fcetal head a forward direction, and facilitate its movement of extension. ARTICLE II. OF THE ATTENTIONS TO THE CHILD DURING LABOR. Immediately after its expulsion, the disengagement of the head is completed, either by carrying it more and more towards the pubis, or by insinuating the index upon one side of the lower jaw; this being accomplished, we must next ascertain whether the cord does not make one or more turns around the neck, and if so, gentle tractions must be made on its placental extremity, to avoid its being dragged upon, and to prevent strangulation of the foetus, &c; and when a sufficient extent of it cannot be brought out, to render the prevention of such accidents certain, we have to cut it, and terminate the labor as promptly as pos- sible, by hooking one or the other shoulder with the forefinger.1 After the head is born, the womb, exhausted by its last efforts, remains passive for some instants, and it frequently happens that the child begins to respire and cry, even before the delivery of the chest. We may, therefore, wait patiently until the contrac- tion is renewed, simply supporting the head, lest the mouth and nose be choked up by the cloths or blood found between the woman's thighs; but if the atony is prolonged, and more especially if the face of the new-born infant is observed to be red and tumefied, as sometimes happens after painful labors, the remainder of the travail ought not to be left entirely to nature, but new pains should be at once solicited by frictions over the abdominal walls, and the patient be encou- raged to bear down; and if these measures prove insufficient, the index finger, curved like a hook, is to be placed in one of the armpits, and the disengagement of the anterior shoulder thereby first effected. After the shoulders are disengaged, the spontaneous expulsion of the breech and lower extremities may also be delayed in consequence of inactivity of the womb. Here again, is it especially proper to endeavor to excite the contractions 1 These folds may occasionally be drawn so tightly as to strangle and kill the infant, as occurred in the following case ; " Upon approaching a woman who had just been delivered, I found the child dead, and still lying near the genital parts; the cord made three turns around its neck, and they were so firmly tightened that a deep ecchymosis was seen on this part." (Guillemot.) ATTENTIONS TO THE WOMAN. 465 by frictions upon the abdomen; but, should the life of the foetus appear to be in danger, the extraction should be effected immediately. The artificial extraction of the shoulders or of the lower part of the trunk, we see, ought not to be resorted to until expectation might become dangerous to the fcetus. When the expulsion is left entirely to nature, the womb contracts in proportion as it is emptied, and there is less cause to fear the consecutive inertia which is sometimes produced by too rapid an extraction. In those rare cases, where the occiput remains posteriorly until the end of labor, most accoucheurs have recommended that an attempt should be made to bring it round to the front, but we doubt whether this will often prove successful, although we have never seen it tried, nor ever attempted it ourselves; for we believe that where the process of rotation does not take place spontaneously, all efforts to produce it artificially would be useless, not to say injurious. Neverthe- less, most authors advise, when the head has descended into the excavation, immediately after the discharge of the waters, to make it deviate either towards the right or the left in the interval between the contractions (Velpeau), by slip- ping two or three fingers either along the sacrum, to press the occiput forward, or else upon the side of the forehead, behind the pubis, to carry it backward. If we should ever entertain the thought of attempting this manoeuvre, we would much prefer acting during the contraction, for then we should only aid, without absolutely supplanting nature; we would prefer, whilst acting upon tlie occiput, as indicated by Velpeau, applying, at the same time, two fingers on the temples, and acting thereupon in such a way as to turn the forehead posteriorly. But, we repeat, this appears unnecessary in the great majority of cases, because it only hastens the process of rotation, which would have subsequently taken place without it; and even hurtful in others, for the efforts used to bring it about might exert a pernicious influence both on the mother and her child. In fact, in ordinary cases, where the rotation is produced by the natural powers, the trunk follows the movements of the head; but where the latter has been turned by the fingers, the body remains immovable, and hence the process of forced rotation may dislocate the atloido-axoid articulation and kill the child. The older accoucheurs thought that a spontaneous delivery, in face presenta- tions, was altogether impossible, and consequently they advised an endeavor to be made, in the very outset of labor, to convert them into vertex positions; but we of the present day understand better the value of such opinions. However, the rotation by which the chin is brought under the symphysis pubis, whatever might have been its primitive relation to the superior strait (see Mechanism of Delivery by the Face), is difficult, painful, and sometimes, in the mento-posterior positions, does not take place at all. It will be seen, further on, that the non- accomplishment of this movement forms one of the most serious complications met with in practice, and that craniotomy often becomes necessary in conse- quence. Therefore, whenever the attendant is fortunate enough to detect such a position before, or just after, the membranes are ruptured, and consequently while the part still retains a considerable degree of mobility, it seems advisable to make an effort to flex the head, and thus convert a mento-posterior into an occipito-anterior position; but we shall have occasion to revert again to this subject hereafter. When the face is engaged at the inferior strait, and the chin 30 466 LABOR. is found under the pubic arch, the movement of flexion begins, and then, as has been shown, the pressure to which the vessels of the neck are subjected, during the fourth stage, may retard the circulation enough to determine death by cere- bral congestion. Hence, we learn what great precaution is necessary in support- ing the perineum, since it must be evident that too great a pressure made upon this part would necessarily augment the compression of the child's neck. The delivery by the pelvic extremity ought to be abandoned entirely to nature, unless there are some unfortunate complications. We have already insisted upon this point in the note at page 4o8; but do not hesitate to repeat again the advice, not to resort to any traction in a natural labor by the breech, because, as there stated, a stretching out of the arms, and sometimes even an extension of the head, result from such imprudent tractions, whilst these complications are scarcely ever met with where the expulsion is left to the uterine contractions entirely. Now, there is no difficulty in comprehending these different results, for when the womb is the sole agent of the delivery of the child, the latter is forcibly urged on by the circular fibres at the superior part of the organ, and at the same time is strongly pressed on its sides by the longitudinal fibres. The upper extre- mities are therefore maintained against the lateral and anterior parts of the chest, the head is kept flexed on the thorax, and all these parts descend together; but, on the contrary, if any tractions are made, they only act on the trunk, which then descends alone, while the arms, being arrested by the margins of the cervix uteri, or by the periphery of the straits, do not participate in the descent, and are ultimately found placed against the sides of the head; hence, the accou- cheur's exclusive duty consists in receiving and supporting the lower parts of the child as they become disengaged; taking care, as soon as the breech has cleared the vulva, to ascertain the condition of the cord. For that purpose, the fore- finger is slipped up as far as the navel, when, if the cord is found to be tight- ened at its umbilical insertion, he joins the thumb to the index so as to produce some traction on its placental extremity only, with the view of preventing both its being dragged upon, and its possible laceration. The cord sometimes gets between the infant's thighs; and, in such cases also, the loop thereby formed must be enlarged by pulling on the placental extremity, and then by disengaging it from the posterior limb, bring it into contact with the perineum, that is, with soft parts whose compression will be less severe, and consequently less dangerous to the circulation than what it would suffer from the symphysis pubis; but if it is too short to be brought to the exterior, it must be cut, and have a ligature applied on its umbilical extremity, and the labor be terminated as rapidly as possible. But, whatever may have been the cause, the death of the foetus always results from the slowness with which the shoulders and head are expelled, for it is only during this last part of the travail that the cord is compressed, or that a separa- tion of the placenta takes place; hence, although we have condemned all traction in general, it must be otherwise under such circumstances. But how is it pos- sible to determine the period beyond which it would be imprudent to wait? We answer, that as soon as asphyxia comes on, the suffering condition of the child may easily be detected by examining the portion of the cord which has been de- livered; and if the pulsations still maintain their intensity, their frequency, and ATTENTIONS TO THE WOMAN. 467 habitual regularity, the rest of the process may be abandoned without danger to the powers of nature; but, on the contrary, if they are found to relax, or even to become more rapid, though at the same time more feeble, thread-like, and espe- cially if intermittent or irregular, every effort must be used to remove the foetus from the danger which threatens it. The signs furnished by the irregularity of the pulsations of the umbilical arte- ries, and to which great importance has been attributed by authors, only become sensible after the asphyxia has lasted for so long a time that it is not always possible to overcome it; therefore we regard as much more available the pheno- mena next to be mentioned. When the head alone remains behind in the pelvic excavation, the child is very often observed to dilate its chest actively, and make a violent inspiratory effort, which may be referred to a rapid convulsive contraction of the diaphragm and abdominal muscles, repeated at irregular intervals; now such acts never take place while the fceto-placental circulation remains intact, since the pulmonary respiration is unnecessary so long as the placental one is going on, and therefore these struggles constantly announce a state of suffering, or of imminent asphyxia, from which the infant must speedily be relieved. Where the head alone is un- delivered, the patient must be encouraged to bear down strongly, so as to hasten the termination of her labor, and avoid a prolonged compression of the cord; and the accoucheur might facilitate the flexion of the head by gently carrying the trunk up in front of the symphysis, or when the flexion appears difficult, he may, by insinuating two fingers under the symphysis, press slightly on the occiput; for a comparatively light force exercised on the posterior part of the head is often sufficient to reverse the great occipito-mental diameter, and terminate the labor. When the head resists all these attempts, other measures become necessary; but they belong to instrumental delivery, and we shall treat of them in the article on Version. Finally, should it be impossible to extract the head immediately, we may en- deavor to introduce the fore and middle fingers into the mouth of the child, and then separate them slightly, so as to leave an open space through which air might find its way to the mouth. The same object would be effected with still greater certainty, by introducing a large catheter into the mouth. It is not at all uncommon to find the meconium escaping in greater or less quantity during parturition; and, as previously stated, this peculiarity most fre- quently occurs in the positions of the pelvic extremity, and is then of little con- sequence; but this does not. hold good in any other presentation; for then its discharge is always an unfavorable sign, one calculated to arouse the anxious solicitude of the medical attendant, as it usually indicates a state of suffering on the part of the child, which is almost always due to a compression of the cord. It must be apparent, on the least reflection upon the part performed by the placenta during the intra-uterine life, that an interruption of the fceto-placental circulation produces asphyxia, which latter determines a cerebral congestion, and sometimes even an apoplectic effusion, whence a paralysis of the sphincter ani results. Now, if to this palsy of the sphincters, we add the instinctive acts of respiration1 made by the foetus, which are the more violent as they are the 1 Mayer has observed respiratory movements in embryos, even within the ovum, as soon as he compressed the cord. 468 • LABOR. more ineffectual, we can understand without difficulty how an escape of the meconium may result from a compression of the cord. As regards the prognosis, it is important to observe the precise moment at which this discharge takes place, as it is always serious when it does not occur till some time after the rupture of the membranes; though the waters, when they escape, are often colored yellow, and the presence of the meconium then is not necessarily an alarming symptom. In some cases, it may indeed indicate an actual compression of the cord; but it may also result from a compression that had existed some time before birth, which may have compromised the child's life for a few moments, and then have suddenly disappeared in conse- quence of some brisk movement of the infant. It is not difficult to conceive that the cord might undergo a momentary com- pression during the last months of gestation, as also that it might be displaced by a sudden motion of the child, and the fceto-placental circulation be re-esta- blished in consequence. Now, this compression may have lasted so long as to threaten asphyxia, and consequently to produce a discharge of meconium. Endeavors have been made to determine by the physical characters of the meconium, whether its discharge was occasioned by a presentation of the breech, or by the sufferings of the foetus. It has been said that, in the latter case, the meconium is very fetid, thinner, and more diluted, than when the breech is above the uterine orifice. Such signs, however, are very inconclusive. On the whole, therefore, a discharge of meconium in breech presentations is of little consequence; but, in the other presentations, and where occurring some time after the rupture of the membranes, it is always an unfavorable sign; though, to judge of its value at the time of the rupture itself, recourse must be had to auscultation. Finally, whatever may be the child's position, we should, contrary to the opinion of certain authors, abstain from introducing the fingers into the lower part of the vagina, or making pressure on the perineum and coccyx; in a word, from performing what they call their little labor. There are, however, a few measures which may be useful; for instance, when the genital parts exhibit great rigidity, heat, and dryness, the emollient injections, or frictions with mild ointments, such as cerate, or cucumber ointment, emol- lient fumigations, or bathing in lukewarm water, may be very advantageous. This last remedy, especially, is of marked utility where the abdomen is tender and painful, and the cervix uteri is rigid and resistant. ARTICLE III. REGIMEN OF THE WOMAN IN LABOR. Those women whose labors are unusually short, need not, as a general rule, take any nourishment whatever; but when the travail drags along, it is neces- sary to sustain their strength by articles of easy digestion; thus, as many arc in the habit of taking coffee with milk every morning, this may be allowed them without danger; and then, during the day, a few cupfuls of some broth may be given, though always in small quantities at a time. Where the stomach ATTENTIONS TO THE WOMfN. 469 is disordered and vomiting takes place, as very frequently happens, even these liquid aliments will have to be restricted. This plan, however, is not applicable in all cases, since some must be allowed what we should refuse to others; for example, there is no necessity for subjecting robust country women to the same severity of regimen as the delicate ladies of large cities. The choice of drinks is also a matter of some importance, and we may recommend some pure or sugared water, or a weak infusion of lime, or orange leaves, of mallows, violets, &c. Lemonade, or wine diluted with water, will be very agreeable to most women at first; but, in general, they soon produce a sour stomach and eructa- tions ; all hot cordials and fermented liquors should be positively prohibited. In the country districts, there is often much difficulty in overcomjng the vulgar prejudices on this subject; but the physician must insist upon it, for he ou°-ht never to lose sight of the distress and agitation that follow the administration of spirituous beverages, and which expose the patient to inflammations and active hemorrhages. Should it happen that her feeble condition requires any resto- ratives, then some good broth, or a little old wine, or a few spoonfuls of sherry wine, are the only and the best means that can be employed. The excretion of the fecal matters always demands attention, since pregnant women are usually costive, especially in the latter periods of their gestation; and it often happens that, when labor comes on, they have not had a passage for several days. The faeces accumulate in the rectum and obstruct the passage of the head in the excavation; besides, the pressure the distended intestine is then subjected to, is an occasional cause of inflammation of the gut, and facilitates the development of hemorrhoidal tumors. In the last stages of the labor, these matters are pressed on by the child's head, and the violent bearing- down then made by the woman occasions their involuntary expulsion; whereby the accoucheur's hand, which supports the perineum, is soiled, and the patient, who is aware of the circumstance, is greatly mortified. These dangers and little annoyances ought, therefore, to be prevented, by taking the precaution to admi- nister an injection early in the labor, so as to empty the bowel. The accumulation of urine in the bladder ought likewise to be prevented, by persuading the patient to urinate in the very commencement of her parturition; for, where she has not observed this precaution, or the physician arrives too late to insist upon it, the emission of water becomes more and more difficult, and sometimes quite impossible, owing to the compression which the head, engaged at the superior strait, makes on the neck of the bladder. In such cases, he should endeavor to push the head up somewhat by two fingers, so that she can urinate; and, if this does not succeed, the catheter must be resorted to. We have elsewhere stated that it was advisable, under such circumstances, to use a male catheter, the curvature of which is greater; though, even by taking this precaution, a considerable resistance is occasionally experienced to its introduc- tion. This condition requires the most careful manipulation; the woman must lie flat on her back, and then, while with one hand the womb is pressed back- wards from the strait, the other introduces the instrument into the urethra. The accumulation of urine is attended with such grave consequences as to warrant a persevering effort to introduce the catheter. The least of all the acci- dents which may result therefrom, is a relaxation, or even the total cessation of 170 LABOR. the pains; for the distressing sensation caused by a distension of this organ, which is increased when the abdominal muscles contract, induces the woman to suspend the contractions as much as possible; besides which, the pain itself is sometimes so acute as to paralyze, as it were, the action of these muscles; and again, as they are separated from the uterine walls by the mass of urine shut up in the bladder, their action is transmitted to the womb in but a very feeble manner. The paralysis of the bladder, so often met with after labor, is a com- mon consequence of prolonged retention of the urine; and, finally, the walls of this reservoir are occasionally ruptured just at the moment when the woman gives way to the most violent bearing-down. Doubtless this last accident is rare, but still it is not without example, since Ramsbotham, Sr., has observed two cases of the kind. (Obs. Pract., cases 89, 90.Y The tumor thus formed by the over- distended organ may easily be recognized, more particularly after the rupture of the membranes, by the soft, fluctuating tumefaction detected immediately above the pubis, extending at times nearly as high as the umbilicus, at the side of, and behind which, the hard resistant mass constituted by the uterus can be distin- guished, whose consistence varies according to whether the examination is made during or after a pain. Within a few years, Professor Simpson has introduced into obstetric practice the use of those anaesthetic agents, which are daily productive of such wonderful results in surgery. The Edinburgh accoucheur does not, however, reserve ether or chloroform for difficult cases, but advises their use in the most natural labors. The importance of the subject demands of us a detailed examination; and a long article will be found appended, in which, after having stated the known results, we shall give frankly our own opinions. ARTICLE IV. OF THE ATTENTIONS TO THE WOMAN IMMEDIATELY AFTER LABOR. The expulsion of the placenta and its annexes, whether spontaneous or assisted by the accoucheur, generally follows very shortly after the exit of the foetus. In order to avoid separating the study of this natural delivery of the after-birth from that of the difficulties and dangers which may attend it, we shall treat of them separately. (See Delivery of the After-birth.) After the delivery, the accoucheur should ascertain, both by the external exa- mination and the vaginal touch, whether the placenta has drawn down or in- verted the fundus of the womb, for the purpose of rectifying it at once if such an accident has occurred. If everything proves to be in its natural condition, frictions with the hand are to be made over the hypogastric region from time to time, in order to excite the retraction of the uterus, and thus favor its disen- 1 The symptoms of thi3 accident are very similar to those of a rupture of the womb, ex- cepting that the child remains in situ. There is, besides, a sudden and sharp pain in the vesical region, and the patient complains of the sensation caused by the effusion of the liquid into the abdominal cavity, syncope, &c. The signs peculiar to the vesical rupture are the collapse and disappearance of the tumor previously formed by the bladder (which could be felt above the pubis), and an obscure fluctuation in the belly. ATTENTIONS TO THE WOMAN. 471 gorgement, and the expulsion of the coagula which may be still contained there. The patient is allowed to remain for some minutes on the bed where she was delivered, so as to give her a little repose, as well as time to the uterus and vagina to clear themselves of the blood, which flows at first in abundance, and would soil the linen in which she is about to be enveloped. Besides, a few minutes are ordinarily devoted to paying those necessary attentions to the infant, hereafter pointed out. In fact, she might remain upon the same bed a still longer period, when the delivery has either been preceded or followed by syncope, hemorrhage, or any other accident, or even where there is reason to fear some- thing of this nature, taking care, however, to substitute dry things for those that have been soiled. She ought to lie perfectly flat, the thighs stretched out along- side of each other, lightly covered, and be left in silence, and the most absolute rest both of body and mind. In about half an hour, the patient will again require special attention; the genital organs, and upper part of the thighs, are to be first washed carefully and gently with lukewarm water, pure or mixed with a little wine; then they are to be wiped with warm and well-dried towels, and all the garments worn during parturition that have been soiled by the perspiration, discharges, and fecal matters, are removed, and replaced by others, previously well dried and warmed; their shape is unimportant, the only point requisite is to have them large enough not to incommode the woman in any way, and to admit of being changed easily and promptly. The greatest celerity is to be used in this toilet, lest she should be long exposed to the air; the arms and breast particularly ought to be well clothed, so that the patient may, during the day at least, keep them out of bed without danger of taking cold. All these preparations being completed, she is next to be transferred to the bed intended for her reception during the lying-in. Many females, finding them- selves well enough, want to walk across to the permanent bed; but against such an imprudence the physician must interpose the whole weight of his authority. The one to which she is to be transported must be previously warmed, and pro- vided with a sufficient amount of covering that can easily be changed; though the coverlets should not be thicker or more numerous than those used before pregnancy. There is a custom much in vogue of surrounding the belly with a moderately tightened bandage; and the women, for the most part, attach the highest im- portance to this measure as a preservative against the wrinkles and folds that are found after labor on the skin of the abdomen, as also to prevent the latter from remaining too voluminous. Their desires may be yielded to the more willingly, as such a bandage, when moderately drawn, supplies the pressure no longer afforded by the abdominal walls, and thereby prevents the afflux and stasis of the fluids, the engorgement of the uterine walls, and the dilatation of the cavity of this viscus; and it has the further advantage of obviating the tendency to syncope, and of diminishing the after-pains. But, in order to obtain all these benefits, it should be large enough to compress the whole sub-umbilical region equally. Care should be taken to prevent its becoming doubled up, whereby a circular cord is formed, which, from opposing the ready return of the fluids, would then prove a cause of hemorrhage. Some women, influenced by a feeling of coquetry, also desire to compress their 472 LABOR. mammae by means of a bandage, with a view of preventing their enlargement, and their consequent softness and flaccidity, and some even go so far as to apply topical astringents for the purpose of obviating an over-abundant secretion of milk; but such measures should be proscribed in the most absolute manner, since they might prove very dangerous. These organs only require a sufficient amount of covering to protect them from the contact of the external air, and to maintain a proper degree of heat. Before proceeding to the consideration of the proper government of the lying- in woman, it seems indispensable to first point out the principal phenomena that take place after delivery, as the importance of the hygienic precepts we are about to lay down will then be much better understood. ARTICLE V. OF THE PHENOMENA APPERTAINING TO THE LYING-IN STATE. This term is applied to the period immediately following the delivery, during which the uterus and genital organs, and indeed the whole economy, gradually return to their ordinary condition. The attendant phenomena may be divided into the natural, and the unnatural or morbid, including under the latter head all the diseases to which the lying-in woman is exposed; but the former only claim our attention here. A feeling of depression, or lassitude, such as that experienced after an unusual or an immoderate exercise, succeeds the agitation caused by the labor; and it not unfrequently happens that the patient has scarcely reached her bed, when she is attacked by a chill, severe enough at times to produce a chattering of the teeth; but this soon passes off, the pulse increases in strength, the heat of the surface returns, the skin becomes humid, a salutary moisture appears, and the various functions are re-established, while the most perfect calm and the most delightful slumber replace the past disorder. Now, although this slumber of the patient is to be respected, nevertheless it is desirable that it should not take place until a few hours after the delivery, unless the physician should be at hand to watch attentively over the state of the circulation, and the condition of the womb during this recuperative repose, because some women have been attacked when in this state with internal discharges, and have awakened exhausted by the loss of blood. Therefore, although on account of the rarity of this accident the patient should not be prevented from sleeping, it is necessary to watch over her during her slumber, or at least to have her carefully observed by an intelligent nurse. After the first nap is over, she might sit up in bed a few moments to take a little broth, as this position refreshes her, and also facilitates the escape of the lochia that had accumulated in the vagina. The pulse, which was frequent and contracted immediately after the delivery, now becomes soft and developed. The patient is the more enfeebled as the loss of blood has been greater, or the duration of the labor prolonged. The nervous susceptibility is also highly exalted, and the skin, whose activity was diminished during gestation, now regains a more exalted vitality; it is soft, humid, and is always covered with a dewy perspiration during the first week. ATTENTIONS TO THE WOMAN. 473 This sweat is sometimes very abundant, particularly when she is too warmly covered, and it is not at all unusual to find it followed by a miliary eruption and a distressing pricking sensation. Such eruptions were exceedingly frequent in former times, when it was thought useful to push the skin, as it was called, and to make the woman perspire by surrounding her with thick coverlets; now, on the contrary, they are quite rare, and, where they do show themselves, are easily made to disappear by taking the necessary precautions to diminish the cutaneous secretion. In general, the secretion and excretion of urine do not present anything pecu- liar; occasionally, however, its emission is obstructed by the swelling of the mea- tus urinarius, or the bladder is momentarily paralyzed by the prolonged labor, and the excessive compression it has undergone, and the catheter must then be resorted to. Hence, it is always necessary to inquire whether the patient urinates freely and easily during the first two or three days; for an accumulation of water in the benumbed and half paralyzed bladder would often account for the uneasi- ness and suffering that could not otherwise be explained. The constipation, that is so common during the last stages of gestation, often- times still persists after the delivery for four, six, or even eight days; and this prolonged retention of the fecal matters may give rise to anxiety, headache, loss of sleep, and sometimes even to a feeling of weight, or actual pain in one of the iliac fossae; all which symptoms disappear like magic upon the administration of some mild laxative. Where the costiveness continues, a state of suffering very frequently results, which may occasion a slight febrile movement; and the fre- quency of pulse, thus produced, coinciding with the pain caused by an unusual retention of the fecal matters, which pain is most commonly located in some part of the hypogastric region, and is augmented by pressure, may give rise to sus- picions of a peritoneal inflammation that really does not exist; and I have known this error to be committed where the pain and fever that had resisted the appli- cation of leeches, rapidly disappeared after the exhibition of a purgative. The retention of the faeces may also result from a paralysis of the rectum, which para- lysis is itself a consequence of the pressure made upon it by the head during its prolonged sojourn in the excavation. I have known, says M. Martin, of Lyons, the faeces to be retained more than twenty days after a laborious delivery, and to accumulate in such large quantities, and acquire such a firm consistence as to equal the size of a child's head at term; and, as all the usual laxatives failed, I was obliged to introduce a scoop, and bring the hardened matters away piecemeal; but even then the gut did not at once regain its functions, though a fresh accumulation was prevented by the use of irritant injections, and the contractility of the intestine was not perfectly re-established until twenty-nine days afterwards, at which period the patient left the hospital. ( Comptes Rendus, p. 32.) Let us now study the important modifications that take place in the genital organs, as they gradually tend towards a return to their primitive state. There is then a rhythmical contraction established in the womb, that is, an alternation of expansion and contraction, until the latter finally reaches the point where it ceases altogether: thus, if we examine the relaxed walls of the abdomen imme- diately after the child's birth, the uterus will be found constituting a tumor above 474 LABOR. the pubis, about ten inches in length by seven in breadth; but in the course of a few days, this length diminishes to six inches; and though in thin women particularly those who have often had children, the womb still remains at the end of two weeks about two fingers' breadth above the pubis, yet the fundus in primiparae, more especially in such as are at all inclined to embonpoint, cannot be distinctly felt after a week; and by the end of the sixth week this organ has nearly regained its primitive condition, being still, perhaps, a little larger, and more relaxed than usual. The rapidity with which the uterus after delivery tends to resume the volume and dimensions which it possessed before impregnation, is, to say the least, quite as surprising as the rapidity with which it underwent its enormous hypertrophy during gestation. An examination of the various changes through which this rapid absorption is effected, induced M. Retzius, of Copenhagen, to conclude that it is preceded by a fatty degeneration of the muscular fibres. He asserts that, during the lying-in, a larger amount of globules of fatty matter are detected in the blood by the microscope than is the case under ordinary circumstances. This diminution in the size of the uterus is not always so regularly graduated, for it will be seen hereafter, that when the contractility of the tissue has been feeble after delivery, the walls of the uterus often preserve a considerable thick- ness for four or five days, the fundus being found all this time close up to the umbilicus. The same observation may be made at a still later period, in cases where an inflammation of the peritoneum, of the uterine mucous membrane, or of the neighboring organs has supervened. Again, it happens that, after having been diminished, its volume augments anew, for some hours, at times, even for a day or two, and then soon returns to its former size. I can explain this cir- cumstance only by supposing some local congestion, which has not been acute enough to produce an active hemorrhage, but whose action has been limited to distending and engorging the uterine vessels, and consequently to increasing the thickness of the walls; or this abnormal volume may be owing, in certain cases, to the presence of newly formed coagula. But, however that may be, I felt bound to point out these anomalies, to prevent the inexperienced practitioner from falling into an error. The condition of the internal surface of the uterus, after delivery, has of late been studied attentively by M. Colin; who, although deceived as to the nature of the lining membrane, has at least given a much better description of it than any writer who has preceded him. He states that, a few hours after delivery, the internal surface of the womb is covered with clots of blood, which, upon being removed, discover a soft, moist, reddish surface, occasionally presenting in some points an uneven and gashed appearance. Very soft, filamentous laminae adhere to this surface, and may be pinched up by the fingers, or raised by immersing the organ in water. If the surface be scraped with the blade of a scalpel, a layer varying in thickness from the one-eighth to the one-sixteenth of an inch may be raised from it. This layer, which increases in thickness towards the middle and fundus of the organ, is of a reddish-gray color and friable, tearing like a newly-formed pseudo-mem- brane, and even giving way beneath the fingers. Below it is found the muscular tissue, of a white or grayish appearance, entirely distinct from this layer, and ATTENTIONS TO THE WOMAN. 475 easily recognized by its clearer hue, the appearance of fibres and their transverse direction, as also by its greater consistency. The point of attachment of the placenta is marked by a much greater thick- ness of the mucous membrane. There the surface is mammillated, rounded, anfractuous, and projecting to the extent of a quarter of an inch above the level of the surrounding surface. The anfractuosities are filled up with coagulated blood, which is removed from them with difficulty. These inequalities, which have been regarded by some anatomists as tufts des- tined to dip down between the cotyledons of the placenta, are due, according to Desormeaux, to the excessive distension which the arteries and veins, the last especially, have undergone during pregnancy, and upon the slowness of their subsequent retraction; though, according to Velpeau, they are owing, in women that die shortly after delivery, to the swelled and fungous character of that por- tion of the internal uterine surface which corresponded to the placenta. We prefer the following explanation, given by M. Jacquemier, viz., the internal mus- cular layer of the womb is perforated in all the space occupied by the after-birth, by a great number of holes, which give a peculiar aspect to this portion of its inner surface, and render it less contractile than at other parts; and conse- quently, as the organ retracts, it has a tendency to project into its cavity, and when it arrives at the final state of repose, a tumor is formed, which is ordi- narily larger than the palm of the hand, with a very irregular lacerated surface, spongy, as it were, in character, and often standing out in considerable relief; the torn utero-placental vessels are comprised in this mass, which renders them tortuous and nearly inextricable. But whatever the explanation may be, it is highly important, adds M. Jacquemier, to bear this arrangement constantly in mind, for an attentive perusal of several cases of artificial delivery of the after-birth, has convinced me that, in those instances, the tumor formed by the most internal layer of the womb was mistaken for debris of the placenta, which the medical attendants endeavored ineffectually, though not without danger, to extract. At the upper boundary of the cavity of the neck, this membrane is terminated by an irregular edge projecting above the latter, and from which are put forth small shreds or laminae, from one to three-sixteenths of an inch in length, of the same nature as the layer covering the wall of the uterus. The cavity of the neck contains a glutinous, transparent, and slightly-reddish mucus. The color of its internal surface varies greatly according to the mode of death, from a reddish-gray to a blackish-brown. The thickness of the mucous membrane lining the cavity of the neck varies from the one-thirty-second to the one-sixteenth part of an inch; it is very moist and flexible, although firm and torn with difficulty. It remains intact, and does not participate in the exfolia- tion which that of the body undergoes. The condition of the mucous membrane at a period still more remote from delivery, has also been studied by M. Colin. Thus, from the twenty-eighth to the thirtieth day, the membrane has assumed a rose-red or grayish color, espe- cially in the vicinity of the neck; it is smooth, moist, and soft, but resists the action of a stream of water, though it may be scraped off entirely by the scalpel, so as to expose the muscular fibres. Numerous vessels, whose greatest diameter 476 LABOR. does not exceed the one-ninetieth part of an inch, proceed from the muscular tissue, and ramify ad infinitum in its substance. By the fortieth day, the mem- brane is of a rather deep red color, opaque, and of about the one-thirty-second part of an inch in thickness, toward the fundus; it is semi-transparent and thinner in the lower part of the body, where it is continuous with the mucous membrane of the neck, which presents no peculiarities. It is soft, and easily removed by the back of a scalpel. It is traversed by a very close network of capillary vessels. By the sixtieth day, it is smooth, gray, and traversed by small vessels; it has the true consistency of a mucous membrane, and the scalpel re- moves from it but a slight pellicle, which has no longer the pulpy appearance of the substance detached from it at an earlier period. This new mucous membrane, which, according to M. Robin, begins to be formed by the fourth month of gestation, is, therefore, after delivery, the seat of a reparatory process, which ends in the completion of a new mucous membrane. The mucous membrane of the neck is not thrown off; it is simply hypertrophied during pregnancy, and after delivery continues to exhibit the arbor vitae, though of a somewhat modified form. Professor Stoltz has studied the modifications that occur in the neck of the uterus, after the delivery, with a great deal of care, and we extract the following passage from his excellent thesis on this subject: "As soon as the child is born, the cervix is partly formed anew, but it is soft, short, wide, and irre- gular, and one or more fingers can easily be made to penetrate it; the inter- nal orifice offers the greatest resistance, as is proved when an attempt is made to introduce the hand into the womb, for it enters with considerable difficulty, and only when this orifice has been progressively dilated. The latter is some- times so contracted as to induce inexperienced persons, who endeavor for the first time to carry the hand up into the womb, to believe they have succeeded, when in fact they have only reached the dilated vagina, where they find a large cavity, but no opening to get any further, and the clots of blood, then collected at the upper part of the vagina and around the cervix, add still more to this confusion." The internal orifice, formed after the expulsion of the child, offers but little resistance; and, consequently, it has scarcely occasion to dilate again for the passage of the placenta, as it yields readily; and when the delivery of the after- birth is effected, the womb contracts, and the neck becomes longer, and more consistent; although it must again open several times to permit the numerous clots of blood to escape. During the lying-in, it gradually returns to its natural size; sometimes, even, it is longer; but it acquires the ordinary disposition more or less, as it regains its proper consistence, and, by the end of the first month, it generally exhibits about the same dimensions as it had prior to gestation; at times, however, it is a little shortened, but the consistence is nearly as firm as usual, although the inferior part has seemed to us rather more softened. It no longer presents a conical shape, but is more cylindrical, from the fact of the summit having become larger. As a general rule, the scars on the lips are pro- portionally more numerous, as the patient has had a greater number of children, and her labor has been more tedious. The transverse fissure is deeper, and more angular; and, in such women, the upper part of the cervix is sometimes larger ATTENTIONS TO THE WOMAN. 477 than the base, though it is much shorter than usual, and at times is divided into two lips that are more or less flat, broad, and uuequal, and the anterior of which is longer than the posterior; indeed, in some cases, the latter seems to have been altogether destroyed, while, in others, it is well marked, and the anterior one is scarcely perceptible. In fact, almost as many varieties exist on this point as there are different subjects. The vagina becomes shorter, and the ridges that were effaced during the last Btage of labor, gradually but slowly reappear, and the orifice of this canal, and the vulva, also regain their primitive condition. At first, the labia externa, as well as the perineum, are thin and distended, and the posterior part of the con- tour of the vulva is flabby, wrinkled, and projecting outward. Sometimes the epidermis is fretted, at others, actual lacerations are found, which produce a smarting sensation; and as to the fourchette, it is almost inevitably torn in the first labor. The broad ligaments seem to re-form by the • approximation of their two constituent layers, while the round ligaments gradually become shortened and retracted. The abdominal muscles and integuments, which were at first soft and flabby, and exercised but a very imperfect pressure on the viscera and vessels contained in their cavity, again retract; although this process is very often incomplete in women of a soft fibre, or who have had many children. This slow and gradual retraction of the uterus takes place, in some instances, without the least pain, and without the knowledge of the patient; but it more generally becomes intermittent and distressing, and, as the sufferings the women then experience have a great analogy to those of childbirth, they are called the after-pains. At the same time, a more or less abundant discharge takes place from the vulva, consisting at first of pure blood, then of blood mixed with a white fluid, and, lastly, of a white sero-purulent liquid; and these discharges have received the name of the lochia. Finally, a function altogether new sets in, in the course of the first few days, which may be considered as the complement of the puerperal functions; this is the milk secretion, whose onset is attended by certain general phenomena, which are ordinarily described under the term of the milk fever; we shall therefore have to examine, in turn, these three principal phenomena of the lying-in state. § 1. Of the After-Pains. The after-pains are certainly occasioned by the contraction of the womb; to be satisfied on this point, it is only necessary to place the hand over the hypogastric region, when we will ascertain that the uterus becomes harder just at the moment when the patient complains the most. These pains are much more frequent and intense in women who have borne many children, than in primiparae; as, also, after an easy than after a long and painful labor; and when the womb encloses some foreign body, such as coagula, or a portion of the membranes or pla- centa, than when its cavity is entirely empty. Now, all these differences in character will be readily comprehended, if the reader will only bear in mind that the object of the contractions is to express from the uterine parietes those liquids with which the walls are still engorged after the delivery, and to expel from its 478 LABOR. cavity all the foreign substances contained therein; that, in very prompt labors, the organ, from being evacuated too rapidly, does not retract so perfectly as it ought, and allows the blood to coagulate and accumulate in its interior, and that the very feeble contractility of its tissue forces out but very imperfectly the fluids remaining in the thickness of the walls. The pains generally commence soon after the delivery, being at first feeble and distant, then more frequent and painful; and, at the moment of their occurrence, the uterine globe retracts, becomes harder, more resistant, and sometimes even seems to rise up, by resting on the posterior plane of the abdomen, as a point d'appui, and projecting in the form of a globular tumor, through the walls of the abdomen. The escape of the lochia is ordinarily more abundant towards the end of, or just after each pain, and not unfrequently a few small coagula come away from the vulva; but, where the uterus contains a large one, the pains con- stantly increase in force and frequency, until it is expelled, after which they again diminish. In most cases, they cease during the milk fever, though they may continue for the first seven or eight days. Sometimes they return after having entirely disappeared, are followed by the discharge of a little blood from the vulva, or the expulsion of a clot, or of a portion of membrane that has remained in the uterus, and then everything returns to its natural condition. As regards the diagnosis, it is highly important to distinguish the after-pains from those caused by a peritoneal inflammation, but fortunately this is not very difficult; for, however strong the after-pains may be, they are generally inter- mittent, and are separated by an interval of variable duration; besides, the dis- tress attendant upon them is rather alleviated than augmented by pressure, and a rather more abundant lochial discharge accompanies or follows them. While they last, there is an absence of febrile movement; finally, when the child seizes the nipple, especially if the latter is the seat of any ulceration, the suffering thereby caused most frequently brings on an after-pain, and this circumstance alone has often sufficed to make them reappear, even after a suspension of seve- ral hours. When existing, these differential characters are quite sufficient to distinguish them, but unhappily they are not always so well marked; for, where they are very acute, or follow each other in rapid succession, they are accom- panied by fever, and sharp pains in the hypogastrium. But even then, there is always a remission, which, conjoined with the absence of the other signs of peri- toneal inflammation, may aid in determining their character. Dr. Dewees states that he had several times an opportunity of observing a sin- gular pain which was manifested almost immediately after the delivery, and yet was altogether different from the ordinary after-pains. It is a very acute pain, referred by the patients to the lower part of the sacrum and coccyx. It com- mences as soon as the child is born, and continues without interruption, and of a frightful intensity. It is declared by the patient to be vastly more insupport- able than the after-pains, for it is quite as violent, besides being constant; the latter character serving as a ready means of distinguishing it. Camphor and opium appeared to him the most successful means of relieving it. The after-pains, of which we have just spoken, are sometimes so severe as to claim the attention of the physician, and although they may be useful when caused by the retention of a foreign body, they are so annoying, that it is cer- ATTENTIONS TO THE WOMAN. 479 tainly advisable to endeavor to prevent them. Dewees states that this may often be effected by observing the following precautions: 1. Do not rupture the mem- branes before the neck is completely dilated; 2, after the head is born make no tractions, but allow the uterus to expel the shoulders and trunk; 3, do not ex- tract the placenta until the womb is thoroughly contracted; 4, after the placenta is delivered, excite the womb so as to oblige the muscular fibres to contract as much as possible. It is evident that all these measures have for their object to insure the slow and complete contraction of the walls of the uterus, in proportion as its contents are expelled. In the cases of women who have suffered much from after-pains in previous confinements, I have made it a practice to administer a few doses of ergot imme- diately after delivery, with the effect, I have thought, of preventing their occur- rence in many cases, or at least of lessening their violence. When the womb contracts feebly, it has seemed to me of advantage to add pressure upon the uterus to the use of the ergot. This is done by means of the ordinary bandage, and made more effectual by placing a compress, formed of one or two folded towels, upon the fundus of the organ. If the after-pains are feeble, nothing need be done; if, however, they are very violent, the physician should interpose. Provided the patient has not suffered from hemorrhage, or been threatened with it, we may begin by placing warm and emollient cataplasms upon the abdomen. Lotions containing laudanum may be used upon the belly, and the cataplasm may be wet with the same substance. An injection may also be given of from twenty to forty drops of Sydenham's laudanum, in as small an amount of vehicle as possible. Dewees professes to have derived great advantage from a camphor mixture, consisting of a drachm of camphor to six ounces of vehicle, a tablespoonful to be taken every hour or two. When the mixture disagrees with the patient, ten grains of finely-powdered camphor, every hour or two, mixed in a little syrup of any kind, may be sub- stituted for the julep just mentioned. When the after-pains are accompanied by signs of general plethora, blood may be taken from the arm. Finally, should there be cause to suspect the presence of large clots or portions of the membranes in the cavity of the uterus, one or two fingers may be introduced within the neck, in order to seize them, or at least to bring about their expul- sion. These are, perhaps, the only circumstances under which the use of ergot, so highly vaunted by Crozat and Velpeau as a remedy for after-pains, is likely to be successful. § 2. Of the Lochia. Of all the various excretions that take place after the delivery, the lochia are certainly the most interesting to us as practitioners. This name is applied to the matters that escape from the vulva during all the period from the delivery of the after-birth, until the womb has regained its normal size and consistence. The order in which these discharges appear has been very accurately described by Desormeaux, as follows: Immediately after the delivery of the placenta, and the escape of the accompanying blood, all further sanguineous discharge becomes temporarily suspended, probably because the blood that transudes from the sur- face of the womb accumulates in the cavity of that organ; but the pure fluid 480 LABOR. soon begins to flow again, although, in the course of twelve or fifteen hours, it loses its consistence, and its color becomes lighter, and, after a short time, it is changed into a bloody serosity. When the milk fever comes on, which is usually in about forty-eight hours after the parturition, the flow of the lochia is either diminished or entirely suspended. When it is over, the bloody discharges reappear, and continue during the four or five succeeding days, though with characters varying greatly in different individuals : thus, in some women, those especially who menstruate profusely, they appear with the same characters, quantity excepted, as before the milk fever. They are still composed of pure blood, which sometimes contains numerous small clots; with the majority, how- ever, they become more and more serous, though still exhibiting here and there some bloody streaks, or perhaps are slightly tinged by the blood, the quantity of which diminishes every day. It usually disappears altogether about the sixth day; the lochia being thenceforth composed of a more or less consistent yellowish-white liquid, and they thus continue for two or three weeks or a month; though in some women, who do not nurse, they do not pass off until the menses reappear, that is, in about six weeks or two months after the delivery. These discharges have been divided, according to their color, into the sangui- nolent, the serous, and the milky, puriform, or purulent lochia. As the uterus retracts, its walls gradually disgorge the fluids they had imbibed, and these naturally run towards its central cavity. So long as the large venous canals in its substance are not empty, the discharge consists of pure blood; somewhat later, it is composed of serum, together with the detritus of the ovum and the mucosities of the organ; and still later, a true suppurative irritation is established, the products of which, analogous in some respects to the non-contagious dis- charges of the urethra, constitute, in a great measure, the white or the purulent issue. The lochia have a peculiar odor, called gravis odor puerperii, which varies in strength according to the individual and her habits of cleanliness ; and to this is also added the scent from the perspiration and the milk, which latter, distilling from the breast, is imbibed by her garments and turns sour. Sometimes the lochia become fetid, and where this circumstance is not owing to slovenliness, it is always an unfavorable sign, since it most generally announces that coagula or some other foreign substances are putrefying in the uterus; and where the lochial fluid has the color of coffee-grounds, and a cadaverous smell, it is almost uniformly an evidence of the existence of an inflammation of the womb or vagina, which has terminated in gangrene. Again, whenever the patient is afflicted with carcinoma uteri, the discharges resemble the washings of flesh, and have a very nauseous smell. In all such cases aromatic injections, infusions of elder or chamomile flowers, for instance, should be made several times a day. The lochia are also very variable in quantity and duration, though we may state, as a general rule, that the patient soils ten to twelve napkins in the course of the first twenty-four hours; but after the milk fever is over, the flow dimi- nishes more and more, its amount being usually proportionate to that of the menstrual evacuation. It is more copious in women who have borne many children, or who make use of an over-nourishing or a heating regimen, and in ATTENTIONS TO THE WOMAN. 481 those who do not nurse. The sanguineous discharges vary much in amount during the first days, according to the force of retraction with which the uterine walls were endowed immediately after or during the delivery of the after-birth; thus, at times, they are very copious, frequently coinciding with a considerable development of the organ; and, in such cases, I have known the womb to con- tinue as high up as the umbilicus for several days after the delivery. This condition, which Leroux calls humoral engorgement, depends, in his esti- mation, on the fact that the vessels and pores of the womb, from being distended with blood, do not become empty as soon as usual, because the contractility of tissue is not then active enough to expel it; for the walls of the uterus con- stitute a true sponge, whose meshes are composed of muscular fibres, and which must retract forcibly so as to express all the liquids contained in the vessels and vacuities which they form; hence, if this contraction is not strong enough, the parietes remain engorged, and preserve an abnormal thickness, which singu- larly augments the whole volume of th,e .uterus, although its cavity may be en- tirely effaced. Soon, however, the contractile action of the tissue is aroused, and the muscular fibres forcibly compress and flatten the vessels that ramify between them, and thus force the liquids which had hitherto remained there to discharge into the cavity of the organ, whence they flow towards the exterior in conside- rable quantities. This discharge might very readily be mistaken for a flooding, occasioned by a retention of some part of the after-birth, or of voluminous coagula, the more especially as it is accompanied at times by sharp after-pains; but if one finger can then be introduced into the uterus, the accoucheur will ascertain that it contains no foreign substance, and by placing the other hand at the same time on the hypogastric region, he will easily satisfy himself that the unusual size of the organ depends only on the engorgement of its walls. In these cases, there is nothing to be done, as the sanguineous discharge is itself the best remedy; for it slowly empties the uterine texture, diminishes the after-pains, and the womb gradually returns to its normal size. This slowness of the retraction also prolongs the flow of the sanguineous lochia, and the same result is observed whenever one of the layers of the uterus or its enveloping cellular tissue is affected with inflammation. Indeed, we can readily understand that from this sluggishness of the uterine fibres, this defect of reaction, as Leroux called it, to a more or less perfect inertia of the womb, there is but a single step, and that a secondary hemorrhage might result from the absence of contractility, if it were carried to the extent of relaxation. Lactation lessens the duration and amount of the lochia. Some women have them for a few hours only (Van-Swieten), and others have none at all (Millot). An instance of the latter kind came under my notice quite recently (1855), in the case of the young wife of a medical friend. After an easy and happy labor, the lochia were almost completely suppressed. She hardly lost a few spoonfuls of blood within the first twenty-four hours; after the second day there was no discharge whatever, and the husband, who examined the linen daily with the greatest care, assured me that he was unable to detect the slightest evidence of lochial discharge. Everything went on well during the lying-in, with the excep- tion of a very fetid odor from the genital parts during the first seven or eight days. After satisfying ourselves that there was no foreign substance in the 31 482 LABOR. uterus, we recommended the use of injections, frequently repeated, and all passed off well. This young lady had been delivered once before, on which occasion she had a perfectly regular lochial discharge. In a case observed by Bruckmann, and quoted by Velpeau, the lochia were substituted by haematemesis. In some instances, the sanguineous lochia are prolonged far beyond the usual term; while, in others, they reappear at various intervals, though this latter cir- cumstance, in the absence of inflammation of the uterus or of its appendages, is ordinarily owing to some error in regimen, more especially to getting up too soon; and, therefore, the best plan is to persuade the patient to remain in bed. In the course of a short time the lochia cease their continual flow, and intervals of several hours of duration are observed at first, then of a day, and sometimes of two days. When, in spite of this precaution, the bloody discharge continues for two or three weeks after labor, its cause should be sought for in a local alteration of the uterus and of the neighboring parts, or else in the general condition of the patient. Thus, it is not unusual for it to be kept up by a circumscribed peritoneal inflam- mation, an inflammation of the uterine mucous membrane, a chronic or acute engorgement of one or both ovaries, or a phlegmon of the broad ligaments, of the iliac fossa, or of the cellular tissue surrounding the uterus. It is important to diagnose these various affections from the outset, as it is they which should be attacked, in order to stop the discharge, which is here but a symptom of the disease. The continuance of red discharges is connected, perhaps, more frequently with ulcerations of the neck of the uterus, having their origin in many cases in the lacerations which occur during labor, and the cicatrization of which is prevented by circumstances which elude our detection. When, therefore, it is certain that no symptom of engorgement or inflammation in the pelvic or hypogastric region is present, the patient should be examined with the speculum, taking care to separate the lips of the neck with the valves of the instrument, when very often a fungous and bleeding ulceration will be discovered either within the cavity of the neck or upon the os tincae. The only means of arresting the discharge con- sist in cauterizations with nitrate of silver or acid nitrate of mercury, and even if the fungosities are very projecting, with the actual cautery. In some cases, it is necessary to repeat the cauterizations several times. Amongst the causes of these anomalous lochial discharges, should be reckoned a local irritation sustained by obstinate constipation. Here the use of purgatives is demanded. Sometimes no lesion can be discovered, but the discharge seems evidently to be connected with an over-excited condition of the entire organism. This con- dition is indicated by heat of the skin, fulness of pulse, some febrile movement towards evening, and disturbed sleep. Notwithstanding the apparent weakness of the patient, great care should be taken in reference to the use of tonics, which, unfortunately, are too often employed; a moderate antiphlogistic treat- ment, on the contrary, is the one indicated. A small bleeding from the arm, mild laxatives, and a restricted vegetable diet, might be directed with advantage. Stimulating or even tonic drinks should be proscribed, and only after the general ATTENTIONS TO THE WOMAN. 483 irritation shall have been quieted, is it proper to endeavor to increase the strength of the patient by the appropriate means. In some rare cases, however, the abundance and persistence of the bloody dis- charge seem to be sustained by the general debility. The absence of the general symptoms, just now mentioned, allow of recourse being had immediately to a tonic treatment; then it is that infusions of cinchona and sulphate of iron are capable of rendering effectual services. (See in Part Fifth the article devoted to Secondary Hemorrhage.) The white or purulent lochial discharges sometimes become very profuse, and have at the same time an exceedingly disagreeable odor. The discharge is no longer colored with blood, but appears as a reddish water flowing in large quan- tity, and sometimes even escaping in gushes. They are occasionally so acrid as to inflame the parts over which they flow. The patients are almost always much weakened by the evacuation, and their general health evidently demands the use of tonics. The irritated parts should be washed frequently with warm water, and injections of infusion of chamomile flowers, afterwards made rather more astrin- gent, should be thrown into the vagina five or six times a day. A few spoonfuls of chloride of soda might be added with advantage. My friend, Dr. Casaubon, informs me that he has met with several cases of this kind. These purulent lochia, also, sometimes continue long after the usual period of their cessation. This circumstance is sometimes connected with some one of the causes mentioned as productive of the anomalous persistence of the bloody dis- charge, though it has oftener seemed to me to be the result of a catarrhal metritis or peri-uterine phlegmon. Both these affections may hinder the gradual retrac- tion of the uterus, which may remain of considerable size for a month or six weeks after delivery. Large flying blisters upon the abdomen, frequent alkaline baths, and bleeding from the arm, when there is fever and the strength permits it, have appeared to me to be the most effectual under these circumstances. The suppression of the lochia long before the time at which they usually dis- appear, is an unfortunate symptom only when it seems to be connected with the development of a serious inflammatory affection, or when it is replaced by a sup- plemental hemorrhage. It then merits the closest attention of the physician; but when the contrary is the case, there is no occasion for uneasiness, since it is the evidence of a rapid and forcible contraction of the uterus, which is a favor- able circumstance. § 3. Of the Milk Fever. One of the most important phenomena appertaining to the lying-in state, is that usually designated under the name of the milk fever. It has already been seen, when studying the modifications impressed on the whole organism by ges- tation, that the breasts in most women, even in the very commencement of their pregnancy, are apt to become tumefied, that the swelling persists, and that some- times they become the seat of an abundant secretion long before delivery. After the delivery, they yield on suction a liquid of a yellowish color, and some- what more consistent than the preceding, which in some women escapes during the latter months of gestation. This fluid has a sweetish taste, and is called the colostrum. It retains these qualities for twenty-four hours; but becomes whiter 484 LABOR. after that period. In the course of forty to sixty hours, the breasts enlarge greatly; the subcutaneous veins, seen through the skin, are more swollen than during the pregnant state, and the former become manifestly harder. Headache very often accompanies this enlargement, as also, at times, though more rarely, slight shiverings, or heat and dryness of the skin, which is succeeded in a few hours by a copious perspiration; there are thirst and loss of appetite; the tongue is slightly furred ; the pulse, at first small and contracted, soon becomes full, soft, and accelerated; and the face is flushed and animated. During this febrile movement, which is generally slight, though in certain cases the symptoms may acquire a great degree of intensity, the enlargement of the mammae continually increases, extends as far as the arm-pits, and involves the surrounding cellular tissue, whence the patient can no longer bring the arms down alongside of her body, and therefore has to hold them off. The skin is sometimes so stretched as to become painful and incommode the inspiratory movements of the chest; and lastly, as elsewhere stated, the discharge of the lochia either disappears altogether, or else is greatly diminished. This fever lasts for twelve, twenty-four, thirty-six, or possibly forty-eight hours; and then is followed by a calm; at times,however, it is continued for three or four days; but, in such cases, it is often due to a deep-seated inflammation, or else soon exhibits a well-marked intermittence, and may degenerate into a true intermittent fever, which yields readily to sulphate of quinine. The pulse is ordinarily not very rapid, and whenever it exceeds 100 per minute, the cause should be sought elsewhere than in the lacteal secretion. Authors have stated that the milk fever is less intense with primiparae than with others. The same is the case with those who begin to suckle their children very soon after delivery; indeed, it is not at all uncommon for the latter to escape it entirely. Finally, certain females, even of those who do not nurse at all, have no milk fever whatever, and this notwithstanding that the breasts are consider- ably swollen and the secretion of milk is abundant. This is a much more com- mon occurrence than is generally supposed, and I have frequently had occasion to point it out to students. Still, I am far from supposing, as some do, that it forms the rule, and from regarding every febrile movement occurring in a lying- in woman, even when the lacteal secretion is commencing, as indicative of an apparent or concealed inflammation. Nothing, indeed, could be more reasonable than to regard the swelling and painfulness of the mammary glands as the cause of the general reaction which usually accompanies them, and which diminishes or ceases, as soon as the breasts become soft, or the system habituated to the new condition of things. In some women the breasts remain inactive, and no milk is secreted; it really would seem, as Prof. P. Dubois has remarked, that nature has left her work un- finished in them; that, being capable of becoming mothers, and able during the whole term of gestation to furnish the necessary materials for the child's nutri- tion, yet their organization is absolutely inadequate to supply its wants after birth. I have at this moment under observation a young primiparous woman, convales- cing, it is true, from an attack of varioloid which came on immediately after de- livery, who has not had a single drop of milk. The milk fever generally manifests itself about forty-eight hours subsequent to the delivery; at times a little sooner, at others somewhat later; thus, I have seen ATTENTIONS TO THE WOMAN. 485 two patients at the Clinique (and all observers record similar facts), who had this fever, the one on the fifth and the other on the sixth day; and, since that time, I have often had occasion to make the same remark. Where the child's death takes place at an advanced stage of gestation, and the dead body is not expelled for several days afterwards, it is by no means uncom- mon to find all the phenomena of milk fever manifesting themselves. In ordinary cases, by the time the fever is over, the breasts have acquired their highest degree of distension, and the secretion of milk is very abundant. If the child draws well, they are emptied and the patient relieved; but, should the mother not suckle her infant, the engorgement continues for a longer period, though it wears away the more promptly as it was less considerable in the first place, or as the milk flows more easily from the nipple, and as the perspiration and lochia are the more abundant. The question, as to the cause of milk fever, has been discussed again and again; but, without entering into all the arguments which this point of doc- trine has given rise to, we will merely remark, that the febrile movement (which, however, is not always constant) most probably is a consequence of the greater activity the mammae then assume, and that it is nothing more than what takes place whenever any organ undergoes a very considerable and rapid deve- lopment. To women who do not nurse, the lacteal secretion may be the cause of acci- dents which are to be prevented or opposed. Everything that could tend to increase the secretion of milk, such as succulent food, and the practice of drink- ing freely, should be strictly avoided. Warm and soft towels should be applied to the breasts, and renewed as soon as they become moist. A still better appli- cation is cotton wadding. By these means, perspiration is excited, and the heat of the parts maintained. Should the secretion diminish gradually, everything may be left to nature, but should the breasts become too much swollen, the dis- charge from the nipple should be facilitated by the use of emollient cataplasms, or efforts be made to empty them by suction. In case of these measures proving ineffectual, recourse must be had to lotions containing laudanum for the purpose of relieving the pain, and to sudorifics and purgatives as revulsives. As amongst the most commonly-employed diaphoretics, we may mention weak tea, and the infusions of Parietaria and Borage. The purgatives are those which have been already mentioned. Of all the preparations which have been extolled as lacti- fuge, the petit-lait of Weiss1 is, according to Desormeaux, the only one which is still employed. The same author states that he knew a lady to apply an ammo- niacal liniment with success. Neuter asserts, as proved by experiment, that the application of cups to the back diminishes the flow of milk, and Van-Swieten knew a galactorrhoea to yield to a strong infusion of sage, taken in doses of from one to two ounces every three hours. 1 The petit-lait (whey) of Weiss is prepared by infusing in boiling whey a species of galium, flowers of elder, hypericum, and of the linden tree, together with senna and sul- phate of soda. It acts as a purgative.—Translator. 486 LABOR. ARTICLE VI. OF THE NECESSARY ATTENTIONS TO THE LYING-IN WOMAN. Hygiene.—The patient should be placed in a large, well-aired chamber, which is moderately warm, and free from all strong odors. In summer, the doors and windows are to be opened every day; though, while the air of the apartment is being changed, she ought to be carefully covered, and have the curtains drawn, so as to protect her from any draft; but, at other times, the curtains need not be closed. The room ought to be kept scrupulously neat, and the urine, excre- ments, and soiled linen should be removed at once. The genital parts must be often bathed with lukewarm water, or some emollient decoction. These frequent ablutions have the further advantage of calming any inflammation in the parts that have been contused during the labor; they should be made morning and evening, and without uncovering the patient. The woman should make no exertion during the first few days, and if the labor has been long and painful, or attended with any serious accident, it is best that she should be protected from violent and rude motions, and that the bed be not made up until after the milk fever has subsided. When, however, the patients are but slightly fatigued, the bed may be made on the evening of the day pre- ceding that on which the milk fever supervenes, after which, it should be left until the next day but one; thereafter it may be made every day. The woman should on these occasions be transferred to another couch. It is very important that the patient should not rise before the ninth day; and, where she is in easy circumstances, and can, without detriment to her interests, abstain for a longer period from her household duties, she should be required to remain in bed for at least two weeks. At this period, she may be carried to an easy-chair, where she will remain seated for an hour or two, and again, on the following day, for two or three hours. On the third, she might try her strength by making a few turns around the chamber, and then through the apartments; but it would be imprudent to venture out of doors, especially in the winter sea- son, before the fifteenth or twentieth day, and only then in fine weather, and about the middle of the day. Most women, actuated by a religious feeling, go to church on the occasion of their first going out; and, as these buildings are always cold and damp, they often return with the germs of an inflammatory disease, which, sooner or later, develops itself; and hence, the physician should advise the deferring of this re- ligious ceremony, called the churching, to a more distant period. As regards her diet, the articles ought to be of the mildest character, and of easy digestion; thus, as a general rule, she will only need, during the first day or two, a little porridge two or three times in the course of the day, and some broth during the night; and she should observe an absolute diet pending the duration of the milk fever, for fear of adding to its intensity; though even here, if the general reaction is moderate, she might be allowed some broth. After the fever is over, the quantity of nourishment is gradually augmented; so that, by the twelfth or the fifteenth day, the woman has resumed her ordinary habits. In those who do not nurse, the regimen must be more restricted, especially when the breasts still remain engorged or painful. ATTENTIONS TO THE CHILD. 487 Throughout the whole lying-in period, the patient should use some diluted ptisan, moderately sweetened and rendered aromatic, as an ordinary drink; such as, a solution of gum, or an infusion of mallows, of violets or linden, the orange or chamomile flowers, &c, &c.; but acidulated drinks must never be allowed to those who nurse. About the seventh or eighth day, most patients ask their medical attendant for something to drive away the milk, which, of course, is generally a useless precaution; but, perhaps, it would be better to yield to a very popular prejudice, so as to escape all subsequent reproach. The Canne de • Provence, and the infusion of periwinkle, &c, enjoy a high reputation for this purpose; and, as the root of the former is nearly inert, it will, on that account, be preferably employed. The excitability of the nervous system is such, in lying-in women, that the greatest care should be exercised in keeping away everything that might excite them, and in avoiding all acute moral emotions. A temporary constipation, prior to the invasion of the milk fever, is a matter of no consequence; but should it persist for several days afterwards, injections may be administered, either simple, or else rendered slightly laxative by the addition of an ounce, or an ounce and a half of the miel mercuriale, or a decoction of senna leaves; and, where these measures do not answer, a mild purgative, such as the following, is exhibited by the mouth, viz., from half an ounce to an ounce of castor oil, rubbed up with an ounce of almond' emulsion and a little lemon syrup; or the sal de duobus (sulphate of potash) might be employed, in the dose of fifteen or thirty grains, dissolved in her usual drinks. The castor oil can be swallowed without much difficulty when it is diffused in a cup of rich broth, made as hot as the patient can bear it. I have observed that it is much oftener retained when given in broth than when mixed with almond emulsion. Most women think it necessary to be purged towards the end of their lying- in ; and though, when the physician discovers any positive counter-indication to the administration of even a mild purgative, he doubtless should not yield to their desires; yet, under ordinary circumstances, he ought to purge them slightly, both on account of his own reputation and to avoid subsequent unjust reproaches; indeed, this will become necessary, if the tongue is broad, furred, and yellowish, or greenish, the mouth bitter and clammy, and there is loss of appetite. The Seidlitz waters and castor oil are perhaps preferable, from their mildness and certainty of operation. CHAPTER V. OF THE ATTENTIONS TO THE CHILD IMMEDIATELY AFTER ITS BIRTH. The management of the new-born infant necessarily varies according to whether it is strong, vigorous, and healthy; or whether, on the other hand, it is born in a state of debility or disease. LABOR. ARTICLE I. OF THE CHILD IN A HEALTHY STATE. When the child escapes from its mother's womb living, and in a healthy state, the circulation existing between it and the placenta is observed to continue for some time, where the delivery is abandoned entirely to the powers of nature; the » after-birth is soon detached and expelled, and then it as well as the cord loses its vitality, the circulation becomes weaker and weaker, and the pulsations in the arteries gradually cease, commencing at their placental extremity; and some authors have advised this eveut to be waited for before cutting the cord; but as this spontaneous delivery most generally requires a long time, it is customary to make the section immediately after its birth, and then the following attentions to the new being become necessary, namely: where the infant is entirely clear of the mother's parts, the cord is disengaged if it had been twisted around its neck or body, and the child is placed on the side, having its face turned away from the vulva, so that it may breathe freely without running the risk of being suffo- cated by the liquids that escape from the vagina. The umbilical cord is next cut at about five or six fingers' breadth from the abdomen, generally using the scissors for this operation, though it may be done with any cutting instrument whatever. As soon as the section is effected, the cut extremity is slightly pinched between the thumb and forefinger, while the remaining three fingers grasp the breech, and the other hand is placed under the shoulders and neck of the child, which is thus lifted out of the bed, and placed on the nurse's knees prepared for its reception. It may then be examined more at leisure, to ascer- tain that no loop of intestine exists at the base of the cord, and to permit the latter to bleed if judged advisable, before applying the ligature. A ribbon, eight or ten inches long, may be used for this latter purpose, or a cord consisting of a skein of coarse thread; but, before applying it, the gut is to be reduced if there is an umbilical hernia, and then it ought to be tied at about two, three, or four inches from the surface of the abdomen; the only precaution requisite is to avoid placing it around the skin, which is prolonged more or less upon the cord; for pain, inflammation, and ulceration would thereby result, the subsequent cure of which might be attended with some difficulty. As a general rule, it is best to leave sufficient space between the ligature and the fold of the skin, to allow of the application of a second, should the first prove insufficient. The ligature must be drawn tight enough to obliterate the arteries completely and permanently, without cutting their coats. If the cord happens to be thick and infiltrated, the ligature will strangle its vessels but very imperfectly; and when it afterwards becomes diminished by the escape or evaporation of the fluid parts, the vessels being no longer compressed, will obviously permit a free discharge of blood from the cut end. Besides, the putrefying of the lymph will soon produce a very fetid smell, and irritate the skin wherever it comes in contact; and it is therefore, to prevent such accidents, that authors very properly recommend the expression of this viscid fluid by pressing and slipping the cord between the fingers, and even by pricking its enveloping membrane, taking care, however, to avoid wounding its vessels; and lastly, if the cord were unusually large, it might, for greater ATTENTIONS TO THE CHILD. 489 security, be bent backward after the first knot was tied, and be included in a second one. Where there is reason to suspect a twin pregnancy, it is necessary, after cutting the cord of the first-born, to apply a ligature around its placental ' extremity also. Though the applieation of the second ligature is, in most cases, a useless precaution, yet the fact that in some very exceptional cases in which a communication exists between the vascular ramifications of the two placentas, it might prevent a hemorrhage which would quickly prove fatal to the second child, is sufficient reason for never dispensing with it. Numerous discussions have sprung up as to whether the ligature of the umbi- lical cord was absolutely indispensable, and, if so, whether it should be applied prior to the section, or whether the cord might be cut before it is tied. Now, although it is highly probable that the circulation in the umbilical vessels would be arrested spontaneously, after the regular establishment of the respiration; as, also, that the ligature is almost or entirely useless in the great majority of cases; yet, if it is certain that a hemorrhage has taken place in some few, even though they be exceptional instances, from the cord having been imperfectly tied, or else not ligated at all; this, of itself, is a sufficient reason for not neglecting so simple a precaution; and as to the second question, the course just pointed out is, in our opinion, decidedly preferable. The surface of the child's body is next to be cleansed of the ceruminous substance that covers it, and from the blood and other matters which become attached at the moment of delivery; but, as this can scarcely be removed by a simple rubbing with dry towels, it should first be diluted with a little oil, or fresh butter, and then be gently wiped off; the yolk of an egg would produce the same effect, and besides, would render this matter more miscible with water. To get rid of the blood, and other impurities, water mingled with wine, or else a simple bath, into which the child is plunged, is most generally employed; the tempera- ture of the bath should be about twenty-five degrees (77° Fahr.). The infant being well washed, sponged, and wiped, is next to be dressed; but, before doing so, the physician himself should first envelope the cord in a com- press intended for that purpose; which compress is merely a piece of fine linen, of a square shape, and having an opening at its centre large enough to allow the cord to pass through it easily, and then, after having ripped one of its sides from the free margin down to this hole, the root of the cord is lodged at the bottom of the resulting fissure; then the uncut part of this little compress remains below, and the two halves of the divided portion are turned over and crossed in front of the cord, the whole being placed at the upper and left side of the abdomen. A second soft and square compress covers the first, and a band three or four fingers' breadth wide, and long enough to go twice round the body, supports the whole of the little apparatus in this position. Before enveloping the cord, the dressing of the child had already commenced, its head, arms, and chest being then covered. The rest of its clothing should be warm, soft, and moderately tight. In France, it consists of a camisole, or little woollen jacket, furnished with a soft chemisette that is fastened behind by pins, then one of linen, and another of wool or cotton. The English envelope their children in a long, loose robe, or something like a flannel sack. Before dressing the child, the physician should ascertain whether it is affected 490 LABOR. with any malformation; and during the three or four days following its birth, he ought carefully to watch over the excretion of urine and of meconium (for the expulsion of the latter is sometimes delayed for that length of time), and to faci- litate it by plunging it into a tepid bath, when he is certain the infant is well formed. The prolonged retention of the meconium is -also an indication for the employment of some mild laxative, such as whey, the syrup of violets, the oil of sweet almonds, or manna; the compound syrup of succory is also very gene- rally used, or the compound syrup of rhubarb, either alone, or mixed with sweet almond oil, in the quantity of two drachms or half an ounce in the course of the day. Some persons administer these gentle remedies to all children without dis- tinction, more especially to those that are wet-nursed, for the purpose of supply- ing, they say, the place of the colostrum, or first maternal milk, whose slightly purgative action clears out the intestinal canal; but the warm water and sugar ordinarily given to the child as nourishment on the first day, is usually quite sufficient to facilitate the expulsion of the meconium, and the viscid fluids that sometimes obstruct the fauces and stomach. All questions having reference to the hygiene and nursing of infants will be treated of in a special chapter. ARTICLE II. OF THE CHILD IN A FEEBLE OR DISEASED STATE. The ordinary attentions to the child, when born in a healthy condition, have just been described; but it not unfrequently happens that the infant, at the mo- ment of its birth, is in a state of great debility, or even of apparent death, which would soon be followed by a real one, if adequate measures were not resorted to at once to prevent it. This apparent death shows itself under two widely dif- ferent aspects, which have been described by most authors as the apoplexy and the asphyxia of new-born children. Many English and German accoucheurs have for a long time rejected these denominations, as characterizing but imper- fectly the pathological conditions to which they were applied; and M. P. Dubois, in a more recent article, after having remarked that the most constant anatomical character of apoplexy in the adult is wanting in what has been called the apo- plexy of the child, and that wide differences also exist between the symptoms of asphyxia in grown persons, and those of the asphyxiated state of the new-born infant, likewise concludes that the same name has been improperly applied to such dissimilar conditions; and consequently he, like M. Naegele, designates that state of the. child in which no sign of life is observed, and none of those of death is recognized/under the title of apparent death. Both terms of this definition are evidently contradictory, since death is charac- terized by an entire absence of the signs of life. For our own part, we regard apparent death as a state in which, notwithstanding the abolition of the actions of animal life, some at least of the functions of organic life continue, and, of necessity, the pulsations of the heart. Now, in carefully examining the symptoms of the child's apparent death, it is found that it is sometimes characterized by a vivid redness of the face and upper ATTENTIONS TO THE CHILD. 491 part of the body, by a prominence and injection of the eyeball, and a swelling of the countenance, the skin of which is dotted here and there with bluish spots; while at others, we are struck with the discoloration in the skin, and the flabbi- ness of the flesh. In the former case, the head is swollen and very warm, the lips also swelled and of a deep blue color; the eyes start from the head, and the tongue adheres to the roof of the mouth; the head is often elongated, hard, and the features slightly swollen; the pulsations of the heart, though sometimes quite strong and distinct, are at others obscure and feeble; occasionally the umbilical cord is distended with blood. In the second, the child exhibits a mortal pallor; its limbs are pendent and flabby; the skin is discolored, and is often soiled by the meconium ; the lips are pale; the lower jaw hangs down, and the umbilical cord and heart either do not palpitate at all, or but very feebly. An infant, in this condition, often moves at the moment of birth and cries, but soon falls back again in a state of apparent death; These diversities in the physical characters of children born in a state of ap- parent death, may be occasioned, doubtless, by various causes, though they are also often due, simply, to a greater or less advanced condition of the same patho- logical state; hence it is wrong to regard them as the characteristic signs of quite dissimilar lesions. Therefore, although I am convinced that they sometimes furnish indications for very different kinds of treatment, and that under this point of view it is important to observe them carefully, I cannot regard them as affording a basis for nosological distinctions which it is impossible to justify. As the expression apparent death presupposes nothing in regard to the nature and cause of that state, it deserves on that very account to be retained. That what we are about to state respecting the apparent death of new-born children may be the better understood, we shall give, first, a brief exposition of the mechanism by which respiration is established immediately after birth. All physiologists admit, that the medulla oblongata is the centre and regulator of the respiratory movements of the adult. From it also is sent forth the motor impulse which gives rise to the first act of inspiration. Marshall Hall has endeavored to prove, experimentally, that the first inspira- tion is the result of a reflex action,1 produced by the excitement of the nerves of the surface of the body, especially of the trifacial, by the contact of the external air, and that the respiration, when once established, is sustained through the 1 An impression made upon our organs may give rise to movements of different charac- ters, by pursuing different routes to the cerebro-spinal axis. Thus, sometimes, when transmitted directly to the encephalon by the sensitive nerves of the cranium, or indirectly through the nerves of the spinal marrow, it is transformed into a sensation in that part of the encephalon in which the sensorium commune is situated, and consequently reaches the consciousness of the animal, who is then capable of reacting by voluntary movements. Sometimes, also, it is transmitted by the nerves of sensation either to the encephalon or to the spinal marrow, which impression, without necessarily being transformed into a sen- sation, may produce an excitement which is immediately reflected upon the motor nerves, and gives rise to the so-called reflex movements, in the production of which the will has no part whatever. The power which thus gives rise to movements without the participation of the will, has been regarded as a special endowment of the cerebro-spinal axis, and has been designated as the reflex power, faculty, or property. 492 LABOR. influence of the reflex action due to the irritation of the pneumogastric nerves by the contact of the air introduced into the lungs. The same physiologist also holds that the respiratory movements may take place under the influence of other causes; such, for example, as the impression pro- duced upon the medulla oblongata by a great loss of blood, as also the excite- ment which it undergoes from the contact of venous blood. Into the latter category enter all the respiratory movements of incomplete asphyxia. In normal cases, the fcetus, having in no wise suffered during the labor, retains its cutaneous sensibility intact, and the irritation produced by the contact of the air with the cutaneous nerves is transmitted to the medulla oblongata, which, acting in its turn upon the respiratory nerves, produces the movements of respi- ration, f But should it happen that the fcetus from the moment of birth has been deprived for a certain time of those means of respiration which it finds in the placenta, or that, the latter being separated immediately after the child is ex- pelled, any obstacle should arise to the introduction of air into the bronchia, there would be, in both cases, a commencement of asphyxia. The contact of the non- oxygenated blood would irritate the medulla oblongata, and this irritation being transmitted to the inspiratory nerves, may also give rise to respiratory move- ments of the muscles of the face, breast, and abdomen, and produce, in short, the first inspiration.1 The central motor impulse would soon be substituted by the reflex action of the ramifications of the pneumogastric nerves, which are irritated by the air introduced into the lungs, and the respiration would continue under its influence. When the fcetus is threatened with asphyxia in the latter stages of pregnancy or during labor, in consequence of compression of the cord or separation of the placenta, its death is preceded by convulsive movements and efforts to breathe; then the mothers tell us, that the child, after having moved actively, suddenly became quiet; and Beclard saw a fcetus enclosed in the unruptured membranes make inspiratory movements, and breathe water instead of air. It is for this reason, also, that in certain positions of the face, the child has been enabled to respire, although still enclosed in its mother's womb; and the uterine vagitus, which always supposes a previous inspiration, can be explained in no other manner. In all these cases, in fact, the non-oxygenated blood acts as an irritant to the medulla oblongata, which transmits the irritation in its turn to the nerves of inspiration. Nothing can be claimed here for reflex action. We must be careful, however, not to confound these two excitors of the inspi- ratory act. The first is the natural excitant, whilst the other is always patho- logical, and only intended to replace the normal stimulus. Now, every pathological v 1 Marshall Hall removed the brain of a kitten, cut the pneumogastric nerves, and opened the trachea. He found the respiration to become slower, though it continued with regularity. When he stopped the opening in the trachea, the scene changed immediately; the animal opened its mouth widely, made violent inspiratory efforts, and was affected with some move- ments of a convulsive character. When the trachea was re-opened, the respiration became as regular as before, and when closed again, the symptoms of asphyxia reappeared ; in both these cases, the central organ, or the medulla oblongata, was evidently the source of the respiratory impulse; since the destruction of the brain and the section of the pneumo- gastric nerves rendered all reflex action impossible. ATTENTIONS TO THE CHILD. 493 act is but an effort to accomplish some physiological process, which has become difficult or impossible; and though it may in some cases restore life to a child, it is likely, in many others, to prove insufficient. It very often happens that a child born in a semi-asphyxiated condition, in consequence of a difficultflabor, makes a few sudden and violent inspiratory move- ments, but would nevertheless succumb rapidly, were not the reflex action called into play, and did it not soon replace completely the pathological excitant, which, just before, had acted alone upon the spinal marrow. As the skin, in this state of diminished sensibility, is no longer stimulated sufficiently by the external air, special means should be resorted to whilst there is yet time to arouse the excito- motor action of the cutaneous nerves, and provided the asphyxia has not gone too far, they will often be crowned with success. But if the child is small and feeble, or if the causes of the asphyxia have acted for too long a time, the con- tractions of the inspiratory muscles are feeble and distant, and soon cease entirely; the heart, too, ceases to beat, and the child dies. Though, whilst the heart is still beating, we may succeed in exciting the reflex action of the muscles of inspiration, to the extent of producing a sudden inspiratory movement after every excitation, the symptoms of asphyxia remaining, however, unchanged, the child will die in spite of all that can be done. If it be true that the impression produced by the external cold upon the skin of the body and face, is the first and only cause of the reflex action of the medulla oblongata upon the nerves of inspiration, and thus produces the first inspiratory act, we can readily understand that everything calculated to diminish notably or to destroy the cutaneous sensibility, will retard, or even render impossible, the first inspiratory effort, and reduce the fcetus to a state of apparent death. The causes of the latter are, therefore, such as paralyze to a greater or less extent the nervous centres, whose influence, though completely foreign to the main- tenance of foetal life, becomes indispensable to the establishment and continuance of extra-uterine existence. Now, these causes are quite numerous; and, with the exception of a few, exert their destructive influence during the latter periods of labor. They may be divided into: 1, lesions of respiration; 2, lesions of circulation; 3, lesions of the nervous centres. The first are capable of producing various degrees of asphyxia; the second may give rise to a fatal hemorrhage as regards the child; the third affect the nervous centres directly, and render them incapable of per- forming the functions to which they are destined immediately after birth. 1. Lesions of the Respiration.—These are occasioned by everything which obstructs the respiration. Thus, there have been pointed out as occurring during labor, the compression of the umbilical cord between the sides of the pelvis and the head or body of the child; the winding of the cord so tightly around the neck or some other part, as to obstruct simultaneously the venous circulation in the brain, and that of the blood in the umbilical vessels; the premature separa- tion of the placenta, whether it be inserted upon the neck or not, for since the separation necessarily produces the rupture of the uteroplacental vessels, it ren- ders the fcetal haematosis as impossible as does the compression of the cord ; the great retraction of the uterus, when in delivery by the breech the head only remains in the excavation, and the child is unable to respire; for this retraction 494 LABOR. renders the vessels of the uterus almost impermeable to blood. In all these cases, the asphyxia results, evidently, from a suspension of the placental respira- tion, and it is the contact'of black blood with the brain, which, paralyzes its action in the fcetus as well as in the adult. Finally, it is plain that after the child is born, the accumulation of mucus in the nose, mouth, and air-passages, may also produce asphyxia by preventing the introduction of air into the bronchia); here, however, the mode of operation is precisely the same as in the adult, since it results from a mechanical obstacle to the introduction of the external air into the pulmonary vesicles. In consequence of the action of some one of these causes, the fcetus may be born in a state of apparent death, and exhibit the very different symptoms which we have already mentioned; thus, in most cases, the surface of the body has a swollen appearance, and is of a violet, or rather of a blackish-blue color, the dis- coloration being more marked at the upper parts of the trunk, and more particu- larly on the face than elsewhere. The muscles do not exhibit any motion ; the limbs preserve their flexibility, and the body its heat; the pulsations of the cord, of the radial artery, and even those of the heart, are obscure or insensible. Where a post-mortem examination is made, the vessels of the encephalon are found engorged with blood; at times, this fluid is even effused on the surface of the membranes, or into the substance of the brain itself, though most generally, says M. Cruveilhier, the effusion is limited to the surface of the cerebellum; sometimes it covers the posterior lobes of the cerebrum, but it is rarely found in the ventricles of the brain; and, in all the cases examined by him, there was blood enough in the cavity of the vertebral arachnoid membrane to distend the dura mater. Again, those congestions of the liver, that are so common in infants, are then particularly apt to be met with; but, says Billard. they vary considera- bly as regards the quantity of blood accumulated in the tissue of the organ; for, in some instances, it is found there in such great abundance as to give rise to a sanguineous exudation on the exterior of the organ, the convex surface of which is discolored and moistened by a layer of effused blood, and I have even known an extravasation of this fluid into the abdomen to result from this turgescence. The lungs are^lso gorged with blood. The external condition of the asphyxiated fcetus is not always such as we have just described, for, as M. Jacquemier has observed, nothing is more common than to find the fcetus born without any anomalous coloration of the skin, and even with a remarkable degree of pallor and flaccidity of the limbs; and this, not- withstanding the apparent death has been produced by compression of thie cord. Can this difference be due, as M. Jacquemier supposes in the latter case, to a sudden suspension of the placental respiration, whilst in the former the cessation was slow and\gradual ? This explanation is probable, inasmuch as the same differences are observed in the asphyxia of adults, and as, according to M. De- vergie, those persons who are killed by the falling in upon them of earth, pre- sent the same discoloration of the integuments. The suddenness of the real death may explain the peculiarity under these circumstances; but it must not be forgotten that this external pallor is also the consequence of a slow but pro- longed asphyxia, and that it often succeeds to the violet hue of the tissues; that we every day witness this succession going on before our eyes when the asphyxia ATTENTIONS TO THE CHILD. 495 has lasted too long, and that a child born with a very deep color, becomes ra- pidly pale and flaccid, if the means employed fail to excite respiration. In the latter case, the discoloration of the tissues is the symptomatic expres- sion of a more advanced stage: the pulsations of the heart, which before were sufficiently strong and rapid, become less frequent and feebler, return only at long intervals, and real death soon succeeds to the apparent one. Now, these phe- nomena, which we observe occasionally, take place in the same manner whilst the fcetus is still contained in the womb, but is deprived of the placental respi- ration. When, at the moment of birth, the asphyxia has lasted but a short time, the child will exhibit turgescence of the face, the violet hue of the skin, firmness of flesh, and frequent and regular pulsations of the heart; if a longer period has elapsed since the interruption of the fee to-maternal circulation, the child will be pale and discolored, and the pulsations of the heart and cord feeble and inter- mitting; finally, if the asphyxia has lasted longer than is compatible with the life of the heart, the child will be really dead at the time of its expulsion. These two conditions, which are apparently so different, are due to the same cause, and are simply two degrees of asphyxia. Though, in an etiological sense, no distinction can be made between them, they are important as regards the prognosis, for one is much more serious than the other, and, as regards treat- ment, the same means are not applicable to both. M. Pajot informs me that he has found these observations to hold true as re- gards the adult. 2. Lesions of the Fcetal Circulation.—Ruptures of the cord or of the placenta may, of themselves, give rise to such a degree of hemorrhage as to endanger the life of the foetus; fortunately, however, they are quite rare. When the hemor- rhage is profuse, the child dies before the labor is over; but should anything happen to arrest the discharge of blood, the child may be born alive, but in a state of apparent death resembling syncope. The deficiency of nervous influ- ence is here manifestly due to the fact that the medulla oblongata and the brain no longer receive a sufficient amount of blood to enable them to react upon the nerves of inspiration. The condition is a most dangerous one. The child is pallid, and its muscles completely relaxed; sometimes, however, it makes a few short inspirations, and utters some very feeble cries; but if the hemorrhage has been at all profuse, it succumbs in a very short time. 3. Lesions of the Nervous Centres.—The cerebro-spinal system presides over none of those functions whose integrity is necessary to the maintenance of fcetal life; the respiration, circulation, and nutrition, being subject exclusively to the nerves of organic life. These ganglions and their nerves derive from the arte- rial blood that principle of organic sensibility and motility which is necessary to the production of involuntary or automatic movements, as also to the mainte- nance of the irritability and vitality of the organs. Although the fcetus pos- sesses organs of animal life, its vitality is purely vegetative or organic. This fact serves to explain the life and development of acephalse, for where the organs are absent, the functions are also wanting; yet these monsters are en- dowed with irritability, are capable of motion, and theirlife is preserved intact, until the termination of pregnancy. 496 LABOR. Since the brain and spinal marrow have nothing to do with the performance of the fcetal functions, we readily foresee that any lesions which may affect them during pregnancy or labor, cannot disturb the harmony of those functions, or have any influence whatever upon the intra-uterine vitality. Therefore, it is only after birth that the cerebro-spinal alteration or paralysis prevents the establish- ment of animal life, even though the organic life is still manifested by the inte- grity of the circulation, and even of the placental respiration. The first respi- ratory act is, as we have said before, the consequence of an excitement of the medulla oblongata, produced by the impression of the temperature of the sur- rounding air upon the skin of the new-born child. For this impression to be effectual, however, it is necessary that the sensation should be perceived by the central organ, which is rendered incapable of perceiving it by serious lesions of the cerebro-spinal axis. This important distinction should therefore be made between the various circumstances capable of reducing the fcetus to the state of apparent death, namely, that the foetus may be destroyed in the womb by as- phyxia and hemorrhage, whilst lesions of the nervous centres always cause it to be born in a state of apparent death. We should also interpret in this way the effect which may be produced by the violent compression which the brain undergoes in certain cases of contracted pelvis; that which may result from the application of the forceps or lever under circumstances of difficulty; that which results from vascular congestion due to an obstruction to the return of venous blood in certain deliveries by the face; in cases where the cord is wound tightly several times around the neck, as also where it is strongly grasped by a spasmodic contraction of the neck of the uterus; and finally, to the compression sometimes produced by effusions of blood, either upon the surface, or into the substance of the brain itself. So, also, is to be explained the mode of action of lesions of the medulla oblon- gata, such lesions.as we know are easily produced by extreme rotation of the head, by tractions upon the head, or the pelvis when the head is arrested in an elevated position, and finally, by effusions at the base of the brain and upper part of the vertebral canal. As lesions of the brain are not absolutely incompatible with the establishment of respiration, they are not so dangerous as those of the medulla oblongata. The destruction of a large portion of the encephalon has not always prevented the child from breathing and crying after its birth, and even from living for several days. A similar fact is presented by anencephalous foetuses. By this we are advised that, in difficult labors, the temporary compression of the head may also suspend momentarily the action of the brain, but that as this suspension does not absolutely preclude respiration, the species of shock or concussion which the brain experiences may pass away so soon as not to interfere with the continu- ance of life, i It is different, however, with lesions of the medulla oblongata, which is the only motor of the respiratory movements: it cannot be seriously affected without rendering extra-uterine life impossible. This explains the frequent death of children in pelvic presentations, when tractions have been made upon the trunk with the object of disengaging the head. Treatment.—Since apparent death, however produced, may present the very ATTENTIONS TO THE CHILD. 497 different symptoms already mentioned, it is evident that mere inspection of the child can afford no information as to the cause of its condition. Although we regard the discoloration of the skin and relaxation of the extremities as signs of very grave import, it is impossible to determine the extent of the cerebral disor- ders, and consequently to foresee the result of measures calculated to restore the child. In this state of uncertainty, all cases should be treated as though they afforded a chance of success. The lapse of half an hour, an hour, or even more, from the time of delivery, is not sufficient cause for despair, since a number of facts may be mentioned going to prove that children have been in an asphyxi- ated condition for an hour, and were afterwards restored to life. Long-continued silence of the heart, the entire absence of pulsations at the praecordial region, frequently determined at intervals, is the only sign which can be regarded as destructive of all hope. The heart is the ultimum moriens, and I do not believe that efforts to restore its pulsations, when once completely extinguished, have ever been crowned with success. But the softness and flaccidity of the tissues, and coldness of the body and face,1 are no reason for abandoning the child, pro- vided the heart still beats, however feebly, slowly, or irregularly. When the child is born with a general injection of the capillaries of the face and trunk, when, in short, it presents the characters of the state formerly termed apoplexy, it is evident that the first indication is to relieve the engorgement of the head and lungs, which is done by promptly cutting the umbilical cord, and allowing a few spoonfuls of blood to escape, when the respiration is most usually established soon after, if there are no mechanical obstacles, such as mucus in the fauces, to the introduction of air into the lungs; and, where these do exist, they may be removed by the extremity of the little finger, or with the feathered end of a quill; the blue and violet color of the surface will then be found to gra- dually disappear, and give place to a rosy hue, at first on the lips, then on the cheeks, and afterwards over the rest of the body. However, in practice, we some- times find the circulation so enfeebled or benumbed, as it were, that the blood will not run from the umbilical arteries; its effusion may then be encouraged by plunging the child into a warm bath, or by squeezing the cord several times from its insertion towards the cut extremity; and where this does not prove successful in obtaining blood, some advise the application of a leech behind each ear. But as this application would occasion the loss of precious time, it is better to have recourse at once to other measures. The small bleeding being practised or not, every effort should be made, by the use of various stimulants, to excite the sensibility of the skin, and the reflex action of the cutaneous nerves. According to Marshall Hall, the best plan is to sprinkle the face and body of the child vigorously with cold water; immediately after which, it should be im- mersed in a warm bath, and then wrapped in warm flannels. The efficiency of this plan of treatment, which may be repeated several times, depends, espe- cially, upon the rapidity with which it is executed. The impression of both the cold and heat should be sudden. Afterwards, the skin may be stimulated by 1 The experiments of M. Brown-Sequard on warm-blooded animals, prove that the time for which they are capable of resisting asphyxia is greater in proportion as they are sub- jected to a lower temperature. 32 498 LABOR. frictions with the hand, or a brush, by dry flannel, or with any irritating liquors, such as vinegar or brandy; M. Moreau strongly recommends, and with reason, slight blows to be made with the palmar surface of the fingers upon the shoulders and thighs. In grave cases, I prefer flagellating the thorax and loins vigorously with a piece of wet linen. It is also often very useful to irritate the mucous surfaces. A little brandy or vinegar may be placed in the mouth, or the fumes of burnt paper blown into the anus. A feather may be dipped into vinegar and then introduced into the nose or fauces; this may be used at the same time to clear away the mucous secretions of the latter, which prevent the inhalation of air; and, where there is reason to suppose that such secretions have accumulated to a considerable extent in the air-passages, the advice of Dewees should be fol- lowed, by placing the child on its belly, taking care to elevate the feet higher than the head, and at the same time gently shaking it, so as to clear out the trachea, and thus facilitate the introduction of air; '• for," says the American author, "this is a measure of great utility, by which I am every way persuaded that I have preserved the lives of many children." After a few moments, the child should be again plunged into a warm bath, rubbed with warm flannels, and then immediately subjected to cold aspersions. The child's body may be exposed with advantage to a current of cold air, giving it at the same time a swinging motion, and even after it has been re- stored and dressed, its face may be exposed to the fresh air, or, what is better, fanned, for a short time. It has been advised to make use of strong suction on the breasts, for the pur- pose of dilating the thorax mechanically, "which," says Desormeaux, "although without effect for the proposed object, appears to me admirably calculated to stimulate the muscles that move the ribs." But a more powerful remedy, highly extolled by the same author, is a sort of douche made by the mouth directly on the parietes of the thorax; this douche is performed by taking a mouthful of brandy and blowing it forcibly against the breast; and it is rarely necessary, he remarks, to repeat it many times, for it is found to produce a convulsive contraction of the inspiratory muscles almost immediately; the blood and air penetrate the lungs, and the respiration is irregularly established, being at first feeble and spasmodic, but soon becoming stronger and more regular. I have often used successfully with the same object, a cold douche, produced by pouring a stream of cold water upon the praecordial region, from an elevation of about a yard. If the excitation of the spinal and facial nerves is insufficient, the branches of the pneumogastric nerve should be acted on by insufflation. This measure can now boast of such a degree of success, as to make it proper to have recourse to it whenever the means just mentioned have failed. M. Depaul has, in an excellent memoir upon the subject, completely refuted the objections urged against it, and confirmed by his experiments the previous results of Dumeril and Magendie. Like them, he found that a false idea has been entertained of the powers of resistance of the pulmonary vesicles, and that it is necessary to blow much more strongly than is required to produce a simple dilatation, in order to effect their rupture. He has proved by instances, that children have been restored to life, whom the failure of the means commonly ATTENTIONS TO THE CHILD. 499 advised seemed to devote to certain death; also, that in cases where it was unsuccessful, because the lesions occasioning the apparent death were beyond the resources of art, it had the effect, when the pulsations of the heart had not ceased entirely, to render them stronger and more frequent, and sometimes even to determine a spontaneous though imperfect inspiration. I would add, that long continued insufflation seemed to me, in three cases, to be more effectual than is claimed in the above paragraph, for not only did it excite spontaneous inspirations, but the respiration became gradually regular, and existence was prolonged for ten, twelve, and in one case for twenty-two hours, in spite of mortal lesions of the brain. Now it will readily be under- stood that, in very many cases, the family might attach great importance to twenty-four hours of life in a new-born child. M. Depaul, who has rendered a real service in calling attention to a measure generally abandoned by some as dangerous, and by others as useless, also pro- poses some rules of conduct, which I think it right to mention briefly. He uses Chaussier's canula, dispensing, however, with the lateral openings, and substituting for them a terminal one. The child, whose temperature is to be maintained by warm coverings, should be placed with the breast higher than the pelvis, and the head thrown a little back, so as to render the front of the neck rather more projecting. Having cleansed the tongue and pharynx from mucus, the forefinger of the left hand should be conducted along the median line of the tongue to the epiglottis. The right hand holds the tube like a pen, and directs its small extremity along the finger to the opening of the larynx, inclines it towards the left commissure of the lips, and by gentle movements endeavors to raise the epiglottis; it is then only necessary to elevate the instrument, carrying it at the same time toward the median line, when its extremity will pass through the glottis. This is the only part of the operation which presents any difficulty, for it is not uncommon for the tube to enter the oesophagus. Before resorting to insufflation, we should make sure of its situation by passing the finger upon the larynx and trachea, and observing whether the larynx follows the instrument when the latter is moved from side to side. However, the first insufflation reveals the error im- mediately, for when the instrument has passed into the oesophagus, a considerable elevation of the epigastrium precedes that of the base of the chest; if, on the contrary, it is in the larynx, the chest is dilated uniformly, and the epigastric projection is produced exclusively by the depression of the diaphragm. To prevent the reflux of the air. and to oblige it to enter the air-passages, every point of exit by the oesophagus, mouth, and nostrils should be closed. The anterior wall of the oesophagus is applied against the posterior, by a moderate pressure with the instrument. The lips are pressed closely to the sides of the canula by means of the thumb and forefinger, whilst the nostrils are stopped by pinching the nose between the two middle fingers. The insufflations should be quite near to each other. M. Depaul thinks that from ten to twelve should be made in a minute. The greater part of the air is expelled after each by the elasticity of the pulmonary vesicles; it may be useful, however, especially at the commencement, to render the expiration more complete, by pressure properly applied with the whole hand on the front of the chest. 500 LABOR. The length of time for which it is necessary to continue the insufflations varies much. Thus, there are facts showing that sometimes a quarter of an hour has been sufficient, whilst at others, it was necessary to continue them for three- quarters of an hour, an hour, or even an hour and a half. AVhen, under their influence, the action of the heart has been so far restored as to be at from a hundred to a hundred and thirty times a minute, I think, says M. Depaul, that the physician should continue until spontaneous inspi- rations appear, and are repeated at the rate of at least five or six per minute; since to stop after the first one, would in many cases endanger the life of the child. When, however, after having awakened the pulsations of the heart, and even obtained some efforts at inspiration, all become more feeble and disappear, the insufflation may be dispensed with after the lapse of from ten to twelve minutes, for, under these circumstances, I have never known a child to be saved. It is necessary to withdraw the canula from time to time, in order to clear it of mucus. When the trachea contains much mucus, which is manifested by gurgling, it may be drawn into the tube by suction, and the future insufflations be thus rendered more useful. When spontaneous inspirations occur, the insufflations may be suspended for the moment. Finally, all these means having failed, should a galvanic battery be at hand, currents of electricity might be passed through the muscles of inspiration; it is, however, an auxiliary upon which but little reliance can be placed. Electricity has, in fact, much less action upon the foetus than upon the adult. It has, for example, been proved by experiment, that well-developed fcetal ser- pents were but slightly sensitive to the action of galvanism before having breathed, whilst shortly afterward they were endowed with a very delicate sensibility. Some persons have recommended that the umbilical cord be not cut in cases of asphyxia, until after the pulmonary respiration has been fully established, hoping that the continuance of the fceto placental circulation might replace the extra-uterine one that is wanting. Without admitting, with Dr. King, that this practice, by allowing the contractions of the heart to drive all the blood into the placenta, would expose the foetus to death from loss of the circulating fluid, I think that in the majority of cases the precaution is, to say the least, useless, and even hurtful, by occasioning the loss of precious time. In fact, the placenta is almost always partly, or even entirely detached, shortly after the child is expelled; and even were this not the case, the retraction of the uterus following its expulsion, has so modified the circulation in the walls of the uterus and that of the utero-placental vessels, that the newly-born infant would certainly find its resources in that direction exhausted. However, if the touch does not discover the placenta situated upon the neck, and, consequently, there is reason to suppose that it retains its normal relations with the womb, we may, when the fcetus is pale and discolored, defer cutting the cord, especially should it still exhibit pulsations. As soon, however, as the pul- sations have ceased, or it is ascertained that the placenta is detached, its section should be practised immediately. Some children, after having cried and breathed quite freely, fall, after the lapse ATTENTIONS TO THE CHILD. 501 of several hours, and sometimes even days, into a state of apparent death, which soon terminates in real death unless assistance is promptly rendered. Therefore, it is prudent to be carefully on the watch for the first few days. This secondary apparent death may be due, like that just described, to a true asphyxia, or to a deficiency of nervous influence, for which the stimulants employed immediately after birth have proved but a momentary remedy. Asphyxia may be produced either by a foreign body placed over the mouth and nostrils, or by an accumula- tion of mucus in the fauces. To remove the foreign bodies, and clear out the fauces with the aid of a feather, and the bronchia by exciting vomiting by tick- ling the palate, are the first measures to be used. If the face is of a violet color, a leech may be placed with advantage behind each ear, or, as recommended by Kennedy, upon the fontanelles. When the accidents are attributable to deficient cerebral action, the excitants already mentioned must again be had recourse to. ARTICLE III. DEBILITY OF THE FCETUS. As the excessive debility of the child may generally be referred to some of the circumstances already pointed out, it should be combated by the same means. In those cases where the infant is only very feeble, because it is born before term, or in consequence of a prolonged sickness on the part of the mother, very great care is requisite to maintain a high degree of temperature by surrounding it with cotton wadding and bottles containing hot water, since heat is then the best stimulant. For the first few days, and sometimes even weeks, its alimentation demands some precaution. It is very important that a nurse should be procured for it as soon as possible, whose milk flows so easily that she can herself project a few spoonfuls into the mouth of the child; for its feebleness is often so great as to render the necessary effort at suction impossible. It is equally important to give it only the first milk, which being lighter is of easier digestion. Whenever a child is born in a state of apparent death or of extreme weakness, the accoucheur should, in Catholic families, cause the rite of baptism to be ad- ministered immediately. For, whatever the religious opinions of the physician may be, it is his duty to respect the feeling of families, and he would be truly blamable, were he not to yield in this respect to the wishes of the parents. PART IV. OF DYSTOCIA, OR PRETERNATURAL AND PAINFUL LABORS. Although labor is a natural function, and the resources of the organism are usually sufficient for its accomplishment, yet there are a number of circumstances which may interfere with the work of nature, and render the process difficult, dangerous, or even wholly impossible. It is to the exposition of those difficulties and dangers, and more particularly to the indication of the appropriate measures for preventing or for remedying them, that the fourth part of this work, which we shall arrange in two principal divisions, is devoted. In the first we shall point out the accidents that may complicate the labor, and thereby render the intervention of art imperative; and we shall further study such accidents in their causes, symptoms, prognosis, and therapeutical indications. In the second, we shall carefully describe the various operative processes, by the aid of which all those indications may be met; in fact, this last might be designated, without any impropriety, as the surgery of labor. FIRST DIVISION. OF THE CAUSES OF DYSTOCIA, OR THE CIRCUMSTANCES THAT REQUIRE THE INTERVENTION OF ART. The causes that render a labor either difficult, impossible, or dangerous, and which therefore require the more or less active interposition of the accoucheur, are numerous, varied, and far from always having the same mode of action; some, indeed, operate only by enfeebling or reducing the forces necessary for the expul- sion of the child, while others constitute an obstacle to its delivery by occasion- ing a disproportion between the dimensions of the pelvic canal and those of the body that must traverse it, thus rendering the most powerful contractions of the womb entirely nugatory. On the other hand, when all the conditions are appa- rently most favorable to a natural labor, we may find a number of accidents suddenly manifesting themselves, of a character dangerous to the lives of both mother and child. EXTREME SLOWNESS OF THE LABOR. 503 Consequently, as regards the causes that may thus interfere with the regular process of nature, we may distinguish three different groups of difficult labors, namely: 1. Those rendered difficult, impossible, or dangerous, by a deficient or excessive action of the expulsive forces; 2. Those rendered difficult, impossible, or dangerous, by obstacles to the expulsion of the fcetus; 3. Those complicated by accidents liable to endanger the life or health of the mother and child. BOOK I. OF LABORS RENDERED DIFFICULT, IMPOSSIBLE, OR DANGEROUS, BY A DEFICIENCY OR AN EXCESS OF ACTION IN THE EXPULSIVE FORCES. In practice, we meet with numerous cases in which the position is favorable, the organs of the mother and child well formed, and in which none of those grave complications, hereafter spoken of, that have given rise to the title preter- natural labor, are met with; but in which, notwithstanding, the different stages of the labor are not accomplished with the customary ease or regularity. Now, everything seems so admirably arranged in the works of nature, that the least deviation is sufficient to interfere with their accomplishment; and whether this deviation be dependent on an unusual slowness or an excessive rapidity in the course of the phenomena of parturition, it may prove detrimental, in either case, to the mother or her child, and require the intervention of art just as imperiously as would a hemorrhage or a contraction of the pelvis. We therefore believe it will prove serviceable to treat, with a little more detail than has hitherto been done, of the causes and proper measures for preventing the disastrous conse- quences of extreme slowness or a too rapid progress of the labor. CHAPTER I. OF EXTREME SLOWNESS OF THE LABOR. Whilst stating, page 385, the usual duration of labor, we were careful to remark that it was often prolonged beyond the fixed period, and that a duration of eighteen or twenty hours, in primiparae especially, could not be regarded as an alarming circumstance; but that, in all cases where more than twenty-four hours have elapsed from the time of its commencement, serious accidents might result therefrom, either to the mother or the child, which should always be pre- vented by removing immediately the cause of this excessive slowness. In natural labor, the phenomena occur with such a marked degree of regularity that, as regards the duration, the period of dilatation of the cervix is to that of 504 DYSTOCIA. the expulsion as two or three to one ; though it is proper to state that the delay may be manifested during either the first or the second stage, and then, of course, this proportion no longer exists. This distinction, which might serve to establish a classification of the causes that retard the labor, if, indeed, they do not make their influence felt in all stages, merits a particular attention with regard to the prognosis; for, although the first stage may be prolonged without danger, the second, on the contrary, cannot pass beyond certain limits without greatly endan- gering the health of the patient, and oftentimes the life of her child. It is found that the latter is lost at least one time in four, when the head remains in the excavation longer than seven or eight hours after the complete dilatation of the os uteri, and the rupture of the bag of waters; whilst it nearly always survives when the first period is prolonged even to forty, fifty, or sixty hours and more.1 Besides, in the latter case, there are scarcely any symptoms worth mentioning presented by the mother, for the great fatigue caused particularly by the loss of sleep, and in nervous women, a considerable irritation, depression of spirits, and alarm, are about the only inconveniences that result from it; since the contrac- tion, although feeble, returns at regular intervals, and the labor makes some pro- gress, notwithstanding it is slow. But, when the period of expulsion is extended beyond ten or twelve hours, the pain, as a general rule, is found to become irre- gular, both in its returns and intensity; and, although it be sometimes more severe and frequent, it is in reality less efficacious, to such an extent, indeed, that the foetus really seems to be retrograding instead of advancing; in a word, there are uterine pains, but no expulsive contraction. The local disorder is accompanied, or at least is 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 yel- lowish liquid escapes from them, which occasionally has a fetid odor; the pres- sure of the child's head on the neck of the bladder prevents the emission of urine; and the parts that line the superior strait and the pelvic excavation, being com- pressed for a long time by the head, may become inflamed or even gangrenous; which complications may subsequently prove a source of the most serious acci- dents. If the woman still remains undelivered, these symptoms augment in intensity in a frightful manner; the vomitings become more frequent, and the abdomen more distended; the excitability of the patient knows no bounds; the pulse is more and more feeble and frequent, and she falls into a half stupid, or a semi- delirious condition, which 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 com- promised. 1 The following summary, which I take from Churchill, is calculated to confirm the above: in one hundred and thirty-three cases, where the first stage was prolonged from twenty- four to sixty hours, only eight children were lost; in eight that lasted from sixty to a hun- dred hours, but one died; and in three cases ranging from a hundred to a hundred and seventy-seven hours, not a single death occurred.—Churchill, 192. EXTREME SLOWNESS OF THE LABOR. 505 We have felt bound to point out these differences in the danger of the symp- toms, in order to prove the necessity of the distinction we have made; and we may now proceed to study the divers causes which, at times, retard the course of labor, and also to indicate the means calculated to remedy them, without the necessity of repeating, in each, that the dangers to which they expose the mother and child are much more grave in the second than the first stage of the labor; and that, although in the latter, we may trust longer to the resources of the organism, in the former, the intervention of art is demanded at an earlier period. The causes that may retard the delivery depend either on the patient's general condition, or on a special modification of the genital organs; and, in both cases, their influence may be exerted at the commencement, or only at a subsequent period of the labor; consequently, we have to consider the three following con- ditions : 1, where the pains or contractions are slow or feeble in the commence- ment; 2, where, after having set in with considerable energy, they afterwards relax, diminish, or even cease altogether; and 3, where they exhibit great irregu- larity in their duration, intensity, and returns ; an irregularity that almost wholly destroys their expulsive action. The English writers have applied the term tedious labor to all these varieties, and this appellation merits our adoption, for it is perfectly adapted to the cases we are about to describe. § 1. Of Slowness or Feebleness of the Contractions. A slowness or feebleness of the contractions may occur at the very commence- ment of the labor, and persist throughout its whole duration; the pains are quite feeble, the dilatation of the os uteri is effected very slowly, and at a rather later period they seem unable to effect the expulsion of the head. This slowness of labor may be dependent either on the woman's general condition, or on a local disposition of the womb. In the former case, it occurs in women endowed with a delicate or debilitated constitution, or in those accidentally enfeebled by chronic diseases. It should, however, be borne in mind that, as was stated, page 119, general debility of the muscular system has but little influence upon the contractile power of the uterus, the latter being often very strong, as in consumptive pa- tients for example. The labor sometimes progresses even more rapidly than usual in such individuals, for when the uterine fibre preserves its contractile powers, the slight resistance of the floor of the pelvis seems to expedite the de- livery. Generally speaking, there is nothing to be done but to encourage the woman to have patience, and to make use of some light stimulus, such as broth, claret, or a few spoonfuls of sherry wine ; in a word, to sustain her strength as much as possible, resorting to the ergot as soon as the cervix is sufficiently dilated, if the uterine contraction is too feeble to effect the engagement and subsequent expul- sion of the head. But where the slowness of the labor is to be wholly attributed to a local con- dition of the womb, the determining causes ought to be carefully sought after, as they are variable, and require the employment of different means, and hence we learn the importance of a correct diagnosis. A. An excessive distension of the uterine walls, whether dependent on a dropsy 506 DYSTOCIA. of the amnios or on the presence of several children in the womb, should be placed in the first rank of these causes. In fact, this over-distension renders the uterine walls much thinner than usual, benumbs them in some measure, and diminishes their force of contraction. Independently of a considerable enlarge- ment of the belly, and the unusual elevation of the head towards the end of gestation or beginning of labor, which is worthy of attention, there is something then altogether peculiar in the character of the pains. The contractions, though feeble and only returning at distant and irregular intervals, reduce the patient to a state of anxiety and continual suffering; and, if we may judge from her ex- pression, seem to implicate the fundus alone, without extending lower down, for the amniotic pouch, if still unruptured, scarcely bulges out during their con- tinuance. Under such circumstances, we should carefully avoid resorting to stimulants, which would have no other effect than to augment her sufferings, without rendering the contractions any more energetic. The rupture of the membranes is here the only remedy, because, by facilitating the discharge of the waters, we relieve the excessive distension of the organ, as well as the continual distress thereby occasioned, and then the genuine pains become more frequent and more effectual. B. The slowness and feebleness of the contractions may likewise depend on a sanguineous engorgement, or plethora, of the uterine tissue. This condition, when it exists, can be recognized by the following signs : the pains are at first quite energetic, but soon diminish, both in frequency and intensity; the cervix uteri is soft, supple, and non-resistant, but the presenting part does not engage during the pain, which latter is equally diffused over the whole abdomen ; the phenomena of general plethora nearly always manifest themselves at the same time; thus, the respiration is laborious, the pulse hard and full, and the pains are very irregular, both in force and frequency. Bleeding in the arm, propor- tioned to the general condition of the patient, is then the best remedy. C. Or it may be owing to a debility, or an imperfect organization of the uterus itself, though the patient may otherwise be perfectly healthy, that is, the mus- cular apparatus of the womb may be deficient in contractile force, while the other muscles of the organism are endowed with their usual energy. The dilatation of the os uteri is effected slowly, for notwithstanding the cervix no longer offers any resistance, the organ appears incapable of determining the expulsion of the foreign body it encloses. In such cases, the ergoted rye is the only article capable of stimulating the enfeebled contractions. Dr. Franck, of Wolfenbutten, has recently recommended the employment of electro-magnetism in cases marked by weakness or absence of the contractions, giving four observations, in which, he states, it was used with advantage. The perusal of these cases fails to convince me of its utility. Besides, the difficulty of obtaining a proper apparatus when wanted, will render its employment a thing of rare occurrence.1 1 The author's apparatus is composed of a concave metallic plate, moistened with salt water, applied upon the lumbar region, and connected with the positive pole of a rotating electro-magnetic machine. The negative conductor is attached to a hollow cylinder filled with salt water, and passed into the vagina to the neck of the womb. The electro-magnetic current is applied for five or six minutes between the contractions, and suspended during their continuance. EXTREME SLOWNESS OF THE LABOR. 507 D. According to Baudelocque, the death of the child would have the unfavor- able effect of diminishing and enfeebling the uterine contractions; but M. P. Dubois remarks, and very justly, in our opinion, that, if the woman is otherwise healthy, this event has no influence over the progress of her labor; and that, if it sometimes happens that the delivery is more painfully accomplished where the infant has been dead for some time, it is only because the diseases of the mother have been the occasion of its death, and that her forces are weakened by the antecedent malady. E. Finally, a premature rupture of the membranes may have the same effect, in relaxing and weakening the pains, as their more retarded rupture; and the following phenomena may then take place : if the head happens to be very large, and is low down when this occurs, it becomes applied directly to the orifice, and retains a great part of the waters behind it, and if the os uteri is sufficiently dilated to permit the head to engage freely, no water escapes, even during the contraction; but, if the dilatation is still imperfect, the waters leak away drop by drop, it is said, at the commencement and termination of each pain, which latter is wholly employed in thus gradually expelling the amniotic liquid, with- out contributing in anywise to the enlargement of the cervix. The same pheno- menon is observed when the membranes yield at a higher point of the pouch, one not corresponding at all to the neck of the uterus, for in such cases but little water escapes at the moment of the rupture, and each pain is likewise accompa- nied or followed by a greater discharge without accelerating the dilatation in the least. However, this circumstance, according to M. P. Dubois, does not merit all the importance usually ascribed to it, since, properly speaking, the expulsive process has not commenced, and the fcetus, protected by the surrounding liquid, cannot suffer in any wise from the slowness of the labor, and therefore, in most cases of this kind, there is nothing to be done. If, however, the labor lingers too long, we might follow the plan generally advised, and introduce two fingers into the cervix uteri, and push up the child's head, for the purpose of promoting a more ready escape of the waters, or, indeed, of lacerating the inferior segment of the membranes, if the original rupture had occurred at a much higher point. Nevertheless, this manoeuvre is only to be resorted to when the dilatation is already well advanced, for it is evident that, if all the water should escape a long time before the enlargement of the neck, the infant might suffer from the pro- longed and direct compression of its body. § 2. Relaxation or Suspension of the Pains. It is not at all unusual to find a labor which has heretofore been progressing favorably to become at once arrested, and the pains, which up to that time were strong and frequent, to relax or even disappear altogether. Of course, the indi- cations which these phenomena present will necessarily vary with the causes that have given rise to them, and therefore the physician ought to search them out with the greatest possible care. Among those which may thus diminish or sus- pend the pains, the following are usually enumerated, namely:— A. Any vivid moral impressions operating during the labor, any unexpected news or sharp discussions, the announcement of a child of an unwished-for sex, and the arrival or presence of persons disagreeable to the lying-in woman, may 508 DYSTOCIA. determine a cessation of the pains; and in these cases the removal of the cause is the only remedy. But, unfortunately, it is not always an easy matter to ascer- tain what that cause may be, and it is left to the prudence and sagacity of the medical attendant to penetrate the mystery and remove the trouble. b. A pain caused by the coincidence of some malady, either existing antece- dent to, or appearing during the labor, such as distressing and repeated vomit- ings, sharp pains in the muscles of the back and abdomen, gripings in the intes- tines, &c, &c. In all such instances, the woman, experiencing an intense pain, which is further heightened by the uterine contraction, endeavors to suspend the latter as much as possible, and hence the accoucheur should try to remove the cause which thus interferes with the labor. For instance, where the emesis ob- stinately persists, he ought, if the patient bears opiates well, to administer a few drops of laudanum, and, if not, some aromatic drinks or antispasmodics, accom- panied by narcotic lotions over the epigastrium. In case of acute muscular pains, embrocations with an opiated liniment might be practised over the affected part, or a change of position is sometimes all that is requisite to calm them. If, however, as often happens, this pain, which is wholly foreign to the uterine con- traction, cannot be relieved, then the powers of nature must be assisted by an artificial termination of the labor. Those violent cramps, which are occasionally produced by the pressure of the child's head on the sacral nerves, should certainly be classed among the circum- stances that may relax or even suspend the uterine contraction altogether; as occurred in three cases of the kind observed by Professor Meigs, of Philadelphia, where the pain was so violent that it caused the patient the most inexpressible anguish. The women describe this pain as similar to what would be produced by the pinching or twisting of a large nervous trunk; they incessantly demand a prompt deliverance, and the physician is often obliged to yield to their entrea- ties ; besides, his intervention may be further necessitated by the more or less perfect suspension of the contractions of the womb; for the organ seems para- lyzed by the violence of these nervous pains, and we are often constrained to apply the forceps for the double purpose of relieving the patient from the fright- ful sufferings that torment her, and of supplying the want of power in the uterine efforts. c. We have already alluded (page 456) to the unfavorable influence that an extreme distension of the bladder might have over the progress of parturition; and, therefore, if the suspension of the pains could be justly attributed to this circumstance, the catheter should evidently be resorted to at once; but if this operation is rendered impossible by the engagement of the head in the excava- tion, recourse should be had to the application of the forceps; for the adminis- tration of ergot here would appear to be very imprudent, to say the least. D. If caused by general plethora, which is characterized and is easily re- cognizable by the redness of the face, by headache, throbbings in the head, vertigo, dimness of vision, tinnitus aurium, agitation, unusual force and fulness of the pulse, and by weariness of the limbs, it must be relieved by general ve- nesection. E. Debility of the uterus itself is also mentioned as a cause, since there are some women in whom the contractile force of this organ is so easily exhausted EXTREME SLOWNESS OF THE LABOR. 509 that the contractions, after having proved quite sufficient for the earlier steps of the labor, diminish, or disappear all at once, without any other appreciable cause than this feebleness of the organ. In such cases, the patient should be advised to rise up and walk about the chamber for some time, and it is also necessary to rub her abdomen, to titillate the cervix uteri, and to make pressure on the peri- neum; and then, if all these means fail, to administer the ergot, or apply the forceps. f. The second stage of labor is sometimes exceedingly slow in very fat women; in whom the contractions do not cease altogether, but appear to be ineffectual, and do not force the child's head to advance; this impotence of the uterine efforts has appeared to me to be much less dependent on resistances from the lower part of the pelvic canal, than on a default of action in the abdominal muscles; because the thick layer of fat, which lines the anterior walls of the belly, must paralzye, to a certain extent, the synergic action of those muscles, and thus deprive the uterus of the aid which they habitually render. The abdominal compression, which is so much extolled as a remedy, would then appear pecu- liarly applicable; for a circular bandage, applied around the body, would effec- tually replace the point d'appui, which the contracted muscles usually furnish to the womb; besides, as Velpeau observes, this is too innocent a remedy not to be employed before having recourse to ergot, or to an artificial termination of the labor. § 3. Irregularity of the Pains. The contractions may be irregular in their progress, or they may be partial in their operation: that is, only one portion of the uterine walls contracts, the rest of the organ remaining in a state of inaction; which irregularity is sufficiently explained by the muscular structure of the womb. In the first variety, the pains are recognized by the following signs: there is not a complete and perfect inter- val between them, they are continuous, and only interrupted by the paroxysms, during which the intensity of suffering is horrible. In the second variety, the pain returns, it is true, at intervals, but sometimes it is only the fundus, again one of the angles, and at others, some part of the body, which contracts spasmo- dically, whilst the remainder scarcely does so at all. The pains are, however, no less acute than if the whole organ were involved; often, indeed, they are more so, though even then they are easily recognized by the fact of occurring almost without effect, or at least without having a decided influence upon the progress of the labor. For during the pain, and even at the very moment when the woman suffers the most, we may ascertain, by applying the hand on the hypo- gastrium, in the case of partial contraction, that the uterine ovoid does not pre- sent its normal regularity, and that it exhibits instead various bosses and inequalities; besides, we can readily assure ourselves, in all cases, that no impul- sion is given to the fcetus, and that the presenting part does not advance; as, also, that where the membranes are still unruptured they do not bulge out, nor indeed scarcely become tense during the pain. At the height of the latter, just at the moment of the paroxysm, the presenting part seems, at times, to advance a little; but this progression does not correspond, on the one hand, with the violence of the pains, and, on the other, it is not kept up, though the pains con- 510 DYSTOCIA. tinue. The patient is then suffering from an extreme agitation, she weeps and becomes despondent, and very often her pulse is frequent, developed, and febrile; the face red and flushed; the skin hot; the mind confused, and the limbs con- vulsively contracted. These irregular contractions, which have been designated under the title of uterine tetanus, sometimes disappear of their own accord, though they may be prolonged for an indefinite length of time. It is then highly important to remedy them as soon as possible, which is best done by a general bleeding where the woman is plethoric, the pulse full and well developed, and the face red and flushed; but, as this is not practicable in nervous and very irri- table women, we should then resort to tepid baths, emollient injections, and opiated lotions over the abdomen, and more especially to laudanum, given once or twice as an injection, in the dose of twenty to forty drops, diffused in three or four ounces of some mild vehicle. Under the influence of these measures, the last particularly, the pains almost entirely disappear in the course of half an hour or an hour; during which period the patient generally slumbers, and then the good pains, that is the natural and regular ones, come on, and the labor terminates happily. The action of opiates is occasionally much more prompt, being felt in the course of ten minutes or a quarter of an hour after their administration. I wit- nessed this fact in a young primiparous lady, whose labor commenced at ten o'clock in the morning, and the pains progressed slowly but regularly until four the next morning, when they assumed the peculiar character under considera- tion; and, from that moment, notwithstanding the almost continuous suffering and permanent contraction of the womb, the head did not descend. At six, I administered opiates; and, in the course often minutes, the excessive agitation was calmed, the pains disappeared entirely, then returned again a few minutes after, at first slow and feeble, but soon regular and energetic enough to effect the delivery in a short time. When the cervix participates in this state of spasm, the employment of the ointment and extract of belladonna, as we shall have occa- sion hereafter to point out, will be found decidedly useful; though we ought to mention that the employment of belladonna has been objected to on the ground that it suspends the pains, and paralyzes the exercise of the contractility of tissue after the labor is over; but this is an error, for its action is always limited to the neck, and the latter, at most, may be paralyzed for some time. In the case before us, M. Velpeau says he has used the following potion with advantage: R.—Lettuce, or wild poppy water, fgiv; orange-flower, or mint water, fgj; syrup of white poppies, f^j; extract of opium, gr. j. § Ergot. Of all the various means just alluded to as capable of stimulating the weak, enfeebled, or suspended contractions of the womb, there are but few we have so often recommended as the spurred rye; and the importance of this medicine induces us to devote a special article to its consideration, in which we shall first study the nature and physical characters of the ergot, and afterwards its thera- peutical action. 1. The Natural History of Ergot. (Spurred Rye. Secale Cornu- tum.) The spurred rye, which is now used so extensively in medipine, has at all EXTREME SLOWNESS OF THE LABOR. 511 times been considered as an alteration of that grain, the writers on the subject only differing in opinion with respect to the causes which produce it. Some think it depends on atmospherical or local influences, such as long-continued rains, fogs, and noxious dews, or on too poor or too humid a soil; while others have regarded it as being produced by the puncture of certain insects; this latter opinion has even yet a great number of advocates, although at the present day it is most generally considered as a fungus. Paulet has classified it among the clavaria, and De Candolle among the parasitic fungi, under the name of sclero- tium clavus, from its form; and this was the generally-received opinion until Dr. Leveille, in a memoir published in 1826, in the Annals of tlfo Linnozan Society of Paris, announced that the ergot was in reality an alteration of the grain; and that it was produced by the presence of a parasitic fungus, which he .named the sphacella segetum, intending to satisfy by this title both the color of the diseased grain, and the sad consequences which result from its use when mixed with bread. The extended observations of the author have satisfied him that this fungus appears chiefly in the summer season, after the heavy rains, and that it is developed in the grain itself between the integuments and the peri- sperm. At first, it is invisible, but soon increases in size, and breaks through the envelopes of the grain, while the perisperm, which was very small and white, assumes a violet hue, then elongates, or grows, and becomes hard and brittle, escaping from between the paleae (the husk or chaff), and pushing before it the fungus (sphacelia) found at its free extremity. This fungus is soft and yellow, of a disagreeable odor and a sweetish taste; being formed of several lobes joined at their centre, its surface exhibits some small undulations, similar to the convo- lutions of the brain. If a particle of it be placed in water, under the microscope, it is found to become partially liquefied, and the water holds in suspension an immense number of little grains, or spores, which are oval, transparent, and exceedingly minute in size. These facts, which my learned friend, Dr. Leveille, has kindly made me witness, leave no doubt on my mind as to the nature of this affection; and I am satisfied that it is a true fungus, and a perfectly distinct part of the sclerotium clavus. This fungus is rarely met with on the spurred rye found in the shops, as it has probably been detached either by the threshing, or by the friction of the heads against each other. As this product is soft and dif- fluent, it spreads over the teguments and the spur, where it becomes dried and cracked, and forms a thin layer of a dirty white or yellowish color, which dis- solves when thrown into water. Now, does the ergot owe its properties to this fungoid portion, or to its own proper substance? Experience has not yet settled the doubts of M. Leveille on this subject; but as, by the aid of this theory, we can readily explain why the ergoted rye so often proves worthless when administered, we believe the choice of this substance is not an indifferent matter; therefore, such grains as have a smooth and brilliant surface, as well as those that exhibit numerous deep fissures, should be rejected, for the one has been deprived of the sphacelated portion by friction, and the other altered by successive rains and heats. The preference should be given to those which still have the fungus on their summits, and the surfaces of which are entire, of a violet color and dirty aspect, and covered, as it were, with a powder. 2. Therapeutical Action. The action of this medicine is too well ascertained at the present time to per- 512 dystocia. mit it to be any longer called in question; though we have only to speak of it here in its obstetrical relations. Ergot is now recommended by accoucheurs for arousing or accelerating the uterine contractions during the labor, and for preventing or remedying the inertia of the womb and the hemorrhage which so often accompanies it, after the deli- very. This action is prompt, and is recognizable by the following signs : the uterine contractions are observed to become more active in the course of ten to fifteen minutes after its administration, more frequent and energetic if they were previously slow or feeble, and reappearing, if before suspended. Now, we cannot believe, lik« the authors who proscribed this medicine as useless, that this is merely a simple coincidence, and that the labor would have been restored with- out its use, for the thousands of instances in which its administration has always been followed by the same uniform result, will not permit us to consider the latter as the mere effect of chance; and, besides, all those who make use of this article, know full well that the contractions which attend the exhibition of ergot have a peculiar character, that cannot be mistaken; for, as soon as its action is felt, they become permanent instead of intermittent; the uterine globe remains hard and contracted, and the pains are continual, though they are marked, it is true, by exacerbations, or paroxysms, and there are moments, as in ordinary labor, when the patient does not appear to suffer at all, and others where she makes loud cries or bearing-down efforts. The periods of repose are, however, only apparent, for the womb is constantly contracted on the product of concep- tion, and the hand, if applied over the belly, always finds this organ in a remark- able state of hardness; there is not that regular succession of repose and contraction which is constantly observed when the labor is spontaneous; and we may further add, that the patients themselves detect a great difference between the pains excited by the medicine and those previously felt in the same or former labors, and they bear them, as a general rule, more impatiently than the latter, complaining particularly of the want of relaxation. The labor is ordinarily ter- minated in an hour or an hour and a half after the exhibition of the ergot; but the action of the latter wears away and soon disappears after this period, and therefore, if there is any necessity, it must be again renewed, or recourse be had to artificial means for terminating the labor. The permanent character of the contractions produced by ergot makes them very dangerous to the child when they are long continued. The violent retrac- tion of the muscular fibres then renders the circulation difficult, and sometimes even impossible, in those vessels which are distributed between their various layers, and we may readily understand that the fceto-placental functions must be remarkably obstructed. Therefore, it can be prudently administered only when a prompt termination of the labor can be predicted. This remedy is only to be given during parturition, when the pelvis is well formed, the infant presenting by its cephalic or pelvic extremity, and of course when the position is well ascertained; where no serious obstacle exists at the uterine orifice, in the vagina, or at the external parts, that is to say, when the cervix uteri is sufficiently dilated, or at least soft, supple, and patulous enough to admit of dilatation, or where the membranes are ruptured. On the other hand, its administration ought to be avoided as much as possible in primiparae, and, if extreme slowness of the labor. 513 it should become necessary in them, the perineum must be supported with the greatest care, lest it be exposed to a considerable rupture should the delivery prove rapid; in very irritable women, who may have had convulsions either during gestation, or in their previous labors; because the ergot often produces a state of nervous excitement in such persons, which occasionally amounts almost to mania; in plethoric patients, suffering from a congestion about the head, which is characterized by flushing and turgescence of the face, by injection of the eyes, headache, &c, &c.: in a word, in all those cases where venesection is obviously indicated; and lastly, in all those women, where the womb, from being endowed with an acute degree of sensibility, is in a state of irritation, and is habitually the seat of pains, or who, in a former labor, might have been affected with an inflam- mation of this organ. The spurred rye has likewise been employed successfully in the profuse hemor- rhages that follow abortion, which are caused by the retention or tardy separation of the placenta; as also for the floodings that take place after the1 expulsion of the fcetus, whether before, during, or subsequent to the delivery of the after- birth. We shall take occasion hereafter, in the article on Hemorrhage, to refer to its use under such circumstances. The question now arises, can the ergot, which possesses in so high a degree the property of stimulating the enfeebled contractions, and of arousing them when suspended,—can it develope them where they have not yet existed ? If we might judge from certain experiments made for this purpose, by Professor Dubois, in our presence, at the Clinique, in 1837, we should answer this question in the negative ;* but it must be confessed that those trials were not sufficiently numerous to enable us to decide it positively; and although this article has seemed to possess the abortive property in some instances, yet in many others it has proved wholly inefficacious. Again, it has not been observed that abortions are of more frequent occur- rence in those countries where the bread of the inhabitants contains a certain quantity of ergot; but habit, perhaps, might explain its want of action here. This medicine is employed under divers forms; and the powder, the infusion, the decoction, the aqueous extract, or alcoholic extract, ethereal tincture, or the syrup, may be used, almost indifferently; although in France scarcely any other preparation than the powder, the infusion, or decoction, is ever employed. Thus, it is customary to administer two or three doses of the powder, consisting of eight or ten grains each, diffused, at the time it is given, in two ounces of pure or sugared water, or a little wine and water, or some slightly aromatic infusion; and these doses are repeated at intervals of ten minutes. If the contraction is mani- fested after the second dose, as most usually happens, the third need not be given. Some accoucheurs administer it in a small quantity of white wine or tincture of canella, and other excitants; and it has been advised to add a small 1 Such also was the opinion, at the time, of the honorable professor alluded to; but, since then, new experiments have somewhat modified his views; for we have heard him affirm, at the Academy of Medicine (in March, 1840), that, in certain cases, the ergoted rye might bring on the regular pains; and, in consequence, he classified this medicine among the measures calculated to produce a premature artificial delivery. But this opinion does not appear to us to be based on a sufficient number of facts to warrant its general adoption. 33 514 DYSTOCIA. quantity of opium to prevent the medicine from being rejected, though, where the patient either vomits or seems disposed to vomit during the labor, it is better to administer it, as M. Dubois recommends, by injection, and the dose might then be increased a little. The infusion is prepared by diffusing two scruples of the powdered ergot in a glass of water for ten minutes; or, if the article is merely bruised without being powdered, three or four scruples may be infused in the same quantity of men- struum. In conclusion, we shall not again repeat what was said in the com- mencement o£ this article concerning the physical characters that distinguish good and genuine ergot, but we will only add that the apothecaries ought to be cautioned to have the drug freshly pulverized; and as, notwithstanding our earnest recommendations, they will not all take the proper precautions, the accoucheur would do well to always carry a few grains with him, so as to have it at hand in case of necessity. CHAPTER II. OF TOO RAPID LABORS. Although these are much more rare than the preceding class, yet the acci- dents that may result in consequence of too prompt a delivery, are quite as serious as those produced by its excessive slowness; and, therefore, we must endeavor to supply an important omission made by most authors, and ourselves likewise in the first edition of this work, by devoting a few lines to the con- sideration of the attendant circumstances. Some women have the unfortunate privilege, if it can be called such, of being delivered with only a few pains; and this extreme rapidity is apt to characterize every subsequent labor. What is still more singular, this peculiarity even seems to be hereditary in certain families, in which it is perpetuated for three or four generations. In such cases, the rapid termination is always to be attributed either to an excess of energy and frequency in the uterine contractions, or to a want of resistance in the walls of the canal which the fcetus has to traverse. Certain writers have attempted to establish a relation between the phenomena that precede or accompany the menstrual discharge in the non-gravid state, and the activity or slowness of the contractions of the womb during the labor; for, they say, should the periodical flow be difficult, laborious, and painful, and the patient be tormented every month with violent colicky pains, either before or during her terms, the irritability of the uterus, and the energy of the contrac- tions, will almost invariably be excessive in the hour of childbirth; but, on the contrary, there is reason to anticipate the occurrence of slow and feeble pains, where the woman is advised of the return of her menses only by the appearance of blood, and when they pass off without suffering. We do not know exactly to what extent this approximation is true; yet we believe that it is far from being TOO RAPID LABORS. 515 without exceptions. But, however this may be, it is generally found that these very powerful contractions are most likely to be observed in nervous and ex- citable persons; appearing to depend, says Wigand, upon a high grade of irri- tability, the source of which, especially in hysterical patients, seems to be centred in the uterus. The moral affections are often found to have a great influence over the progress of labor; and everybody knows that where an application of the forceps has been seriously proposed to the woman, this of itself has often proved quite sufficient to bring on strong and powerful contractions of the womb, by the fears which the instrument gives rise to, even though they had been languishing before. In certain eruptive fevers, scarlatina especially, the pains very frequently ex- hibit this character, and the child is then expelled with an unusual rapidity; but it is difficult to decide whether this circumstance is not rather owing to a want of resistance from the soft parts, which, like all the muscular apparatus, have been enfeebled by the disease. The same thing also occurs in certain strong, robust, and plethoric women; here, however, the contractions are very strong from the commencement of labor; they are very painful, last for a long time, and are separated by short intervals. While the pain lasts, the patient cannot resist the urgent desire to bear down, and forcibly contract all the muscles of her body; she is much more irritable than usual, and there is something peculiar in her attitude; the head is hot; the face red and puffed up; and the pulse full and accelerated. In some instances, the intervals are scarcely perceptible, for one pain has hardly terminated before another begins; sometimes, indeed, the womb seems in a state of permanent contraction, which only passes off after the expulsion of the foetus. The belly is then very hard; the whole body rigid and contracted; the woman holds her breath, seizes hold of some neighboring object, and, making a loud cry, or grind- ing her teeth, bears down with incredible force, and suddenly expels the child together with the contents of the bladder and rectum. But, after all, however forcible we may suppose the uterine contractions to be, they will hardly explain the rapidity of the delivery, unless we admit that a want of resistance in the walls of the pelvic canal exists at the same time; but may not a very large pelvis, a premature child, or a marked diminution of the normal resistance of the soft parts, so often met with in persons worn out by lingering diseases,1—may they not, we repeat, be considered as singularly favoring a too early expulsion of the child ? Where the phenomena of parturition take place with due regularity, the infant rarely comes into the world under seven or eight hours after the first pain, and this beneficent delay enables the parts which the child has to traverse to become prepared for the dilatation they must shortly undergo; the uterine orifice gra- dually enlarges ; the soft parts, that line the excavation and the pelvic floor, being lubricated for a long time by the liquids exhaled from the womb, or secreted by the upper part of the vagina, become more soft and supple and better prepared 1 This want of resistance from the soft parts may be met with in women who are other- wise healthy, as occurred in a case reported by Dr. Rigby, where a patient, in the enjoy- ment of good health, was delivered by two pains; the first of which aroused her from a sound sleep, and the second expelled the child into the bed. 516 DYSTOCIA. for the distension they will be subjected to, at the moment when the head is born; besides, their dilatation being effected under the influence of intermittent contractions, alternated by an interval of rest, is slow and gradual, and takes place without causing the patient any very acute suffering and without compro- mising the life of the child; but it is far different in the case before us, where the over-hasty expulsion of the infant exposes it as well as the mother to grave accidents. Thus, not to speak of inertia of the organ, which will be treated of hereafter as one of the circumstances that may complicate the delivery, we must note as of possible occurrence the laceration of the perineum, vagina, and vaginal portion of the cervix, so often produced by the rapid passage of the fcetus through the pelvic canal; the prolapsus of the womb, which, not being yet sufficiently dilated to allow the child to clear its orifice, is forced down beyond the vulvar ring; the serious and sometimes fatal syncopes to which the too rapid depletion of the womb exposes the patient;1 and, lastly, death itself, produced solely from the violence of the nervous shock caused by such pains. The child is likewise exposed to real danger; for if the membranes are rup- tured and the waters entirely discharged early in the labor, it must be apparent that, when the pains become permanent, the umbilical cord might be compressed between the fcetal surface and the uterine wall, or that the infant itself might suffer from the direct pressure it then undergoes. On the other hand, if the woman, supposing herself only at the commencement of her labor, should happen to be still standing or walking when surprised by these violent pains, the child may be forcibly expelled, and, striking against the floor, be killed, perhaps, by the severity of the fall; besides which, the umbilical cord is stretched from its placental insertion to the navel, and, if its rupture does not result in consequence, the traction made upon the still adherent after birth may be sufficiently great to depress, or even to invert the womb completely; though this latter circumstance is an exceedingly rare one. A rupture of the cord has been observed much oftener; but this is seldom attended with much danger, so far as the child is concerned, because the laceration usually occurs at two or three inches from the navel, and because, by tearing the umbilical vessels, it is likely to prevent a mortal hemorrhage, even should the pulmonary respiration not be established imme- diately. Treatment.—Where there is reason to believe that the child is very small, as it would be in a case of premature labor, or if previous deliveries have led us to suppose that the pelvis is larger than usual, the woman ought to lie down on the occurrence of the very first pain, and she should avoid bearing down or contract- ing the muscles subjected to the influence of her will, as much as possible, during the pain; the same object would be materially aided by applying a mode- 1 There is no difficulty in explaining the production of syncope in this case, for the womb, being distended by the product of conception, necessarily exercises a greater or less degree of compression on the large abdominal vessels ; and when the fetus is slowly delivered, as in a natural labor, this compression diminishes in the same proportion, and the blood re- turns in a very gradual manner into the great trunks, in which its course was before im- peded ; but in the case before us the depletion of the uterus is sudden, and the vessels are relieved all at once from the strong pressure they previously experienced, the blood flowa into them in abundance, and goes in but small quantities to the brain: whence the latter, deprived of its natural stimulus, no longer acts on the heart, 4c, &c. DEFORMITIES OF THE PELVIS. 517 rately drawn bandage around the abdomen (Rigby). Finally, every precaution is to be taken to retard the rupture of the membranes as long as possible. If, notwithstanding these precautions, it is found that the inferior part of the uterus is strongly pressed downward towards the floor of the pelvis, or even through the vulvar orifice, it must be carefully sustained until the cervix is suffi- ciently dilated to permit the free passage of the head. We might, like M. Naegele, apply a large T bandage in front of the vulva, extending up over the prominent part of the womb, and having an opening at its centre corresponding to the orifice of the vagina. If the patient had been delivered too rapidly in her previous pregnancies, opiates might be administered, either by the mouth, or by injection, for the pur- pose of calming the excessive irritability of the uterus. Wigand has recom- mended venesection, which, perhaps, might be employed with advantage in strong and plethoric women, but experience has not yet determined the efficacy of the measure as a general remedy. BOOK II. OF LABORS RENDERED DIFFICULT, IMPOSSIBLE, OR DANGEROUS, BY OBSTACLES THAT OPPOSE THE READY EXPULSION OF THE FCETUS. The material obstacles which too often render spontaneous labor difficult or impossible, are exceedingly numerous, and depend either on the mother or child. The diseases and deformities, or faulty direction, of the canal which the foetus has to traverse, are naturally included among the first; and to the second we must refer the diseases and malformations of the infant itself, as also the un- favorable positions in which it may present at the superior opening of the pelvis. We shall commence our description with the obstacles appertaining to the mother's organs, and will first treat of deformities of the pelvis. CHAPTER I. OF DEFORMITIES OF THE PELVIS. Whenever the pelvis departs from the dimensions heretofore described as the normal ones, it is said to be deformed; which, as the reader will readily understand, may imply either an enlargement or a diminution of the average size; and this explains the division, admitted by accoucheurs, into pelves de- formed by excess of amplitude, and those deformed by excess of retraction. I say by excess of amplitude or of retraction, for it must not be supposed that a pelvis is reputed to be malformed, whenever it does not exactly present the dimensions before given as the ordinary standard; because its development is 518 DYSTOCIA. subjected to the influence of the same laws that regulate the whole organism, and we all know what great varieties those laws exhibit in their accomplishment. Therefore, as a few lines, more or less, do not constitute a deformity, we shall only include under the title of malformed pelves those which, from their exces- sive size or narrowness, are capable of producing notable difficulties in the exercise of the puerperal functions. § 1. Of the Pelvis, Deformed by Excess of Amplitude. A large pelvis is not always a favorable circumstance, as might at first sight be supposed; because, if the amplitude is too great, it exposes the woman to serious accidents, both in the non gravid, the pregnant, and the parturient state. Thus, in the unimpregnated condition, the uterus, not deriving an adequate support from the walls of the excavation, and being free and movable in an over-spacious cavity, is much more liable to the various displacements known as descent, anteversion, and retroversion of the womb; which accidents are then the more unfortunate, as they are the more difficult to remedy During gestation, the womb, 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 compressing the rectum and the bladder, often occasions an excesssive tenesmus in these parts, which proves very distressing to the patient; sometimes, even the discharge of the urine and fecal matters is impeded, besides which, varices, hemorrhoidal tumors, or a considerable infiltration of the lower parts are found to be developed, in consequence of the mechanical obstacle to the circulation in the inferior extremities. If this excess of amplitude is restricted to the excavation, while the straits vary but little, if any, from their normal dimensions, the fundus of the womb is often turned back into the hollow of the sacrum; and, somewhat later, when its volume is too great to permit a longer sojourn in the lesser pelvis, it meets with difficulties at the superior strait which it cannot surmount; and the impediment then offered, in either case, to the ulterior development of the organ, frequently brings on an abortion. At the end of gestation, the head engaging early at the superior strait, gets low down into the excavation, and presses on the neighboring parts; whence all the unpleasant symptoms that had accompanied the outset of pregnancy are found to be renewed in its latter months. During labor, the excess of amplitude of the pelvis exposes the woman to all the dangers that may result from a too rapid delivery; for, if she brings into play the voluntary muscles, long before the proper dilatation of the os uteri, or bears down too strongly during the pain, the organ, being imperfectly sustained by the osseous walls of the canal, may be forced down as far as the vulva; and, indeed, be driven completely beyond the parts of generation; or, possibly, the circumference of the cervix uteri may yield, and thus give rise to a laceration. Supposing the dilatation is already perfected, then the child, being urged along by the energetic and repeated contractions of the womb, and not encountering a due degree of resistance on the part of the straits, speedily reaches the perineum, and tears its way through, because the latter has not yet had time to become dis- tended. The expulsion of the foetus may thus take place at a moment wheu the patient and her attendants believed it still distant; and hence, the absence of DEFORMITIES OF THE PELVIS. 519 the ordinary precautions, and the erect position in which she may happen to be, will expose the child to a fall on the floor, or produce a premature separation of the placenta, a rupture of the umbilical cord, or an inversion of the womb; and, last of all, the womb, from being suddenly emptied, is sometimes affected with inertia, and becomes the source of a profuse flooding. After delivery, a very large pelvis permits the uterus, notwithstanding its volume, to sink down into the excavation, and the compression thereby produced on the adjacent organs may become the cause of an inflammation that is always to be dreaded. It is further evident that an excess of amplitude must favor the displacements of the organ; and it is highly probable that the cases of retro- version reported by Martin, of Lyons, and Yermandois, as having occurred in the first few days immediately following the delivery were owing to this circum- stance. (Martin, 158.) The indications for treatment, which malformation of the pelvis, from excess of amplitude, present, are exceedingly simple; for all that we have to do is to keep the patient recumbent throughout the labor, and recommend her not to aid the pains in anywise, and particularly not to bear down until the os uteri is fully dilated. Where this process is not yet completed, and the cervix, pressed down by the head, appears at the vulva, we must endeavor to push it back during the interval, and then, by supporting it with the hand, oppose its escape during the contraction; though, on the contrary, if the neck is sufficiently dilated, the labor is to be terminated by the application of the forceps. For the indications to be fulfilled during the progress of gestation, we refer to Article IV, Diagnosis of Deformities, Sensible Signs, et seq.; as also, for those presented by the displacements of the uterus in the course of the labor itself, to the following chapter.- § 2. Of the Pelvis Deformed by Excess of Retraction. Among the various conditions necessary to a spontaneous labor, there is one whose importance cannot be contested, namely, that a just proportion exist be- tween the dimensions of the canal, and those of the body that must traverse it; for, whenever this relation does not appear, whether owing to a retraction of the pelvis, or to an abnormal size of the child, the delivery is no longer possible; aud whenever this disproportion is carried to an extreme, we have only to choose between two resources that are equally disastrous in their consequences, that is, to diminish the volume of the infant, or to enlarge the way it has to pass through. The retractions of the pelvis, therefore, are the most terrible accidents that can occur in the practice of our art, and their importance, in every point of view, sufficiently warrants the detail into which we are about to enter. The various degrees of retraction, the differences in their seat, and the varie- ties of form the pelvis then assumes, are so numerous, that it is indispensably necessary to adopt some general arrangement; to collect them into classes, to form groups, and then to attach these to certain principal types that are easily recognized; the number of which, however, to aid their acquisition by stu- dents, should not be too great. After having thus classified the different va- rieties of deformities from retraction, we must study their principal characters, and endeavor to point out their causes, their mode of development, the means of recog- nizing them, and, lastly, the indications for treatment that each of them presents. 520 DYSTOCIA. ARTICLE I. PATHOLOGICAL anatomy. As regards their form and external configuration, the retracted pelves may be divided into two very distinct groups; for either the pelvis, although greatly re- tracted in all its dimensions, is properly formed, and presents no irregularity in its exterior aspect, or else the retraction affects only one or more of its diameters (the others maintaining very nearly their normal length), and this partial altera- tion completely changes its form. § 1. Of the Simple Contracted Pelvis, without Curvature or Malformation of the Bones. (Absolute Contraction.— Velpeau.) Before the researches of Professor Naegele, whose principal works on the pelvis will soon be disseminated throughout France, by means of the translation just published by M. Danyau, there was scarcely any mention made of this variety of contraction in the leading classic works; for most of the French and English authors merely stated that a narrowness is rarely met with in all parts of the pelvis at one and the same time, and that it is still more rarely carried to a point demanding the intervention of art. It was reserved for M. Naegele to point out the importance of this particular variety. In his collection, he numbers four pelves that are contracted through- out, and all their diameters are one inch less than the normal dimensions; these all required either the Caesarean operation or the mutilation of the foetus. Three of them were obtained from women of ordinary stature, the fourth belonged to a dwarf thirty-one years of age, and only forty-six inches in height, though otherwise well formed. As regards the respective lengths of their different diameters, and the form of the pubic arch, each one of these presents the cha- racters of a regularly-formed pelvis, whose dimensions may be supposed to have been reduced; and, as to the condition of the bones, that is to say, their color, strength, and texture, there is no departure from the healthy standard. In one of them there is even a tendency to a greater density of the osseous tissue. Further, these pelves have nothing in common with those deformed in conse- quence of rachitis, as the consistence, density, thickness, and size of the bones, aud the regular shape of the pubic arch sufficiently prove; besides, the indi- viduals from whom they were procured, presented no traces of that affection during life; and the examination of other parts of the skeleton fully confirmed this distinction, which we hope to prove in a still more decisive manner here- after, when the causes and particular development of this species of contraction shall be studied. M. Naegele admits two distinct varieties in the malformed pelvis under con- sideration. In one, he says, the pelvis, with respect to its thickness, strength, texture, and indeed all the physical characters of the bones, size excepted, does not differ from a normal one; and it is met with in persons of either a small, an ordinary, or a high stature, who may be otherwise well-formed and thin, and whose external appearance would not cause the least suspicion of such a forma- tion; whence it can only be recognized by a local exploration. In the other, DEFORMITIES OF THE PELVIS. 521 the pelvis is wholly different; for, as regards their volume, substance, and strength, the bones exhibit the characteristics of childhood; and the same re- mark is applicable to their mode of union with each other. This variety is only observed in very small individuals, such as dwarfs; and the relations of the dia- meters with one another, and the form of the pubic arch are such as are found in the girl, when the sexual system has just completed its development. Thus, for example, in the dwarf before cited, whose height was but forty-six inches, the pelvis had the following dimensions, viz. :— From the promontory of the sacrum to the point'of the coccyx, . 3£ inches. The antero-posterior diameter of the superior strait, . . . 3£ " Transverse diameter of " " .... 3| " Antero-posterior diameter of the excavation, . . . . . 3£ " Transverse diameter " " . . , . . 31 " Transverse diameter of the inferior strait, . . . . . 3£ '• Depth of the symphysis pubis, .....nearly 1 inch. § 2. Of the Pelvis Contracted by the Curvature and Malforma- tion of the Bones. (Relative Contraction.— Velpeau.) In those cases where the pelvis is contracted by the curvature and malforma- tion of its constituent bones, the deformity may be referred to one of the three principal types described by M. Dubois : that is, either to a flattening from before backwards, to a compression on the sides, or to the depression of the anterior and lateral parts ; the first variety, or flattening, shortens the antero-posterior diame- ters, the lateral compression diminishes the transverse ones, and the depression of the antero-lateral walls contracts the oblique diameters. Again, each of these varieties may affect either the superior strait, the inferior strait, or the excava- tion, though frequently both straits are contracted at the same time. A. The flattening from before backwards, or shortening of the antero-posterior diameter, results from a more or less marked approximation of the anterior and posterior pelvic walls; and this species of malformation exhibits several varieties, as regards the extent of contraction, whether in height or width. For instance, the superior strait alone may be contracted, while the excavation retains its normal capacity; this phenomenon is caused by the unusual curvature of the sacrum, which is sometimes so bent anteriorly as almost to represent an obtuse angle at its middle part, whereby the base of the bone is thrown forward in such a way, as to singularly augment the prominence of the sacro-vertebral angle. But the contrary may also occur, and the sacrum instead of presenting an anterior concavity, be quite plane, or, occasionally, even convex in front; and then the excavation is contracted simultaneously with the superior strait, in its antero- posterior diameter, and it really seems as if the sacrum, having lost its natural curvature, had been pushed forward in totality. The shortening of the antero-posterior diameter of the superior strait, some- times accompanies an enlargement of the corresponding one at the inferior strait. This, indeed, is the most frequent arrangement, and is what generally takes place, when the sacrum, yielding under the weight of the trunk, transmitted to it through the spinal column, becomes tilted, that is, the base is projected forward, while its coccygeal extremity is forcibly pushed backward. 522 DYSTOCIA. A pelvis, in which the contraction of the sacro-pubic diameter is produced by the unusual prominence of the sacro-vertebral angle. Lastly, the coccy-pubic and the sacro-pubic diameters may be shortened, at the same time, if it should happen that the sacrum, instead of performing the tilting movement just alluded to, yields in such a way that its two extremities are thrown forward; the anterior curvature is then greatly augment- ed, and consequently the corre- sponding diameter of the excava- tion enlarged. In the approximation of the antero-posterior walls, the sacrum is nearly always the displaced bone; but although much more rare, a flattening of the anterior wall is also met with; and then the sym- physis pubis, instead of presenting a convexity in front, is perfectly flat, or even (as in one instance re- presented by Madame Boivin) presents a depression, which seems to protrude inwardly towards the prominence of the sacrum. This double inclination of the pubis and sacrum towards 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 fossae, and is separated in the middle by a re- stricted part, of variable width. If the depression is considerable, the antero- posterior diameters of both straits, and of the excavation, must evidently be affected by it. But there is yet another way in which the symphysis pubis may contribute to the narrowness of the pelvis ; for in- stance, its vertical extent is sometimes much greater than usual, and this ex- traordinary length gives rise to what is termed the bar pelvis; or the same effect may be produced by an excessive inclination backwards at its lowrer end. Again, the CGCcy-pubic diameter may be shortened, it is said, by an elonga- tion, or rather an almost horizontal direction of the coccyx, and more par- ticularly by an immobility of the sacro-coccygeal articulation. This latter cir- cumstance has been invoked in explanation of the slowness and difficulty of first labors, in middle-aged women; but, as M. A. Dubois has remarked, the delay in the delivery of the head in such persons does not usually depend on an immo- bility of the coccyx, but upon the rigidity of the soft parts, which then offer great resistance. b. The compression of the lateral walls, by which the transverse diameter is shortened, is the rarest of all the deformities, at least so far as concerns the superior strait and upper part of the excavation; for the inferior strait, The shape of the superior strait in the figure-of-eight pelvis. DEFORMITIES OF THE PELVIS. 523 on the contrary, the approximation of the two ischial tuberosities, which consti- tutes this species of deformity, is quite as frequent as the shortening of the coccy- pubic diameter; the malformation resulting from the approach of those tuberosi- ties, as well as that of the branches of the pubic arch; this latter then assumes the triangular form peculiar to the male sex. Besides which, the lower part of the excavation may be notably diminished in the transverse direction, by the inward projection of the spines of the ischia. The transverse contraction is seldom as well marked as the flattening from before backwards, especially at the superior strait, where it is, in general, limited to diminishing the bis-iliac diameter from a few lines to an inch in its length, by elongating the antero-posterior one to the same extent; for the coxal bones are m then less curved, and the sacrum is thrust backwards, while the pubes are more prolonged in front. Of course, the upper strait will be more or less altered in form according to the degree of compression, for where this is inconsiderable, its periphery is nearly circular; but, when greater, it represents an ovoid, the larger extremity of which is posterior. Another variety of transverse contraction is owing 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 vertebral column is found nearer to the hip of the contracted side; the transverse diameter is likewise diminished at the inferior strait by reason of the obliquity of the entering part of the coxal bone. The antagonism before alluded to, as existing between the antero-posterior dia- meters of the superior and the inferior straits, whereby the elongation of one most frequently coincides with a shortening of the other, rarely exists in the transverse direction; the deformity produced by a congenital displacement of the femurs is probably the only condition in which the transverse diameter of the inferior strait augments at the same time that the bis-iliac one diminishes; the enlargement in the lower part of the pelvis, in this instance, being marked by an unusual width in the pubic arch, a great obliquity of the ischio-pubic rami, a separation of the ischial tuberosities, &c. (See art. Causes.) c. The depression of the antero-lateral walls, which diminishes the oblique diameters, is much more frequent than the preceding variety, though it is more rare than the flattening from before backwards, and it may exist on one, or both sides at the same time. This deformity consists, essentially, in the flattening, or inward projection of the coxal bone, at the part corresponding to the cotyloid cavity, and to the junction of its three constituent pieces; whence there results at this point a greater or less diminution of the curve which the pelvic circum- ference usually describes; and when existing in a high degree, the curvature is even reversed, its convexity being turned towards the sacrum, while, at the same time, the pubis departs from its normal transverse direction and runs almost directly forwards; so that the deformity is produced by the coxal bones having then assumed the form of an old italic S, instead of presenting a regular arch. Where this takes place to the same extent on both sides, the pelvis maintains a degree of symmetry, and the superior strait is shaped like the trefoil leaf; that is. it presents three lobes, one anteriorly, which corresponds to the more acute 524 DYSTOCIA. angle of the pubis, and two posteriorly and laterally, formed by the union of the iliac bones with the sacrum. But, it far oftener happens that the deformity is more marked in the coxal bone of one side than upon the other, and then the shape of the pelvis is the more irregular as the deformity of the ossa innominata is greater. Where this double disfiguration of the hip bones exists in a high degree, more especially when it affects the ante- rior pelvic wall, it vitiates both the oblique and antero-posterior diame- ters at the same time. In fact, these bones are then approximated in a parallel manner, being only , separated from each other by a slight distance, for the extent of an inch or two, while the rest of the pelvis is comparatively regular; and hence, although the symphysis pubis may be at the normal distance from the sacro-vertebral angle, yet it is A pelvis in which the sinking-in of the antero-lateral not the legg irue^ that the anterO- walls exists on both sides. . „ . posterior diameter of the superior strait will be virtually shortened in all its forward part comprised in the fissure left between the two deformed antero-lateral walls, because this contracted por- tion cannot contribute in anywise to the passage of the fcetal head. Again, we may remark, with M. P. Dubois, that as the anterior arch of the pelvis has but very little depth at the point corresponding to the depression of its lateral walls, and as the surface compressed by the head of the femur occu- pies the largest portion of it, the whole of that region must almost necessarily be pressed in; and, consequently, that the shortening must affect all the diameters at once, those of the excavation and of the abdominal and perineal straits; though the retraction is in general less marked at the inferior strait than elsewhere, because the lower part of the ischium is not carried so far backwards as the cotyloid region. As to the variety of deformity recently described by M. Naegele, the celebrated professor of Heidelberg, under the title of oblique contraction, we may evidently refer it also to a shortening of one of the oblique diameters. His book on the subject has recently been translated with the greatest care by M. Danyau, who has enhanced the value of this admirable work by the addition of learned notes; but, as we had induced Dr. Steege, before the publication of Danyau's transla- tion, to prepare for us the chapter in which M. Naegele describes the principal characters of his oblique pelvis, we submit the following translation of it, which we owe to the courtesy of our professional brother. The special conformation of a new variety of deformed pelvis, forming the subject of Nozgele's monograph. " The principal characteristics of these deformed pelves are the following. namely: DEFORMITIES OF THE PELVIS. 525 " 1. A complete anchylosis of one of the sacro-iliac articulations, or a perfect fusion of the sacrum and one of the iliac bones together.1 " 2. An arrest of development, or an imperfect development of the lateral half of the sacrum, and deficient size or contracted opening of the anterior sacral foramina on the anchylosed side. " 3. On the same side, a reduced size of the os ilium, and, consequently, a diminished extent of the ischiatic notches of this latter; that is to say, the distance betweeen its anterior supe- rior and its posterior superior spi- nous processes, as well as an ima- ginary line, drawn at the entrance of the pelvis, commencing at the spot where the sacro-iliac symphysis would be (if it existed), and run- ning along the linea innominata and the linea ilio-pectinea as far as the pubic symphysis, is shorter here than on the opposite side. Further, the part corresponding to the arti- cular surface, on the anchylosed bone, which is here continued into . , . . A figure taken from M. Nsegele's work, which exhibits the sacrum Without any transition, the characters of the oblique-oval pelvis in a high de- extends neither so high up, nor sree- descends so low, as upon the opposite side, or as it would in a well-formed ilium; or, to explain myself more clearly, if we suppose the ilium and sacrum of the anchylosed side to be temporarily separated, and then reunited through the intervention of a fibro-cartilaginous disc, as occurs in the natural state, the articular surface or the junction of these two bones would be found shorter, and, of course, would not descend so low as on the opposite side, which is exempt from fusion, or as it does in a well-formed pelvis. " 4. The sacrum seems to be distorted toward the fused side, and it also has its anterior surface turned more or less towards this side, whilst the symphysis pubis is pressed over to the opposite one; in consequence of which arrangement the symphysis is no longer found directly in front of the promontory, as it ought to be, but is caused to assume an oblique position. " 5. The internal surface of the ilium, on the anchylosed half, is more flat- tened in that part which contributes to the formation of the pelvic cavity, and sometimes even (in cases of great deformity) is almost entirely plane; so that, for example, a line drawn from the middle, or even the posterior extremity of the linea innominata, and running along the body and horizontal branch of the pubis as far as the symphysis, will be nearly a straight line; but we have never 1 We retain the expression anchylosis on account of brevity, and because it is the one generally used to designate the condition under consideration; but we formally protest against the imputation of having admitted that these bones had originally been well formed, and had only contracted this continuity of structure in consequence, of some dis- ease. Perhaps the term synostosis or synezizis would better designate the perfect fusion here alluded to. 526 DYSTOCIA. seen an inclination inwards at this part, nor have we particularly observed that inward projection of the horizontal branch of the pubis that is found in pelves deformed in consequence of mollities ossium in the adult. " 6. The other lateral half of the pelvis, or the one where the sacro-iliac arti- culation still exists, likewise departs from the normal condition; although, where the obliquity is inconsiderable, we may easily deceive ourselves at first sight, and be induced to suppose that there is a natural conformation of the non-anchylosed half; such, however, is not the fact, as can be proved by supposing two pelves to be similarly deformed, with this difference only, that in one the fusion of the sacro-iliac articulation takes place on the left side, while in the other* it is on the right; and then making a section of each through the symphysis pubis and the middle line of the sacrum; when, by attempting to fit the right half of the first of these pelves to the left half of the second, by bringing the cut surfaces of the two sacrums against each other, we shall find that the pubic bones are separated by an interval of three to four inches. " Consequently, the lateral half of the pelvis, exempt from fusion, not only par- ticipates in the abnormal situation and direction of the bones, but also in their irregular form; and this to such an extent that, if a line should be drawn on the non-fused side from the middle of the promontory, along the linea innominata and linea ilio-pectinea as far as the symphysis pubis, it would be more curved in its posterior, and less so in its anterior half, than in a normal pelvis." Whence it follows: - 7. A. That the pelvis is contracted obliquely, that is to say, in the direction of one of the ordinary oblique diameters, while in the other (which runs from the point of anchylosis to the opposite cotyloid cavity) it is not at all diminished, but may even be larger than usual, when the obliquity of the pelvis is greater. " Wherefore, the superior strait, or, in other words, the surface limited by a line traced along the spines of the two pubes, and thence along the lineae inno- minatae and prolonged on the sacrum, as well as the imaginary plane at the centre of the pelvic excavation (in the place where we usually admit the middle opening of the pelvis, upertura pelvis media), will resemble, strictly speaking, an oblique oval when viewed in front; the transverse or small diameter of which will be represented by the contracted oblique diameter, and its great, or longitu- dinal one, by the opposite oblique diameter.1 Therefore, as regards their form, the pelves in question might very properly be designated by the title of the oblique-oval pelvis (pelvis oblique-ovata). " b. That the distance from the promontory of the sacrum to the point corre- sponding to either cotyloid cavity (the sacro-cotyloid interval),3 as well as that from the apex of this bone to the spines of the ischia, would be less on the side where the anchylosis exists. 1 From this it is evident that the lines connecting those points, between which we are accustomed to imagine the antero-posterior and transverse diameters as passing, do not cross at right angles in the oblique-oval pelvis, and that the latter cannot be regarded as possessing oblique diameters such as are attributed to symmetrical pelves. 2 For sake of brevity, we use this expression here in order to indicate the distance re- ferred to, it being one which J. Burns thought it necessary to measure and establish, for the purpose of assisting in an exact representation of the form of the pelvic opening. DEFORMITIES OF THE PELVIS. 527 " c. That the distance from the tuber ischii on the anchylosed half to the pos- terior superior spinous process of the opposite ilium, as also that between the spinous process of the last lumbar vertebra and the anterior superior spine of the ilium on the anchylosed portion, are smaller than the corresponding dimensions of the opposite side. " d. That the distance from the inferior border of the symphysis pubis to the posterior superior spinous process of the ilium is greater on the anchylosed bone than on the opposite side. " e. That the walls of the pelvic excavation converge somewhat obliquely from above downwards, whereby the pubic arch is more or less narrowed, and therefore made to approach in a measure to the form of the male pelvis, as a natural consequence of the improper direction of its ramus which is turned towards the flattened pelvic wall. Of course, these two dispositions, as also the narrowing of the ischiatic notch, the diminution of the distance between the two ischiatic spines and the one-sided and defective development of the sacrum, will be in direct relation with the degree of obliquity. " F. And finally, that on the flattened side the acetabulum is inclined much more anteriorly than in the normal state, whilst on the opposite side it is turned almost directly outwards; and hence, when examining the pelvis from in front, we can look directly into the first cotyloid cavity, but the view will only graze the second, or possibly may embrace a small part of its excavation. Further, to give as clear an idea of the deformity as possible to those who have never seen a pelvis of the kind, we will observe that at first sight the pelvis looks as if it had been pressed in by some external force acting in an oblique direction from below upwards and from without inwards, and making its influence felt on the anterior pelvic wall at the cotyloid region, whilst the other half of the lateral wall has been simultaneously pressed from without inwards, at its posterior part. " Another peculiarity of these pelves is, that they only differ from each other by the degree of obliquity, and on that side only where the anchylosis takes place; whereas, in all other points, that is, in the principal characteristics of their malformation, they are as similar as two eggs. This remark is so true, that an experienced person, who was unaware of the circumstance, would be disposed to take two different specimens, if presented to him separately, for one and the same, and it would even be difficult to persuade him of his error; an instance of which we shall presently give. " As to the other conditions of the bones in the oblique-oval pelvis (laying aside the deviations just enumerated), that is, as regards their strength, size, tex- ture, color, &c, they do not differ in anywise from healthy bones, such as those met with in young persons exempt from all deformity. Thus, for example, none of those signs are observed in them, neither as to their form nor in other respects, which are so often found after rachitis or malacosteon; for if the existing defor- mities were disposed to disappear, all the pelves we have yet had an opportunity of examining would bear a general resemblance to well-formed ones; most of them were of the medium size, and the others were either above or below it, but in no one of the cases that we have particularly traced out has there been a rachitic diathesis, and in no one did the phenomena, symptoms, or morbid modi- fications exist, which would have either preceded or followed the English malady, 528 DYSTOCIA. or mollifies ossium, after puberty; and further, in no instance could the action of external prejudicial influences, such as falls or blows, «fcc, be detected, and there were never any antecedent pains or lameness; although, in one instance, we suspected a slight limping, from seeing the patient walk, but other skilful persons, who were present at the examination, did not detect it, and the relatives and all the family of the woman in question positively declared they had never remarked anything of the kind. " In two of the specimens of this variety in our collection which have the lower vertebrae attached, the spinal column is straight in the lumbar region; but in the others it is inclined on the side exempt from anchylosis. In all that are provided with the lumbar vertebrae, the anterior face of the bodies of these bones is more or less directed towards the anchylosed side." The reader will see, by the translation just given, that M. Naegele attaches a very great degree of importance to the anchylosis of the sacro-iliac articulation, which he makes a pathognomonic character of the deformed pelvis, described by him under the name of the oblique-oval; but, if I might hazard an opinion after such high authority, I should unhesitatingly reject this proposition, because there are numerous pelves which present all the characters of those oblique ones, de- scribed in the monograph of the Heidelberg professor, and yet in which there is no fusion of cither sacro-iliac articulation to be found. M. Naegele himself, with that candor characteristic of the truly learned man, speaks in his admirable work, of pelves that were similar to those previously described by him, and which only differed from them by the absence of anchylosis. He alludes to several others, and states that he knows of the existence of many more, the exact de- scription of which has been promised him. I shall have occasion hereafter to revert to this subject, but I cannot refrain from saying now, that if the anchylosis is no longer to be considered as a constant phenomenon, as a pathognomonic character of the pelvis in question, if it is nothing more than a pathological coin- cidence, happening in most cases, then I can only see in the oblique-oval pelvis the association of two of the three types, to which we have referred all the varieties of pelvic malformation;' for, in considering it in a practical point of view, and laying aside its extraordinary anatomical peculiarities, it will exhibit, simultaneously, the compression of one of the antero-lateral walls, and the oblique prominence of the sacro-vertebral angle. This remark naturally leads us to the important observation that, hitherto we have considered each of the species of deformity that may alter the various pelvic diameters, as being separate and distinct, since there are some which may exist alone, and only change the corresponding diameters; but, besides the fact that different points of the pelvic circle may be simultaneously deformed, and thus contract the pelvis in several directions at once, the form and extent of the pelvis are such that it is difficult for a flattening, a lateral compression, or a de- pression of the antero-lateral parts to take place, even separately, without its being thereby contracted in several of its diameters. Let us suppose, for instance, that one of the oblique diameters has been diminished by the depression of the bottom of the acetabulum; and it must be evident that, should the de- pression be considerable, the body of the ischium cannot be thus thrust inwards DEFORMITIES OF THE PELVIS. 529 and backwards, without drawing along with it at the same time, some con- siderable portion of the anterior part of the pelvis, and of the arch formed by its lateral half, and consequently without contracting, more or less, certain of the antero-posterior and transverse diameters. Again, where the sacro-vertebral angle, from being projected forward, diminishes the length of the antero-posterior diameter of the superior strait, we have supposed that it followed the sacro-pubic line, in its movement of progression ; but, as readily foreseen, it would most often prove otherwise, for the very frequent obliquity in the direction of the forces transmitted through the vertebral column, must compel it to lean towards the right or the left, as well as to the front; whence, the shortening of the antero- posterior diameter necessarily entails that of the sacro-cotyloid interval, and, as a consequence, narrows the whole corresponding half of the pelvis. Now, should the depression of the antero-lateral wall on the same side be joined to this, as just supposed, we should have the oblique-oval pelvis of M. Naegele, excepting the anchylosis of the sacro-iliac articulation.1 Again, the three principal types may be found united in the same pelvis, whereby the latter is greatly deformed in all its diameters. This occurs more particularly in the deformities produced by malacosteon, but it is also sometimes met with, even in a high degree, in cases dependent on rachitis, as fully proved by the facts observed by M. Naegele. From all this, we learn what great diversities of shape may be presented by deformed pelves. Madame Lachapelle has gone so far as to designate these varieties by the titles of the reniform, the triangular, the bi-lobcd, the rounded, the oval, the cordiform, the trapezoid, the pyramidal, and the three-lobed straits ; but she has greatly multiplied the species without any practical utility, and she further admits that there are numerous undescribed varieties for each of these orders. The Degree of Contraction.—The two extremes of contraction of the straits are from three and three-quarters to four inches for the highest, and from two to three lines for the least, and between these two the pelvis may exhibit all the intermediate degrees of narrowness. The causes which produced the deformity greatly influence the degree of contraction, and in this point of view they may be arranged in the following order, viz., malacosteon, rickets, congenital luxa- tions of the femur, deformities of the spinal column, &c.; we shall take occasion hereafter to revert to the mode in which each of these acts. Of the Variations in the Depth of the Pelvis.—The vices of conformation, just spoken of, rarely exist without modifying the depth of the pelvis, in a greater or less degree; which circumstance has been particularly dwelt upon by M. Bouvier, in the able work presented by him to the Institute. For instance, the depth may be either augmented or diminished by the variable inclination of the expanded portion of the iliac bones, or of the branches of the pubic arch, as also by the diversities in the length of the sacrum. 1 This anchylosis is nothing more than a curious pathological fact, one in reality having no practical value, and therefore not worthy of the importance accorded to it by M. Naegele ; on which account we have determined not to make a particular variety of the oblique-oval pelvis, but have concluded to refer it to the compression of the antero-lateral walls. 34 530 DYSTOCIA. Sometimes this latter bone is very short, its contraction being produced either by an excess of the anterior curvature, which brings the two extremities nearer to each other, or by an arrest of development. Occasionally, the iliac fossae are elevated, as if they had been forcibly pressed from without inwards, thus giving it the appearance of a male pelvis; and this elevation may be further augmented by exterior and lateral pressure, whereby the bones are rendered quite vertical, and the normal depth of the pelvis is greatly increased. The contrary may occur where the iliac crests, from being strongly depressed and thrust outwards, enlarge the margin of the pelvis, but evidently diminish its height. It would be difficult to misinterpret the influence of the weight of the viscera in such cases when there is no congenital deformity in question. (Bouvier, op. citato.)' In conclusion, a widening of the pubic arch must clearly diminish its height to a corresponding extent; while the latter, as well as the whole depth of the pelvis, must be increased, where the ischio-pubic rami are very close together. ARTICLE II. OF THE CAUSES AND MODE OF PRODUCTION OF THE PELVIC DEFORMITIES. For a long time the vices of conformation of the pelvis, as also most of the deformities occurring in the skeleton at large, were attributed to the operation of a single cause, rachitis; but the more careful researches of modern surgeons enable us, at the present day, to ascertain more precisely the effects of rickets on the osseous system, and to appreciate the influence that other general or local diseases may have over the perfect or the defective conformation of the pelvis. And here I must again extract largely from the valuable works of Naegele, Bouvier, Guerin, Sedillot, and others. An examination of facts clearly proves that the pelvis may be deformed under circumstances where there has been no rachitis properly so called; and where causes that are purely mechanical in their operation have altered the configura- tion of its constituent parts at a period when their power of resistance was in- considerable, not in consequence of any pathological softenirg, but solely from the tender age of the patient, or the feebleness of its constitution. And hence, as regards the causes that produce the changes in their form, we might classify all the irregular pelves under three principal types, namely: A. Deformities, dependent on a softening of the bones, whether from rachitis or from mollities ossium; B. Those consecutive to, and dependent upon, a previous deformity of another part of the skeleton; and c. Deformities from absolute narrowness. § 1. Of the Pelvis Deformed by Rachitis or Mollities Ossium. We are not about to enter here into a detailed consideration of the causes that preside over the development of the disorders known as rachitis and mollities ossium,1 for the general phenomena produced by them, and, more especially, the 1 In both these diseases, the principal lesion consists in a marked diminution of the salts of lime. In rachitis, however, there is from the outset an insufficient deposit of these DEFORMITIES OF THE PELVIS. 531 greater softening, fragility, and flexibility of the osseous tissue, are so well known to pathologists that we need only mention them; but our present duty is to study their influence in the production of the numerous deformities summed up in the preceding article. For an indication of the characters that distinguish a pelvis deformed by rachitis from one distorted in consequence of a softening of the bones, we refer the reader to the article on Diagnosis; nevertheless, we may ob- serve here that, although these two diseases differ from each other in numerous anatomical characteristics, yet they produce the same result; for, by softening the osseous tissue, they diminish its resistance. But this softening, or want of resistance on the part of the bones, is not of itself sufficient to explain the various deformities exhibited by the pelvis; because except in certain very rare cases, in which the osseous tissue is almost gelatinous in its consistence, it must be evident that the bones can only give way and be- come distorted by the action of an exterior force, without which, their confor- mation would remain intact. For where rachitis affects them, it has no other immediate consequence than to diminish their solidity, and of itself contrib- utes in no wise to the alteration of their shape; though it is true that the soft- ening produced in the adult by malacosteon may be so great, that the weight of the superior parts of the body alone might produce a yielding of the bones; but, laying aside these unusual instances, we must seek in the influence of some external force, which is wholly independent of the principal disease, for the cause of the deformity. Now, this exterior force sometimes resides in the mus- cular action, though still more frequently (so far as regards the pelvis) in the weight of the parts it has to support; for, being placed, as we have elsewhere described, below the trunk and directly upon the lower extremities, to which, in the erect position, it transmits the whole weight of the upper parts of the body, the pelvis is found in the most favorable conditions for the production of de- formity. The weight of the trunk, which, in the erect posture, is transmitted from the lumbar vertebrae to the heads of the femurs in the direction of two oblique lines that intersect the sides of the superior strait, manifestly tends to aug- ment the curvature of the posterior part of the ilium, and to depress the osseous circle which the pelvic cavity represents; and this weight, acting at first more especially on the base of the sacrum, has a tendency to push the latter insensi- bly forwards. The pubic bones would be equally pressed towards the sacrum, though in such a manner that their posterior extremity (the one nearest to the acetabulum, which supports the weight) gets somewhat nearer to the sacro-ver- tebral angle than does their anterior or symphyseal extremity; whence we may learn why the contractions of the pelvis oftener affect the superior strait than other parts; and why, at this strait, the antero-posterior and oblique diameters, and the sacro-cotyloid interval, are far more frequently contracted than the transverse ones. salts in the organic texture, whilst in mollities ossium, the calcareous salts are gradually removed by absorption from bones having their normal organization. These facts seem to prove an essential difference between the two affections, and incline me to reject the opin- ion of those who regard them as but two grades of one and the same disease. In short, I consider rachitis as an arrest of the formation or of the deposition of the lime salts, and mollities ossium as their atrophy or absorption. 532 • DYSTOCIA. And it will be equally evident why, when the weight acts more particularly on one side of the pelvis, the collapse is more marked in that direction, if we bear in mind the change that then takes place in the centre of gravity from the inclination of the spine, the curvature of which so often precedes the deformity of the pelvis, as also the very unequal pressure of the weight of the body on the two sides of the pelvis, where a difference of bngth in the lower extremi- ties depresses one of the coxal bones more than the other; whereby the aceta- bulum of one side is thrown almost directly under the sacrum, and at the same time receives the weight very obliquely. (Bouvier.) It is further evident that thei customary attitude of the individual, and the nature of her exercises, must likewise add to the irregularity in the figure of the pelvis. After having studied the causes that determine the oblique projection of the sacro-vertebral angle, and the flattening of one of the antero-lateral walls of the pelvis, we explained the production of the deformity described by M. Naegele, which, as already stated, appeared to us to result simply from a conjunction of these two varieties in the same person; but there is one circumstance yet remain- ing to be explained, that is, the complete fusion of the sacrum and ilium to- gether, and the consequent disappearance of the sacro-iliac articulation on the contracted side. Now, is this anchylosis congenital ? Is it the result of some inflammation occurring after infancy ? or is it to be attributed to the curvature of the vertebral column ? We confess that sufficient materials are still wanting to decide the question, although M. Naegele seems to think that this fusion, as well as the deformity of which, in his estimation, it is the essential character, results from an anomaly of original development; "but," he adds, in conclusion, " I am not prepared to decide positively." (For further details, see M. Danyau's translation.) Whether congenital, or the consequence of an accidental disease, Professors Ga- varret and Paul Dubois regard this anchylosis as the cause of the flattening of the ilium upon the same side. When, says M. Dubois, one of the sacro-iliac symphyses is affected with anchylosis, the corresponding coxal bone becomes flat- tened, and the same alteration is produced on both sides when the two symphyses are ossified. For my own part, I cannot admit this relation of cause and effect, for there is nothing to prove that in M. Naegele's oblique oval pelves, the defor- mity of the ilium had been preceded by anchylosis. On the contrary, we have shown that, as M. Naegele himself acknowledges, there are pelves which present all the characters of the oblique oval ones, excepting the anchylosis of the sacro- iliac symphysis. How, then, can the anchylosis be regarded as causing the deformity ? If the child is in the habit of sitting much, the weight transmitted by the lumbar vertebrae may likewise press the sacro-vertebral angle forward; but the sacrum also often yields, and its base is carried forward simultaneously with the point of the coccyx, whereby its anterior concavity is augmented, and the antero- posterior diameters of both the superior and the inferior straits are affected. The lateral compression, operating from one side to the other, or the shorten- ing of one or more of the transverse diameters, supposes an action diametrically opposite to the preceding, and it generally results from a lateral force acting from without inwards; which force may be referred either to the weight of the body, DEFORMITIES OF THE PELVIS. 533 where the child uniformly reposes on its side, or to the unequal pressure of some improperly adjusted bandage, or the arms of an awkward nurse. But if, on the contrary, the infant habitually leans more towards one side than the other when seated, one of the ischial tuberosities having to support a more considerable weight than its fellow may be distorted inwardly; sometimes even the pressure will be applied successively to each, with the effect of bringing them very near to each other. Having now studied the softening of the bones as an immediate source of the deformity, a few observations are yet to be made concerning the causes that pro- duce this softening; for it must not be supposed that mollities ossium and rachitis exercise the same influence upon the osseous tissue. Indeed, as a general rule, the softening determined by the former is much more marked than the default of resistance occasioned by the latter; whence it follows that, with the exception of certain rare cases, such as the one cited by M. Naegele, the more considerable contractions may be referred to mollities ossium. Mollities ossium affects all parts of the skeleton indifferently. Rachitis, on the contrary, affects first the bones of the lower extremities, and ascends gradu- ally to the upper parts; in a word, it has an upward tendency. From this results a most important practical consequence, namely, that a deformity of any part of the skeleton from rachitis implies, almost necessarily, deformity of the bones situated below it. Rachitis is a disease peculiar to infancy, while mollities ossium only occurs in the adult; and this peculiarity appertaining to the former, of only exerting its action during the early years of life, satisfactorily explains how this affection may have two different modes of acting on the pelvis; one of which consists of a softening of the bones, and their consequent yielding; and the other of a sort of arrest in their development. " Thus," M. Guerin says, " it would appear from my researches that most of the bones of a rachitic skeleton, when compared with those of a normal one, exhibit an arrested development as regards their different dimensions; which reduction, independently of what results from the deformity of the bones, may amount to one-half of their ordinary size; and further, that this reduction is generally greater in the lower parts of the skeleton, and gradually diminishes from below upwards, from the bones of the legs to the femurs, from these latter to the pelvis, and from the pelvis to the upper extremities and spine, &c." It is, therefore, on the lower extremities particularly, and on the coxal bones, which are appendages of them, that this arrested development exerts its action. " Whence," says M. Dubois, " it necessarily results that the ossa inno- minata are generally much less developed in rachitic pelves than in others; and this disposition must powerfully contribute, together with the deformity that usually accompanies it, to contract the limits of the cavity, which these bones, in a great measure, circumscribe; and I am the more convinced of the importance of this fact, since, in several instances of deformity occurring in individuals known to be rachitic during infancy, it has appeared to me that the yielding of the bones to the degree in which it existed, would have been wholly insufficient to create such insurmountable difficulties, if the bones themselves had been as fully developed as they ought to have been." (These de Concours.) And we may mention, as another fact bearing on the same point, that the pelvis of the 534 DYSTOCIA. patient, on whom M. Moreau performed the Caesarean operation, had experienced the double influence of rachitis just mentioned; for, though but little deformed, its antero-posterior diameter was only two and three-eighths of an inch in length. This influence over the development of the pelvic bones is dependent solely on the tender age at which the affection appears, since it occurs in childhood as stated, that is, at a period when the pelvis is far from having acquired its perfect organization; whereas malacosteon does not appear until after puberty, in other words, at an age when the ossa innominata have reached their normal develop- ment; and, therefore, although it may soften the bones, it cannot oppose their growth. Lastly, this action is not set aside by the cure of the disease, but it continues to be felt during the whole period of development, so that, says M. Guerin, the sum of reduction exhibited by the bones of rickety adults, is made up of two successive results, namely, of the reduction dependent on an absolute arrest, or a mere diminution of growth during the disease, and of that caused by a retarded growth subsequent to the malady. This is an important practical remark, show- ing how far the influence of rachitis over the osseous system may extend. § 2. Malformations dependent upon a Previous Deformity in an- other Part of the Skeleton. We have already alluded, in advance, to the influence that a malformation of the spinal column, or of the lower extremities, might have over the shape of the pelvis, and we now proceed to illustrate the mode of action in both cases. A. Deviation of the Vertebral Column.—For a very long period all the devia- tions of the spinal column were attributed to the baneful influences of rachitis; but owing to the able researches of Bouvier, of Guerin, and many others, this opinion is no longer tenable, since it is now well ascertained that several other diseases may produce abnormal curvatures in this column ; and this distinction is quite as important to the accoucheur as it is to the orthopedists, for it establishes at once a line of division between those deviations which nearly always coincide with an imperfect conformation of the pelvis, and those which often exist, even where the latter is well formed. The former are of a rachitic nature; but the latter are developed under the influence of some other affection. For instance, in sixty-nine cases of deformity in the vertebral column, described by M. Bou- vier, the pelvis was in a normal condition, and the extremities were nearly all exempt from alteration in fifty-seven, and but twelve were accompanied by a mal- formation of this cavity, and by an incurvation of the limbs. It must not be supposed, however, that the deviations of the spine which are not dependent on rickets, have no influence whatever over the direction and shape of the pelvis. It is only in subjects of advanced age, as a general rule, that curvatures of this column, happening after infancy, will ultimately deter- mine changes in the form and direction of the pelvis; and, therefore, they have but little interest for the accoucheur. As regards the curvatures produced by rickets, though they be not the essen- tial cause of pelvic deformities, yet they do not the less exercise an unfavorable influence over the degree of contraction, and the irregularity in the shape of the pelvis; for the same action which gives rise to these deformities in old persons. DEFORMITIES OF THE PELVIS. 535 also produces them, in a great measure, in rickety children. In either case, the pelvis yields under the influence of the spinal deviation; with this difference only, that what takes place slowly in the aged, is rapidly effected in the child, because, in the latter, the softening of the bones favors the action of the cause. The principal alteration consists of an increase of the angle formed by the junction of the lumbar column with the base of the sacrum, which gives the pelvis a figure more or less similar to that described by Professor Naegele, under the title of the oblique-oval. B. Congenital Luxations of the Femur.—M. Sedillot, in a very interesting" memoir on the congenital luxations of the femur, first called attention to the influence which these displacements might exercise on the conformation of the pelvis. The effects of this accident are manifested both in the greater and lesser pelvis, as may be seen from the following distances which he obtained in a case of double dislocation upwards and outwards, into the external iliac fossae, by measuring the principal dimensions of the pelvis:— 1. From one anterior superior spinous process to the other, . . 8 inches. 2. From the middle of one iliac crest to the same point on the opposite side,............8£ " 3. From the middle of the iliac crest to the margin of the abdominal strait,...........3} " 4. From the middle of the iliac crest to the tuber-ischii, . . . 6^ " Superior or Abdominal Strait. 5. Antero-posterior diameter, . . . . . . . . 4J- " 6. The same diameter taken from the pubis to the articulation of the first piece of the sacrum with the second,1 . . . . 4J " 7. Bis-iliac or transverse diameter, . . . . . . . 4J " 8. Oblique diameter,.........4£ " 1 The antero-posterior diameter is generally measured from the upper and internal part of the symphysis pubis to the superior border of the sacrum; but M. Sedillot very justly remarks, that in many of the pelves which are the seats of a double congenital luxation, the upper margin of the sacrum, in consequence of the great prominence of the sacro- vertebral angle, is found far above the pubis, and the articulation between the first two pieces of the sacrum, is then on a level with the superior surface of this bone. Now. in such a case, the true antero-posterior diameter of the abdominal strait would extend from the upper border of the pubis to the part of the sacrum found on the same level, and this interval, therefore, is the only important measurement. But this observation is not new, , as it had previously been made by Bland, and repeated by Merriman, in the following note: "Although the sacrum be carried so far forward that it seems to reduce the antero-poste- rior diameter at the entrance of the excavation to two or three inches, it is necessary in determining the degree of contraction to observe the difference in elevation between the sacro-vertebral angle and the upper part of the symphysis. The pubes being placed some- thing lower than the greatest projection of the sacrum, and opposed to a part of that bone that is directed strongly backward, the real distance between them may be much more considerable than to the touch it may seem to be. Whence it happens that in cases where the projection of the sacrum has occasioned exceeding great difficulty in the beginning of the labor, opposing an almost insuperable bar to the entrance of the head of the child into the pelvis, by directing it too far forward over the pubes, yet when that direction has been altered by the use of instruments, or by any other means, and the head brought into the line of the centre of the pelvis, the conclusion of the labor has been frequently effected with very little exertion or force."—Bland's Observations. 536 DYSTOCIA. Perineal Strait. 9. Coccy-pubic diameter, . . . . . • . . 3 J inches. 10. Transverse diameter,.........5J " 11. Oblique diameter,.........4f ;< 12. Summit of the pubic arch,........1J inch. 13. Base of the arch (taken on a level with the inferior border of the oval foramen),..........4J inches. Pelvic Excavation. 14. Depth of the posterior wall,.......5 " 15. Depth of the anterior wall,........1| inch. 16. Thickness of the pubic symphysis,......£ " IT. Depth of the sacral concavity,.......\\ " 18. From the summit of one ischiatic tuberosity to the same point on the opposite side,.........5J inches. From these measurements it appears: lst. That the transverse dimensions of the greater pelvis are considerably lessened by the vertical elevation of the iliac fossae, which approximate each other to such an extent as only to leave an in- terval of eight and a half inches, whereas the normal distance is ten and a half inches. 2d. That the relation which exists, in the normal state, between the antero-posterior and transverse diameters of the superior strait is changed; since the transverse diameter is somewhat shorter here than the antero-posterior one; whereas, in the ordinary state, it is nearly an inch longer. 3d. That an inverse change takes place at the inferior strait, the bis-ischiatic diameter being five and a quarter inches, while the coccy-pubic one is but three and a half inches. ■ These last modifications, says M. Sedillot, are easily explained, being the con- sequence of the unnatural position of the femurs in the external iliac fossae; for individuals afflicted with a double luxation of this kind, walk with the legs wide apart, so as to bear and rest the heads of the thigh bones against the sides of the ilia; though the effect would still be the same, even if their progression were not performed in this manner, because the external, lateral, and superior surfaces of these bones, which usually incline outwards, will always be pressed upon to a certain extent, by the heads of the femurs, which have a tendency to straighten and carry them inwards. Whence the pelvis, from being thus compressed late- rally, is elongated from behind forwards, and forms, in this latter direction, a more or less acute angle. The iliac fossae, experiencing the pressure more directly, have yielded in a marked degree, though more at their middle than in . front, because the head of the thigh bone is thrown far back, and compresses the middle more than the anterior part of these fossae. The ilium is often rendered more straight and nearly vertical, instead of being inclined outwards ; and, should this phenomenon exist on both sides, it might interfere with the regular develop- ment of the womb; but if on one side only, it might occasion an obliquity of this organ in the opposite direction. The anterior margin of the ilium also presents a singular disposition; for the conjoint tendon of the psoas magnus and iliacus internus muscles, which is in- serted in the lesser trochanter, is then changed from its usual direction, and is carried upward by the ascent of the thigh bone, and, as a consequence, this tendon deepens and changes the direction of its groove; whereby the anterior nferior spinous process is turned aside in a more or less sensible degree. DEFORMITIES OF THE PELVIS. 537 The shortening of the transverse diameter of the upper strait is evidently due to the lateral pressure made by the heads of the femurs almost perpendicular to this strait; and, as a flattening in the transverse direction is necessarily accompa- nied by an elongation antero-posteriorly, the sacro-pubic diameter is found aug- mented in a corresponding degree. The examination of the inferior strait also exhibits a very curious phenomenon, just the reverse of what we have met with at the abdominal one; that is, there is a considerable increase in the extent of its transverse diameter, with a notable diminution in that of its coccy-pubic one. Here, also, the situation of the femurs must be referred to, in explanation of the circumstance ; for these latter are car- ried far upwards, outwards, and backwards, since their superior articular extre- mities have escaped up into the external iliac fossae; and they keep the surrounding muscles constantly tense (more particularly the quadrati, the gemelli, and the internal obturator muscles, which run from the ischiatic tuberosities to the extre- mity of the thigh bones), and thus drag the ischium outwards; the lower fibres of the obturator externus and adductor muscles, and the internal part of the arti- cular capsule act in the same manner on the columns of the pubic arch ; thereby producing a wide separation of the two ischia. The latter, in turn, draw on the greater and lesser sacro-sciatic ligaments, thereby creating a greater curvature in the inferior bones of the sacrum and coccyx, and consequently the diminution of the coccy-pubic diameter, as also a greater depth in the concavity of the sacrum. The want of depth in the pelvic excavation depends on the same cause; for, when the ischium is drawn towards the external iliac fossa, the lower part of the pubic arch is necessarily bent out, and, as a consequence, the depth of the pelvis anteriorly is diminished. (Sedillot.) The weight of the body when erect, is the principal agent of this deformity; which essentially results, as just stated, from the tension exerted from within outwards on both sides by the capsular ligaments of the two deformed articula- tions, which hold the trunk suspended, as it were, between the thigh bones; and the force exerted by these ligaments on the pelvis is equal in power to the ten- dency of the weight of the body to elongate them. Lastly, the contraction of the cotyloid cavity has some little influence over the change in extent, which the pelvis undergoes, though it explains but a very small part of the deformity. (Bouvier.) The deformity is often irregular, or non-symmetrical, because the changes effected in the pelvis are more marked on one side than on the other; though, generally speaking, they are found to bear a relation to the degree of organization in the new joint; and, if any accidental articular cavity exists, they are more developed on that side. A pelvis, which has been referred to by M. Gerdy in his learned report, read before the Academy, on congenital luxations, and which presents some very sin- gular modifications, may be seen at the Musee Dupuytren ; it only has one femur attached, which is fused outside of the anterior inferior spinous process of the ilium on the left side. The anterior superior spine of the opposite coxal bone is two inches higher than the left one, and both bones are fixed with an equal degree of solidity in these relative situations; the sacrum, though very short, is quite broad, and the superior strait exhibits a modification similar to what has 538 DYSTOCIA. just been described; as to the inferior strait, it is very large in every direction, because the sacrum is exceedingly short, and the anterior pelvic wall is bent, as it were, forward and downward, on the same transverse and vertical plane, instead of being curved or bent downwards and backwards as in the normal state. (See No. 252, Muscc Dupuytren.) We have extracted from the memoir of M. Sedillot only those peculiarities that seemed important to be known, though we trust that enough has been given to prove that Dupuytren was greatly mistaken, when he asserted that the pheno- mena of primitive luxations had no influence whatever over the development of the pelvis, and that the latter offered no greater obstacles to delivery than it does in well-formed persons; the incorrectness of which assertion is doubtless suffi- ciently proved by the details into which we have entered. However, it must be acknowledged that in such cases the delivery is seldom impossible, although it may be attended with some difficulties; at least, no instance has yet been re- corded in which the expulsion of the fcetus could not take place without haviug recourse to a bloody operation on the mother or child; which is most certainly owing to the fact that, in congenital luxations, the contraction takes place in the longest diameters, both of the superior and inferior straits. In a recent publication, M. Lenoir expresses an opinion so far contrary to that of M. Sedillot, as to suppose that double congenital luxations produce no notable alteration of the shape of the pelvis; and he mentions, in support of his view, the pelvis of a young woman, the dimensions of which he gives. These dimen- sions hardly differ from those of the normal pelvis, except as regards the in- ferior strait, where they present an increase in extent of rather less than half an inch. The observations of M. Lenoir prove merely that the remarks of M. Sedillot are not applicable to all cases; still, the facts observed by the latter surgeon are of great value, showing, as they do, that congenital luxations may, in some cases, produce a marked change in the form and dimensions of the various parts of the pelvis. M. Lenoir insists much more strongly than M. Sedillot upon the effect of simple congenital luxation. The latter is, he states, accompanied by an arrest in the development of all that side of the pelvis corresponding to the luxation, which atrophy produces so great a deformity of both straits and the excavation, that we may be certain, that although delivery is not always rendered impossible thereby, the labor will at least be longer and more difficult. The latter proposition is, I think, by far too absolute, and facts are wanting to prove it. The deformity which follows simple luxation is much less than that resulting from a double displacement, and the specimen of M. Pacoud, described by M. Lenoir, seems to me in no wise to justify his assertions. Is M. Lenoir more fortunate in his endeavor to trace a resemblance between a pelvis deformed in consequence of a simple luxation than the oblique oval pelvis of M. Naegele ? The points of difference between these two pelves are so numerous, that he has seemed to me to force whatever analogies may exist, by placing them in the same category. The anatomical characters do not justify it, and the prognosis, especially, is much less serious; finally, the indications to be fulfilled in both cases are essentially different. DEFORMITIES OF THE PELVIS. 539 C. Non-congenital Luxations.—The atrophy of the iliac bone corresponding to the dislocated femur may also be met with in luxations occurring after birth, whether the luxation be the result of an accident, or consecutive to an organic alteration of the articular surfaces, as in coxalgia. To produce this effect, all that is necessary is, that the luxation should remain unreduced, and that it should have occurred within the first years of existence. Now, as this atrophy was the cause of the deformities of the pelvis studied in the preceding paragraph, it may have the same consequences in the case under consideration. It is also plain that the pelvic deformity will be great in proportion as the luxation shall have occurred at a very early age. D. Lesions of the Inferior Extremities.—The curvatures, so often met with in the lower limbs, do not always diminish their length in an equal degree; and this unequal shortening determines a variation in the pressure they make on the bottom of the cotyloid cavities; and, consequently, may affect the pelvis on the side where it is the greater. It is so true that the imperfect conformation of the pelvis is then dependent on a difference in the length of the lower extremi- ties, that the latter may often be curved (provided they maintain the same length), without the pelvis being necessarily vitiated; and also, that where any inequality does exist between them, there is quite a constant relation be- tween the direction of the depression, and the side corresponding to the shortest limb. It is further possible, that a shortening of one of the legs, whether resulting from a fracture, a luxation, or an atrophy of the limb, may produce the same result; more especially if these accidents take place in early childhood, when the pelvis is still far from having acquired its full development. Persons affected with chronic diseases of one of these limbs, and therefore under the necessity of walking with crutches, and of bearing the whole weight of the body on the sound leg, incur the same danger. Nevertheless, this latter circumstance has not always such an unfortunate influence; for Dr. Campbell mentions that he had an opportunity of examining the body of a woman who had made use of a crutch since the fourth year of her age, in consequence of a disease in her right lower extremity; this person, who died some time after delivery, had a perfectly formed pelvis. (Campbell, page 249.) Amputation of the thigh, in a young girl, particularly in early childhood, is likewise capable of deforming the pelvis : thus, for example, Madame Lacha- pelle found the superior strait, in a female aged eighteen years, reduced to a moiety of its extent on the right side only, and pushed in totally towards the left thigh, which had been amputated four years previously. Indeed, we can readily imagine that, as the artificial limb only derives its point of support from the ischium, the acetabulum of the sound side will alone continue to be compressed by the weight of the body.1 1 According to Campbell, the deformity of the pelvis may also be produced by contusions received on the dorsal region during childhood. I have, he says, met with several ex- amples of the kind. A few years ago, I saw a patient who, when three years old, received a violent blow upon the lumbar region ; the pelvis was in her case so deformed, that I thought it right to induce labor at the end of the seventh month. Although the pains were powerful, the head remained for seven hours in the excavation, but the child was 540 DYSTOCIA. § 3. Pelves deformed by Absolute Narrowness. To complete our remarks on the causes of pelvic deformities, we have yet to sum up the various opinions that have been given forth concerning those vitiated by absolute narrowness. According to most authors, the absolute contraction of the pelvis results from an arrest of development, whereby this part still retains, after puberty, the principal characters that it had during childhood, and ap- proaches in its form more or less closely to that of the male. But, as M. Naegele remarks, if this were really the case, the relation of the diameters with each other, and the character of the pubic arch, should be such as are observed in the young girl and the male. But all the known pelves of this variety exhibit quite the contrary. Nor are they more in consonance with that of a rickety person; and, besides, the rest of the skeleton has none of the characters appertaining to this disease. Wherefore, it is certainly the wisest plan to say, with the illustrious Professor of Heidelberg, that we have no positive data concerning the causes that give rise to the general narrowing of the pelvis ; and that such pelves, as well as unusually large ones, should rather be considered as a freak of nature, belonging to the same category 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. ARTICLE III. INFLUENCE OF DEFORMITIES OF THE PELVIS UPON PREGNANCY AND PARTURITION. The deformities may certainly have an unfavorable influence over the pro- gress of gestation; for, as we have already stated in the article on abortion, where the contraction of the straits accompanies an enlargement of the excavation, the womb, finding a more considerable space than usual in the cavity of the lesser pelvis, may become developed, and remain there beyond the ordinary period; and we have considered this circumstance as one of the causes of abortion, from the impossibility of its getting subsequently above the superior strait; and, when treating of retroversion, we remarked that this displacement was singularly favored by an increased depth in the concavity of the sacrum. Even in cases of slight contraction of the superior strait, the sort of impaction which the uterus undergoes from the early stages of pregnancy, may produce a violent compression of the organs situated in the excavation. Van Dceveren men- tions a very curious case, in which the patient experienced such acute pain in the hypogastric region from the third month of gestation as at first to excite fears of abortion. The symptoms continued, notwithstanding the use of the most nevertheless expelled. It lived eight days, and died in convulsions. Several fractures of the cranium were discovered at the autopsy, and several subcutaneous ecchymoses, caused evidently by the pressure to which the foetus had been subjected during labor. (Campbell, Introduction to the Study of Midwifery, p. 248.) This observation is too incomplete to justify the opinion of the author. Was the pelvis really contracted? Was not the woman rachitic? &c., &c. DEFORMITIES OF THE PELVIS. 541 rational means. By careful examination, he detected an oval tumor, painful to the touch, and extending above the umbilicus. The patient urinated frequently, though in but small quantity at a time. He suspected dropsy of the uterus. The suffering continued in spite of all that could be done, and the patient grew worse and worse, until one morning when he found her much better and relieved of her excruciating pains. She no longer had fever nor difficult respiration, and the tumor had disappeared; the abdomen was flatter, softer, and presented an obscure fluctuation. He thought that the uterus had been ruptured, and, not- withstanding the contentment of the patient, gave the most unfavorable prog- nosis. She died, indeed, two days afterward. At the autopsy, it was discovered that the greatly distended bladder had given way at its upper part. The uterus filled the lesser pelvis so completely as to leave no space between it and the walls of the pelvis. It compressed the vessels, the pelvic nerves, and the rectum, as also the urethra against the pubis. The sacro-pubic diameter was but three inches and eight lines in extent. When the transverse diameter of the greater pelvis is contracted by the straightening out of the iliac crest, as occurs in double congenital luxations of the femur, the development of the uterus is considerably impeded during the latter months of pregnancy; and this difficulty, according to Ant. Dubois, may prove a cause of premature labor. Where the straightening exists on one side only, the inconvenience is less ; but still it may possibly contribute to the pro- duction of considerable uterine obliquity on the opposite side. In general, however, with the exception of certain inconveniences, which evidently depend more on the extraordinary obliquity of the planes of the pelvis than on a diminution of its cavity, and to which we shall take occasion hereafter to revert, such contracted pelves rarely interrupt the course of gestation; but they have a far different influence upon the labor, to which we now ask the reader's attention more particularly. The impediments to the delivery will usually be greater, as the deformity of the pelvis is the more considerable; however, this proposition, although true in the majority of cases, is not absolutely so, since the degree of narrowing is not the only point that demands the accoucheur's attention ; for the child's position, the size of its head, the flexibility of the cranial bones, the power of the uterine contractions, and the variable degree of relaxation of the pelvic articulations, are so many important circumstances which claim his consideration. One woman, perhaps, is happily delivered at term, whilst another, whose pelvis offers the same dimensions, will require the intervention of art for her relief. The same woman may be spontaneously delivered of her first child, and yet present such difficul- ties at the second labor, that the mutilation of the fcetus may be deemed to be the only remedy for sparing her a bloody operation, without our thereby conclu- ding that her pelvis had become contracted between these two pregnancies; for these differences might depend solely on the greater volume, or a less degree of reducibility of the head, or the bad position of her second child, &c. Most accoucheurs have observed facts of this nature, but we only present the follow- ing: A patient presented herself at the Clinique, in 1838, whose pelvis was only two and three-quarter inches in its sacro-pubic diameters; she was delivered in eighteen hours of a living infant, at term, the dimensions of which were nearly 542 DYSTOCIA. normal, and whose head was scarcely deformed. Baudelocque relates having seen, at the amphitheatre of Solayres, the head of a fcetus which was elongated to such an extent, that its greatest diameter measured nearly eight and a half inches, whilst the bi-parietal one was reduced to two and three-eighths, or two and three-quarter inches; and he speaks of another very similar instance; but in neither of these cases was the child's life compromised for a single instant. M. Martin, of Lyons, has known a rachitic woman to be delivered of a healthy infant at term, by the efforts of nature alone; where the autopsical examination showed that the antero-posterior diameter was only two and a half inches in extent (page 270). What rendered this case still more extraordinary, was the existence of scirrhous tumors in the substance of the uterine walls. The redu- cibility of the head, therefore, is sometimes excessive, but unfortunately it is almost impossible to appreciate this in a positive manner beforehand. To this source of uncertainty, says Madame Lachapelle, let us add that, in certain women, the degree of mobility of the symphyses does not permit a general separation of the bones (which, even if it existed, would scarcely enlarge the area of the strait or of its diameters); but rather a mutual gliding of the arti- cular surfaces upon each other, an overriding of the pubes, so that one of the innominata advances to a range with the sacro-vertebral angle, whilst the other recedes to a greater or less extent. It follows from this mechanism that one of the oblique diameters at the superior strait, the one corresponding to the long diameter of the head, is notably increased; and the sacro-pubic one is also found augmented by the advancement of one of the coxal bones. Finally, continues this skilful midwife, it may be possible for both hip-bones to glide forward simultaneously, thereby enlarging still more the antero-posterior diameter. In most cases of deformity, the child's position is far from being an indifferent matter; for when the sacrum, in being carried forward, is at the same time turned to one side, whereby one of the lateral portions of the pelvis is more contracted than the other, who does not foresee that the labor may then be accomplished spontaneously, if the head presents in such a way as to offer its great occipital extremity to the well-formed side; and that, on the contrary, it would become impossible, if the occiput should correspond to the contracted one? Where the contraction is so limited that it might possibly permit a spontaneous delivery, any unfavorable position of the fcetus would greatly add to the existing difficulties caused by the malformation of the pelvis; if, for example, instead of presenting by the vertex, the child should offer its pelvic extremity, there would be reason to fear an arrest of the head above the superior strait, after the escape of the trunk; the slowness of its passage through this strait would not often warrant the abandonment of the delivery to the resources of nature, both from the dangers the infant incurs from a compression of the umbilical cord, and from the feebleness of the contractions of the womb, which, being almost entirely emptied and retracted, no longer retains its contractile properties. (See Pre- sentation by the Breech.) We need scarcely add, in conclusion, that a proper degree of energy in the uterine contractions bears so prominent a part in the accomplishment of labor, that it cannot be overlooked. In certain cases, for instance, where the pelvis is so little contracted that the child's delivery is still possible by the application DEFORMITIES OF THE PELVIS. 543 of the forceps, it is evident that frequent and strong contractions of the womb would render this instrument useless; again, the labor will terminate alone, in a case where the physician would have been obliged to interfere, if the pains had been too feeble or too slow. We may conclude, therefore, that, in the question before us, there are a number of elements which may influence the result; and that, if the degree of narrow- ing of the pelvis is the most important point to be well ascertained, it is not the only circumstance upon which the obstetrician ought to base his determina- tions. For although the means of arriving at an exact knowledge of the extent of contraction are almost sure, yet, unfortunately, the same does not hold good with regard to the volume and the reducibility of the fcetal head, or the mobility and possible separation of the pelvic symphyses; and it is impossible to calculate in advance all the resources of the organism, or to know how far the uterine efforts will go. From our ignorance, on most of these points, arise the uncer- tainties and hesitations which so often prove fatal either to the mother or the child; uncertainties and hesitations that never influence persons that are not versed in all the difficulties of our art, but which are well understood by learned and experienced practitioners, who have frequently been under the painful necessity of making a decision and of determining a question, whose solution might cost the lives of two individuals whom our mission is to save. The foregoing reflections will, I hope, be sufficient to show that what we are about to say concerning the influence of the pelvic deformities upon the labor is not positive and absolute, but is only applicable to the majority of cases. Under the head of the difficulties and indications presented by these deformi- ties, we shall admit, with M. P. Dubois, three principal divisions. The first is composed of pelves, in which the contraction, in whatever part it may exist, still leaves at that part an opening of at least three and three-quarter inches in all its diameters; the second comprises those in which the contraction leaves, at the point of the canal it occupies, a passage, one or more of whose diameters will be three and three quarter inches as a maximum, and two and a half inches as the minimum; and, lastly, we shall include in the third all the cases where the narrowing is such, that the dimensions of the resulting space will be under two and a half inches. A. Of the Pelvis having at least three and three-quarter inches in its Con- tracted Part.—Here the labor, although in general longer, more difficult, and therefore more dangerous, both for the mother and child, than in ordinary cases, may, however, be accomplished spontaneously; and, indeed, we might hope for such an expulsion in most cases. The slowness of the labor is observable in the dilatation of the os uteri, as well as in the expulsive stage; for, during the first stage, the uterine contractions, though energetic and often regular, have but little action on the dilatation of the cervix; the head is high up, and has no tendency to engage in the excavation, and it remains above the symphysis pubis, against which it is strongly applied, being thrown forwards by the prominence of the sacro-vertebral angle. Indeed, it is highly probable that the extreme slowness of the dilatation is attributable to this latter circumstance; for the lower front part of the womb is so compressed between the child's head and the pubic sym- physis, that the longitudinal fibres of the body can scarcely act at all on the cir- 544 DYSTOCIA. cular ones of the cervix, notwithstanding the energy of their contractions; for we often find, after the size of the head has been diminished by a perforation of the cranium, whereby this compression is relieved, at least in a great measure, that the dilatation that was hitherto stationary now progresses very rapidly. As to the modifications that take place in the period of expulsion, they vary according to the seat of the contraction; for instance, when the superior strait is the place of deformity, the engagement of the head might be so much retarded that it could only succeed in clearing this obstacle under the influence of the most powerful contractions; though, should these be sustained, the labor would terminate happily. But if, as is sometimes observed (see Pathol. Anat.), the corresponding diameter of the inferior strait is simultaneously enlarged, the child's head, after having surmounted the difficulties offered at the upper one, will not find a sufficient degree of resistance at the perineal strait to mode- rate the rapidity of its descent; and, consequently, it might strike violently against, and lacerate the perineum; the disastrous consequences of which are well known. Where the superior strait retains its normal dimensions, the inferior one alone being contracted, the head descends rapidly enough into the excavation, but it can only clear the last parts of the canal with the greatest difficulty; for, as the dimensions of the lower strait are in general somewhat smaller than those of the upper, it follows that the same degree of contraction here is much more unfa- vorable to the delivery, and oftener requires the application of the forceps. Finally, where the two straits are contracted in the same degree, all the causes of difficulty just mentioned are found conjoined. Most frequently, the head succeeds in passing the superior strait; but, having reached the excavation, and being unable to advance any further, it there remains wedged in until the ex- hausted or enfeebled forces are sufficiently renovated to effect its delivery. During all this time, the head, which had been forcibly compressed in order to clear the upper strait, and had its dimensions reduced by the overlapping of the parietal bones, gradually regains its natural size, now that it has entered a larger space, departing also from the conical shape it had acquired in the first stage, as its delay there is the more prolonged, and, consequently, meeting with new obstruc- tions at the inferior strait, which are so much the more difficult to overcome as the uterine forces are already the more exhausted. These differences in the seat of the contraction ought to be known, for they will enable the accoucheur to avoid an error in diagnosis which otherwise he might very readily commit; for example, in the cases where the superior strait alone is contracted, the head gets into the excavation only after very long-conti- nued pains, but then it clears the inferior one almost immediately afterwards; whereas the contrary happens when this latter is the only one contracted, and the attending physician, judging of the future by the past duration of the labor, announces that it will terminate sooner or later, according as the head has de- scended more or less rapidly into the excavation; but he will most always deceive himself; because, in the former instance, the termination will be very rapid, though he believed it still distant; and, in the latter, it will be delayed far be- yond the time that he had fixed. DEFORMITIES OF THE PELVIS. 545 B. Where the Pelvis has at least two and a half inches in its Contracted Part. —A spontaneous expulsion of the fcetus is still barely possible, where there are from three and one-eighth to three and three-quarter inches in the contracted part; though, in reflecting on the length of the head's smallest diameter, which at term is at least three and one-half inches, it must be evident that, in order to render the delivery practicable under such circumstances, the diameters of the cranial vault should present a great reducibility, and the contractions of the womb be strong and prolonged. But in an immense majority of the cases under three and one-eighth inches, the resources of art become indispensable, unless the child's parts should be softened by putrefaction, or the infant itself not have acquired the development it usually exhibits at the ordinary term of gestation. C. Where the Contracted Diameter is less than two and a half inches.—This degree of contraction renders a natural labor at term physically impossible; be- cause too great a disproportion exists between the dimensions of the canal and those of the body which has to traverse it; and no other alternative remains for the accoucheur than to augment the former by symphyseotomy, or to diminish the latter by embryotomy; unless, indeed, he should rather prefer to open for it a new and more easy route by practising the Caesarean operation. As regards the prognosis, it is very important to distinguish a pelvis deformed by rachitis from one whose contraction is dependent on mollities ossium; for although, in the former case, the gravity of the prognosis is only in proportion to the degree of contraction, yet it is not exactly or always so in the latter. Here, indeed, arises the important consideration that the first effect of malacos- teon is to produce an excessive softening of the osseous tissue, the deformity of the skeleton being consecutive thereto; but this softening only reaches its summum of intensity by degrees, and the disease may be arrested in its pro- gress, may be ameliorated, or even entirely cured, under the influence of a proper treatment. Whence it is evident that, during the period of increase and that of its amelioration, which may extend over several years, the softening passes successively through different degrees, and where it happens to exist at the time of labor, furnishes the practitioner a very valuable resource, whatever may be the degree of contraction. In fact, it would appear, from the cases re- ported in the dissertation of M. Spengel, that the bones often retain, at the time of labor, a sufficient degree of suppleness to enable them to dilate spontaneously, and to allow the expulsion of the fcetus, or, at least, its artificial extraction. Thus, in a case furnished by Homberger, the sacro-pubic diameter was scarcely two inches in length; nevertheless, after having ascertained the flexibility of the bones caused by the malacosteon, he declared that the delivery might be effected by the powers of nature. He ruptured the membranes at the end of twenty-four hours; then, after waiting as much longer, the engagement was sufficiently advanced to enable him to apply the forceps; when, by the aid of powerful tractions, he succeeded in bringing away a girl who lived four weeks. In another woman, whose sacro-pubic diameter was two and a quarter inches (French measurement) at the most, Hasslocher, a physician of Landau, was en- abled, by the aid of external pressure, to make the child's head engage in the cavity of the pelvis; he then applied the forceps, and found that only a mode- rate effort was required to deliver a dead child, weighing six pounds and a half. 35 546 DYSTOCIA. Facts of this nature are certainly consolatory, and they well merit attention; but unfortunately, it is a very difficult matter to recognize that precise degree of flexibility in the bones, under which there is no reason to hope for a spontaneous dilatation; for, between the first stages of softening in them and that advanced period when they scarcely have the consistence of a gelatinous pulp, there are numerous intermediate degrees; and the great difficulty consists in determining the cases in which we can trust to the efforts of nature, and those in which nothing can be hoped from this source. A misplaced confidence might be at- tanded with the most serious consequences; for, on the one hand, a prolonged delay may compromise the child's life, that might have otherwise been saved, by resorting to the Caesarean operation at the most favorable moment; and on the other, the tentatives uselessly made with the forceps expose the mother to the greatest dangers; for bones affected by this disease are, it is true, most generally softened, but sometimes it happens that the affection has only rendered them more friable, and, of course, any tractions made by the instrument, in such cases, might give rise to dangerous fractures. It would, therefore, be highly desirable to have a rule of procedure, but in the present state of our science it is impos- sible to lay down any positive one; and the accoucheur must found his opinion on the whole of the phenomena exhibited in the particular case. " Without supposing," says M. Spengel, "that it will be possible to ascertain, positively, to what extent the softening of the pelvic bones has advanced, we believe that, by paying attention to the symptoms which preceded and those that accompany the labor, it may be determined in quite a probable manner. We have collected forty cases of general mollities ossium that occurred in females; in nineteen of which the time when the pains first began is not noted, and no conclusions there- fore can be drawn from them; but, in twelve cases, the first pains appeared during the lying-in, in two others, shortly after the accouchement, and in the remaining seven, during the course of gestation; and, whenever the period has been carefully noted when the pains, after having been once calmed, were aggra- vated anew, it has been found that this exacerbation came on during a new preg- nancy. Whence we may suppose that the softening of the bones is more consi- derable towards the end of gestation than it was before its commencement. Therefore, when the alteration progressively increases until term, and the diffi- culty in the patient's movements or the pains exhibit no diminution, we believe the degree of softening may be regarded as bearing a relation to the violence and duration of these symptoms. Further, by resorting to the manual exploration, we are enabled to detect in some cases a softening to such an extent that the bones yield to the pressure of the fingers. Under such circumstances the accou- cheur may doubtless rely on a spontaneous delivery, or at least on the success of a prudent application of the forceps; which latter should then be made rather than resort to the Caesarean operation, which is so grave at all times, but is still more so when practised on women affected with malacosteon." Independently of the difficulties which the contractions of the pelvis give rise to in the accomplishment of the mechanical phenomena of labor, they often become the source of serious accidents to the mother, and subject the fcetus to the greatest dangers. For, by forming an invincible obstacle to the passage of the head, they expose the woman to a rupture of the womb or bladder, to a vio- DEFORMITIES OF THE PELVIS. 547 lent contusion, and the consecutive inflammation of those organs and of the peri- toneum, and, lastly, to a febrile or adynamic state, which is serious enough of itself to cause her death before the delivery is effected; since this condition is the most frequent source of mortality in those patients who are not relieved. Again, even where the delivery has taken place either spontaneously or artifi- cially through the natural passages, the duration of the preceding travail and the pressure of the child's head upon all the soft parts lining the straits and excava- tion, expose these latter to prolonged contusions, which are most frequently fol- lowed by gangrene; whence we have following in their train utero-vesical, or vesico-vaginal fistulas, &c, &c, according to the point that has been more parti- cularly compressed. The forced engagement of the head in a contracted pelvis often determines the separation of the symphysis, from which inflammations and suppurations, that are often very tedious in their cure, result as the immediate consequences, and a great mobility of the pelvic articulations, limping, and some- times even an inability to walk or stand, as the remote ones. (Lachapelle.) As regards the child, the slowness of the labor may evidently occasion its death; for, in the case before us, the head being retained above the superior strait does not prevent the discharge of the amniotic liquid by plugging up the os uteri, and this nearly all escapes; consequently, the foetus is subjected, soon after the membranes give way, to the direct pressure of the contracted uterine walls during all the time necessary to the termination of the labor. The cord also is very frequently compressed, either in the uterine cavity, between its parietes and the body of the child, or subsequently in the excavation into which it may have slipped; the descent of the cord is here singularly favored by the elevation of the head. This latter itself, having to support all the pressure from the resistance offered by the pelvis, is exposed to very unequal compressions, which may fracture the cranial bones or wound the cerebral matter, Lastly, when the foetus presents by the pelvic extremity, the violent tractions sometimes made on the trunk, for the purpose of disengaging the head, may produce a luxation of the cervical vertebrae or a tension of the spinal marrow, both of which speedily prove fatal. ARTI.CLE IV. DIAGNOSIS OF PELVIC DEFORMITIES. The circumstances whereby the existence of a deformity of the pelvis maybe recognized, have been divided into the rational and the sensible signs. The first include all those that may be learned from the previous history, and a general examination of the individual—her constitution, height, and physical strength ; and the second, on the contrary, are deduced from an external and an internal examination of the pelvis. § 1. Rational Signs. The accoucheur who may be called upon to decide on the good or imperfect conformation of a female, should, before proceeding to an exploration of the pelvis, inform himself minutely of all the antecedent circumstances which might 548 DYSTOCIA. throw any light on his diagnosis, or direct his subsequent researches. He ought to ascertain from the near relatives, all the accidents which the young girl sub- mitted to his care may have met with in infancy; at what age she began to walk; whether standing in the erect position was easy, or even possible, in the early years of life; or whether, after having walked without any marked difficulty, she was subsequently afflicted with a weakness in her lower extremities; and, should there be an existing curvature of the spine or limbs, the period at which such incurvations appeared is to be carefully ascertained; as, also, whether those in the lower extremities preceded or followed that of the spine. Where any limp- ing is observed, he will endeavor to verify the information derived from the family, by examining whether this depends on a difference in the deformity of the two limbs; on the atrophy of one of them; on the flattening of the antero- lateral pelvic walls; on an old or a recent affection of the femoro-coxal articula- tion; on a spontaneous or a congenital luxation, followed by the permanent displacement of the head of the femur; or whether upon an old and imperfectly consolidated fracture;—because the answer to all these questions will render the examination, which is afterwards to be resorted to, much easier. The history of the earlier years of life is particularly important, as it will not only enable us to divine the perfect or defective conformation of the pelvis with a tolerable degree of certainty, but will even serve to enlighten us as to the nature of the general affection that has produced the deformity. In fact, it would appear from the researches of modern pathologists that rachitis, properly so called, is a disease of childhood, though it is seldom observed in the infant at term; it generally begins about the eighteenth or twentieth month, and is rarely found after the age of puberty. Thus, in three hundred and forty-six cases, examined in this respect by M. Jules Guerin, its invasion took place as follows: in three cases, before birth ; in ninety-eight, during the course of the first year; in one hundred and seventy-six, during the second; in thirty-five, in the third; in nineteen, in the fourth; in fifty, in the fifth; and in five children from the sixth to the twelfth year of life. From these and numerous other cases reported by Bouvier, Ruff, &c, it is ap- parent that deformities occurring in infancy are nearly always of a rickety nature; whilst all the varieties of softening that take place in adult bones, as also all the disfigurations occurring exclusively in young girls about the period of puberty, are not caused by this disease. ( Guerin.) A rachitic origin of the deformity can, therefore, be almost constantly relied on where the disease that determined the latter existed during the early years of life; and this suspicion will be confirmed, if it should appear, conformably to the law laid down by the orthopedists, and stated formally by M. Guerin, that the malformation proceeded from below upwards, and that the tibias, the femurs, and the spinal column were successively affected. But if, on the contrary, the first ten years have passed away without any accident of the kind; and if, moreover, the patient has been happily delivered before, but has exhibited since that event all the phenomena of an acute softening, the deformities may safely be considered as having been caused by malacosteon. After attending to all these points, the accoucheur might proceed to a more careful inspection of the individual; and the vertebral column and lower extre- DEFORMITIES OF THE PELVIS. 549 mities should particularly claim his attention. He ought to bear in mind that rachitic deviations of the spine (and, when dating from early infancy, they will be nearly always rachitic) are almost constantly accompanied by deformity of the pelvis; and that, on the contrary, the other varieties, more especially when they first occurred about the age of puberty, do not affect the normal regularity of the pelvis. It is also to be remembered that rickets may possibly give rise to curva- ture of the lower extremities without altering the pelvis, though these two parts of the skeleton are most generally affected at the same time; as also that, even if the form of the pelvic cavity should remain intact after the disease is cured, it is rarely that deformity of the pelvis does not result from the unequal length of the lower extremities, particularly if this inequality is well marked, and has existed from early infancy; but if, on the other hand, the limbs, although curved, retain the same length, this consecutive malformation of the pelvis will not take place. An attempt has been made to establish a certain relation between the direction of the curvature of the spine or lower extremities, and the particular species of malformation the pelvis may exhibit. For instance, the sacrum, being an assem- blage of vertebrae, which are naturally consolidated together, is occasionally modi- fied by incurvations that are continuous with those of the spine, and these are further kept up by the coccyx. Sometimes, the lateral inflexion of these two bones is continuous with the lumbar curve; though, more frequently, they de- scribe an inverse curvature with one or two of the last lumbar vertebrae, and the point of the coccyx is then turned aside. According to M. Hohl, the lateral inflexion of the lumbar column often determines a greater contraction of the pelvis on the side towards which these vertebrae lean. Agreeably to the same author, the curvature of the femurs occasions a trans- verse contraction of the pelvis, and a consequent elongation antero-posteriorly, when these bones are curved forward; whilst their outward curvature is followed by a transverse enlargement; but if one bends outward and the other forward, a corresponding shortening will thence result in the latter direction. However, all these approximations must be substantiated by a more extended experience to render them deserving of confidence, although it would be improper in practice to neglect them altogether. The relations that M. Weber has endeavored to establish between the dimen- sions of the cranium and those of the pelvis are not constant enough to merit any consideration whatever in an examination which requires so much precision. Quite recently, M. Guerin, after having ascertained that rachitis proceeds from below upwards, and that the reduction in the dimensions of the bones follows the same progression, attempts to prove further, that the dimensions of a rickety bone being known, the size of other parts of the skeleton may be approximately determined; and that the reduction in the three diameters of the pelvis in rachitic women, follows the diminution in the size of its component parts; also that the degree of this reduction is intermediate to what takes place in the femur, and in the humerus. These results, so valuable in themselves, had they been deduced from a large number of cases, are, unfortunately, based upon a very limited observation; and, consequently, have not all the weight that I hope they will hereafter acquire; for 550 DYSTOCIA. the great importance of being able to determine, with certainty, from the degree of shortening of the femur and humerus, not only that the pelvis is deformed, but even the extent of the malformation, must be self-evident. In conclusion, it is apparent that the rational signs just spoken of can only give us probabilities or approximations. Now, the indications presented by the deformities of the pelvis demand an exact and a rigorous solution of all the ques- tions of diagnosis appertaining thereto; because it is not on a mere probability that an accoucheur can venture to prohibit a young girl from marriage, or decide on the performance of an operation that mutilates the child, or exposes the mother to the most serious dangers. Such a decision can only be made after a thorough and minute examination of the external form, and the internal dimen- sions of the pelvis; and this examination alone can enable him to detect those sensible signs which afford a positive certainty. § 2. Sensible Signs. The accoucheur should not content himself, therefore, with the foregoing characters, but he ought to seek, in the mensuration of the pelvis, for the ele- ments necessary to his diagnosis. This process is performed both on the exterior and interior of the pelvis; in the former case it constitutes what obstetricians have termed external, and in the latter, internal pelvimetry. When we described the pelvis, in the early part of the work, we only pointed out the dimensions that were absolutely necessary to the full comprehension of the mechanism of natural labor; but we must now supply that voluntary omis- sion; for, in addition to the distances then given, there are several others which are indispensable to the practice of pelvic mensuration; and we give the follow- ing as the average of a well-formed pelvis, viz.: 1. From the anterior inferior spinous process of one ilium, to the same point on the opposite side,........8£ inches. 2. From the anterior superior spinous process of one side to the same point on the other,.........9£ " 3. From the middle of the iliac crest of one side to the same point op- posite, ...........10J " 4. From the middle of the iliac crest to the tuber ischii, . . . 7£ " The superior strait divides this distance into two equal parts, whence the lateral portions of the greater and lesser pelvis are each . 3| " 5. From the anterior superior part of the symphysis pubis to the apex of the first spinous process of the sacrum.....1 \ " From which 2£ inches are to be deducted for the thickness of the base of the sacrum, and \ an inch for that of the symphysis; therefore, leaving for the sacro-pubic interval . . . . 4£ " 6. From the tuber ischii of one side to the posterior superior spinous process of the opposite ilium, the mean extent, in an ordinary pelvis is.......... . . 7 " 7. From the anterior superior spine on one side to the posterior supe- rior spine of the other, the mean is......8J " 8. From the spinous process of the last lumbar vertebra, to the ante- rior superior iliac side of either spine, the mean is . . . 7 " 9. From the trochanter major of one side to the posterior superior spinous process of the opposite one,......9 " DEFORMITIES OF THE PELVIS. 551 10.1 From the middle of the lower border of the symphysis pubis to the posterior superior spinous process on either side, . . . . 6| inches. For the purpose of ascertaining the dimensions just given, in the living female, as well as the principal modifications they may have undergone, accoucheurs have invented a great number of instruments, Fig. 85. to which the title of pelvimeters has been ap- plied ; but I can only allude here to those in most common use. The pelvimeter, or callipers, described by Baudelocque (Fig. 85), consists of two me- tallic blades bent in a semicircular form, so as to embrace the largest part of the pelvis in their concavity. The extremity of each one is terminated by a lenticular button, which is intended to be applied at the end of the line to be measured; a small rule, marked by a' graduated scale, traverses the branches just at the point where the curved blade joins the straight handle, and shows the degree of sepa- ration at the points exactly. This rule shuts , , j. „ , Baudelocque's callipers applied to the mea- up in a deep groove along the handle Of the surement of the antero-posterior diameter of callipers. The instrument is applied exter- the superior strait. nally, and may prove very useful in estimating the measurements above given. In skilful hands, the pelvimeter of Baudelocque may furnish very satisfactory results; but it must be acknowledged that it is far from affording that degree of certainty which its inventor anticipated, even in the determination of the antero- posterior diameter of the superior strait, the one, of all the pelvic diameters, which seems the best adapted to this mode of exploration; for, although one of the buttons can readily be applied at the upper front part of the pubic symphysis, after having carefully pushed aside the soft parts, yet it is far otherwise with regard to placing the other one just over the point corresponding to the .spinous process of the first piece of the sacrum.8 The difficulty of determining this latter point exactly, and the thickness of the soft parts, render this mode of mensura- tion very uncertain in its results. But, even supposing the instrument could be properly adjusted, the results thereby obtained would be scarcely more conclusive. When the pelvis is well-formed, there should be, it is said, seven and a half inches between those two points; from which two and a half inches for the thickness of the sacrum at its base, and half an inch for that of the symphysis 1 The last five measurements are taken from the Memoirs of M. Naegele, translated by M. Danyau. We shall hereafter revert to their importance, in connection with the diag- nosis of the oblique-oval pelvis. 21 have repeatedly made such attempts, and have so rarely succeeded in adjusting the point of the callipers over the spot behind where it is directed to be applied, that I have rather attributed those cases to chance, in which the touch did not set aside my first diag- nosis ; and I will add, further, that I have often known M. P. Dubois to abandon this mode of exploration after frequent ineffectual trials, and to rely wholly upon the vaginal exami- nation. 552 DYSTOCIA. pubis, are to be deducted. But, the question at once arises, are the pelvic bones always uniform in thickness ? or must we still deduct three inches for the substance of the bones, in cases of rachitis, where the skeleton exhibits a more or less marked arrest in its development ? How are we to know to what extent this influence of rachitis over the growth of the osseous system is carried? And may not the thickness of the sacrum at its base, instead of exhibiting the normal average of three inches, be reduced to two, one and a half, or even one inch ?* If such sources of uncertainty exist in respect to the measurement of the sacro- pubic diameter, what must it be with regard to determining the transverse or oblique ones by the pelvimeter ? For, is the interval between the anterior iliac spines always the same ? In the normal state, that extending from the middle of the iliac crest on one side to the same point opposite is ten and a half inches, just double the length of the transverse diameter of the superior strait; but it is well known the iliac fossae may vary in their concavity, and that the crests may approach more or less closely towards a vertical or a horizontal direction, without altering the form of the abdominal strait. Therefore, the supposed relations between these two distances exhibit such frequent anomalies that we cannot place any confidence in the conclusions endeavored to be established therefrom. Again, where one point of the callipers is placed on the external surface of the trochanter major, and the other on the salient part of the opposite sacro-iliac articulation, with a view of determining the oblique diameters, no account is made of the numerous variations in the length and inclination of the cervix femoris, in the depth of the cotyloid cavity, or in the thickness of the soft parts behind. Consequently, the employment of Baudelocque's pelvimeter can only give approximate results; but it is not the less a useful instrument in those cases where it would be impossible to introduce a foreign body into the vaginal cavity; for instance, the internal exploration is not permissible in young girls, and then we must resort to the use of the callipers. Fortunately, at such times, the diag- 1 We have had opportunities of measuring a great number of pelves that were deformed in various ways and in different degrees, says Madame Boivin, in which the thickness of the walls in question departed from the three inches assigned to them by Baudelocque, to the extent of a third of an inch to an inch each, either larger or smaller. This difference in thickness was sometimes observed in the pubis, at others in the base of the sacrum, and again in both of these bones at the same time. Besides, in more than a hundred well-formed pelves, covered by all their tissues, which had not been altered by disease in any way, we have noticed considerable variations both in the volume and the thickness of the parts form- ing the antero-posterior' diameter at the superior strait. Madame Lachapelle has found the sacrum alone nearly three inches thick, in many well- formed pelves, whilst in some deformed ones it scarcely measured two inches. " I consider the results," adds this skilful midwife, " that are obtainedin measuring the transverse and oblique diameters of the strait, by taking certain portions of the iliac crests, the great trochanters, the ischial tuberosities, &c, for the points of departure, as very falla- cious : Because, 1. In the best-formed women, the iliac crests are sometimes inclined to- wards each other, and at others are turned outwards, so that both an everted and a cylindroid variety may exist in natural pelves; 2. The great trochanters are more or less separated, according to the variable direction and length of the neck of the femur, &c." DEFORMITIES OF THE PELVIS. 553 nosis need not be very precise, and a few lines more or less cannot affect the decision of the physician. But the case is far different when the woman is pregnant or in labor, for then it is necessary to learn the dimensions of the pelvic cavity with the greatest exactitude. For this purpose, accoucheurs have devised various instruments, which they have designated by the title of internal pelvimeters. The most ancient of all is the one invented by Coutouly. which closely re- sembles, in its general appearance, the instrument used by shoemakers, some years since, for taking the measure of the foot; it is composed of two iron rules, which slide on each other, and each having a short plate fixed at a right angle on one of its extremities. When it is introduced into the vagina, the two rules are slipped along each other, so as to get one of the plates against the sacro- vertebral angle, and the other just behind the posterior face of the symphysis pubis. One of these rules is marked by a scale, which indicates the degree of separation of the two plates, and, consequently, the length of the sacro-pubic diameter. The use of this instrument is attended with such numerous inconveniences, as to have banished it almost entirely from practice. Its application is difficult; it distends the vaginal mucous membrane greatly, and this distension is often very distressing to the patient. The extremity of the plate that is intended to be applied on the sacro-vertebral angle, is liable to slip and to become displaced; beside which, the organs situated in the excavation oppose its free use. Madame Boivin endeavored to obviate most of the objections against Cou- touly's instrument, by substituting a new one, which she called an intro-pelvi- meter; which, although bearing a general resemblance to the former, differs essentially, in having its two constituent branches simply articulated, so that they may be unfastened and introduced separately; the one into the rectum, the plate of which is to be applied against the sacro-vertebral angle, and the other into the vagina, so as to place its vertical part behind the symphysis pubis. This instrument is perhaps less painful to the patient, and not so liable to be displaced as the other, but it will not furnish us any more accurate results. Besides, the introduction of a foreign body into the rectum is so disagreeable to most women that very few are willing to submit to it; for where, indeed, is the young girl (and Madame Boivin recommends it particularly for virgins) who would ever consent to its employment ? But is unnecessary to allude here to all the other pelvimenters that have been proposed; and I shall only bring forward the one invented by Stein, which I should adopt rather than the preceding, because it is more simple aud more easily applied. It is merely a metallic stem, of the length and size of the female cathe- ter, provided with a slide, and having the metrical divisions marked on one of its surfaces. It is employed by passing its extremity along the forefinger, pre- viously introduced into the vagina, until it reaches the sacro-vertebral angle; the external part is next pressed upwards, so as to bring the graduated face in con- tact with the lower portion of the symphysis pubis, and then, by means of the slide, the point on the stem corresponding to the symphysis is marked. The instrument is subsequently withdrawn, and all that part of it beyond the slide 554 DYSTOCIA. shows the length of the sacro-pubic diameter, or rather the interval existing be- tween the sacro-vertebral angle and the inferior part of the pubis. However, Stein's pelvimeter may be replaced by any straight rod whatever, upon which the finger will take the place of the slide. Many very ingenious instruments have been proposed during the last few years, for the purpose of obviating the various objections we have urged against those just mentioned; such are Wellenbergh's, a description of which is given by M. P. Dubois in the twenty-third volume of the new edition of the Diction- naire; and, more particularly, the one announced quite recently by M. Van Huevel, a professor at Brussels. This latter, in my estimation, has incontest- able advantages over all the others; and I feel warranted in recommending its more general use. It is composed of two round rods; an internal or vaginal one (Fig. 86, A a) flattened like a spatula at each extre- Fi£- 86- niity, and having, about the middle of its upper face, a small blunt hook, or catch, the concavity of which looks to- wards the outer extremity; the other, or external one, B B, is traversed at the upper end, and perpendicularly to its direction, by a long screw, C, which is drawn back by unscrewing. These rods are held together by means of a nut, or articular box, thereby forming The mensuration of the sacrc-pubic diameter with l • j c ii 1 sr „'u:„,l ,. ,T „ ,, , . L a kind of compass, the legs of which M. Van Huevels pelvimeter. r ' ° can be lengthened out or shortened at pleasure, and can likewise be moved in every direction. A turn of the central screw in the nut presses them against each other, and retains them firmly in any desired position. When this instrument is to be applied, the woman lies on her back, having the legs, as well as the thighs, flexed and separated. We then begin by ascer- taining, both exteriorly and interiorly, the exact situation of the upper border of the pubis, marking the skin with ink at the point corresponding to the middle thereof. The ilio-pectineal eminence on each side, just beyond the course of the crural artery, is next sought out and marked in the same way; so that the anterior extremities of the sacro-pubic and the two oblique diameters of the su- perior strait are indicated by the three ink spots on the skin, which are after- wards easily found. This being done, one or two fingers of the left hand are introduced into the vagina, and placed on the angle of the sacrum; and then, with the other, the curved extremity of the vaginal rod is conducted along and under these fingers, which support it against the promontory, while the thumb of the same hand, pressed into the blunt hook, firmly retains it on the exterior. The right hand, which hitherto held the instrument, now turns the long screw, c, in the external branch, the button of which rests on the ink spot made upon the mons veneris. While the operator thus holds the two branches in their re- spective positions, an assistant tightens the screw in the articular nut; when the instrument, being thus fastened, is carefully withdrawn (Fig. 86), and the dis- DEFORMITIES OF THE PELVIS. 555 tance between the two points, that is to say, the interval which separates the promontory from the anterior face of the pubis, is ascertained by a scale. This distance being known, the branches are rendered movable by unfastening the articular screw; and the ope- rator again carries the left fore- finger into the vagina behind the symphysis pubis, to which point he conducts the extre- mity of the vaginal branch (its concavity being in front), by *= slipping it along the palmar surface of this finger, and he sustains it there by one hand, whilst with the other he re- places the Screw Of the exter- • The mensuration of the symphysis-pubis by the same nal branch upon the ink spot instrument. on the mons veneris; taking care to avoid pressing more strongly than in the first operation; for it is only requisite to graze the skin without depressing it. The assistant again tightens the screw in the nut, and the operation is completed. (Fig. 87.)* In order to withdraw the instrument, which now comprises the thickness of the pubic region, the screw C of the external branch is unfastened, and again exactly replaced in the same position after it is withdrawn. This distance is also measured, which, deducted from the first, gives a remainder that extends from the sacro-vertebral angle to the posterior face of the pubis, or, more properly speaking, the sacro-pubic diameter. The oblique diameters can be obtained precisely in the same way. The index and middle fingers are carried into the vagina, and their extremities placed on one of the sacro-iliac articulations, or even, if this cannot be reached, on the promontory of the sacrum; the end of the vaginal branch is slipped up there in turn, and then the button of the screw c is fixed on the ink spot corresponding to the right or the left ilio-pectineal eminence. The branches having been fast- ened in this position, are gently withdrawn from the woman's parts, and the dis- tance between their points is taken by a graduated scale. In a second operation, the thickness of the cotyloid wall is ascertained by conducting the vaginal branch along the fingers behind this cavity, as far as the brim of the pelvis, and by re- placing the button of the external branch over the ink spot corresponding to the ilio-pectineal eminence. Is it necessary to repeat, that the soft parts in the groin are not to be depressed, and that the direction must correspond with the plane of the abdominal strait ? The branches are subsequently fixed, and extracted by turning back the screw c, as described above; when, by deducting this second thickness from the first, the remainder will show the extent either of the oblique diameter, or that of the sacro-cotyloid interval, according as the vaginal branch had originally been placed on the sacro-iliac symphysis or upon the promontory of the sacrum. 1 If the hook should impede the sliding of the branch b b, it might be removed. 556 DYSTOCIA. We may observe here that the opening between the promontory and the coty- loid wall is the most essential to be known in cases of oblique deformity; for the sacro-iliac articulation is never deformed (saving where an exostosis or some other tumor is developed on its surface) ; but it is rather the base of the sacrum, or the cotyloid cavities which project into the hollow of the excavation. In fact, the pelvis sustains the vertebral column behind, while in front and laterally it rests on the thigh bones ; and, therefore, it lies between two forces, which, in the erect position and in walking, have a continual tendency to depress this osseous ring at the three points indicated. Whence it follows that, if there is any softening, there will be a forward projection of the sacral angle, or a pressing backward of the acetabula; that is to say, a contraction of the antero-posterior diameter, and of the right and left sacro-cotyloid intervals, which, in the normal state, are only from three to three and three-quarter inches in extent. As regards the external measurement, we can convert the pelvimeter into a common compass for the inferior strait, by taking the handle part of the two branches, and properly adjusting the nut; these being placed on the tuberosities of the ischia, or one at the point of the coccyx, and the other under the pubic arch, we are enabled to take the transverse and the antero-posterior diameters of this strait directly. Fig. 88. Lastly, by adding a piece to the apex of the vaginal branch (Fig. 88, D. D.), we form a species of callipers similar to the mecometer of Chaussier. This piece is first flattened out like a spatula, and then curved; and its concavity is placed along the anterior surface of the pubis; the branch that supports it passes back- wards between the woman's thighs; and the button of the screw c, traver- sing the other branch, is pressed on the spinous process of the last lumbar ver- tebra.1 The operator holds the extre- mities of the instrument in his two hands, whilst an assistant tightens the screw in the articular nut. It is disengaged by turning the screw C back- wards, when necessary, which is returned to its place before measuring the in- The same instrument converted into a pair of callipers. *If, says M. Van Huevel, the tubercle of the spinous process of the last lumbar vertebra cannot be detected, the following process may be had recourse to : Stretch across this re- gion a string which shall rest upon the upper and middle part of the crests of both iliac bones; then at the distance of an inch and a half below this line, upon the middle of the sacrum, make a mark, from which the string is to be conducted obliquely forwards and downwards toward the upper part of the cotyloid parietes and of the mons veneris. The position of the string, which should follow the inclined direction of the plane of the supe- rior strait, may be rectified, if necessary, by the fingers. Then with an uncut quill dipped in ink, the points to be preserved are marked out along the line of the cord. These points should be made lower at the pectineal eminences and at the pubis, by from one and a half to two and a half inches, than the described limit, in order to correspond better with the con- traction of this strait. DEFORMITIES OF THE PELVIS. 557 terval between the points with the scale. (Extract from the Memoir of M. Van Huevel.) Quite recently (February, 1855), the ingenious accoucheur of Brussels has still further improved his first pelvimeters, besides suggesting another, which appears to me quite as simple, and of more general applicability than the pre- ceding. I therefore think it right to give a detailed description of it. It is simply a pair of callipers (Fig. 89) composed of two branches, one of Fig. 89. Fig. 90, ■HI UN Fig. 91. ■t i in m i il: ......" ' nn 1 ' ■ ■■■ ■ ' " ' ' ■ ■■ ' ' irT which is fixed, and the other movable. The first, A B, is eleven inches in length, slightly curved, and flattened at its extremity; it is inserted into the vagina for 558 DYSTOCIA. the internal measurement, and bears a hooked ring near its middle, beyond which is a non-graduated arc of a circle. It articulates below, like an ordinary pair of compasses, with the prolongation of a sheath, in which is inserted the lower extremity of the other branch. The curvature, length, and hooked ring, are the same as in the small geometric pelvimeter. The second or external branch, c B, may be lengthened or shortened at plea- sure. It carries at its upper extremity a long horizontal screw, like the preceding pelvimeter, for the purpose of facilitating the disengagement of the compass after its internal application: from thence it curves outwardly, and, finally, in de- scending becomes straight and quadrangular, and enters the above-mentioned sheath. The latter, which is open at both ends, is furnished with a groove externally, for the purpose of receiving a projection of the branch, which pre- vents its escaping from the sheath. Its inner side is provided with a spring bearing a point, which passes through the side, and lodges in a small hole in the branch, so as to prevent the latter from slipping up and down, and to keep the two extremities of the branches on the same level. When the spring is raised, the point escapes from the hole in the stem, which then becomes movable; when released, and pressing upon its surface, it keeps it at any height desired. The arc of a circle attached to the vaginal branch is applied against the right side of the external branch. A slide (Fig. 90) is traversed by the latter at right angles, and also by the arc. On the opposite side is fixed a vice, moved by a lever, which presses these two pieces together, and prevents all motion. Lastly, a graduated scale (Fig. 91) serves to measure the distance between the extremi- ties in any given position. Let us now examine the mode of application of the new pelvimeter. The compressing vice of the slide is relaxed, and the point of the spring engaged in the small hole of the external branch keeps the extremities of the instrument on the same level, so as to form a pair of callipers. The extremities are applied either to the anterior superior spinous processes of the iliac bones, to the crest of the ilium and the tuberosity of the ischium of the same side, or the bottom of the horizontal screw is placed upon the spinous process of the last lumbar vertebra, and the extremity of the vaginal branch against the mons veneris by passing between the thighs of the patient; again, one may be applied to the upper, and the other to the lower edge of the pubis, to the tuberosity of each ischium, or, finally, upon the coccyx, and under the pubic arch. Thus are obtained the extent of the transverse diameter of the greater pelvis, the depth of the entire cavity, the distance from the loins to the pubis, the length of the symphysis pubis, and the transverse and antero-posterior diame- ters of the inferior strait, the value of each of which is determined by the scale. To measure the interior of the pelvis, the woman is placed on her back on the bed, with the breech brought to the edge of the mattress. The extremities of the diameters of the superior strait are marked in the manner already described, with the aid of a cord and a quill. Then, one or two fingers of the left hand are introduced into the vagina as far as the promontory of the sacrum. The right hand holds the callipers unfastened and opened to its full extent, and with the external branch depressed in its sheath. The extremity of the vaginal branch is next passed into the genital organs along the previously introduced fingers, which DEFORMITIES OF THE PELVIS. 559 press it against the sacro-vertebral angle, whilst the base of the thumb engages itself in the hook. This instrument is held motionless in its position by a single hand. Then, the thumb, fore, and middle fingers of the right hand grasp the external branch above the arc of a circle, and raise or lower it in its sheath until the button of the horizontal screw corresponds to the mark made upon the mons veneris. As soon as this is effected by merely grazing the skin, the ring finger presses the lever of the vice forwards, to fix the instrument in its place. It is then withdrawn from the woman's parts, and the distance between the two extremities ascertained by means of the scale. The first stage of the operation being accomplished, the vice is relaxed, and the extremities of the callipers again made to correspond. The index finger of the left hand is again introduced into the vagina, and applied this time behind the pubis. The extremity of the vaginal branch is conducted thither, with its concavity in front, by the right hand. As soon as it has reached the upper edge of the symphysis, the branch is seized with the entire hand, and the little finger passed into the ring of the hook. The external branch is afterwards seized above the arc by the three first fingers of the right hand, and the ring finger pushes the lever of the vice forward, as soon as the button of the horizontal screw corre- sponds to the spot on the mons veneris. This second application should be made as gently as the first, merely grazing the skin. Should any difficulty be expe- rienced in the withdrawal of the pelvimeter, the horizontal screw may be screwed back, provided it be restored to its position after the extraction. The distance between the extremities should be again measured by the scale, and subtracted from the first result, to obtain the extent of the sacro-pubic diameter. The only error possible in this process results from the unequal pressure upon the skin in the two applications, or else upon the irregular position of the branch behind the pubis, which may be either higher or lower than the sacro-pubic line itself. A little attention only is necessary in order to avoid these slight causes of error. The proceeding is exactly the same for obtaining the oblique diameters. The pelvimeter is first loosened, opened widely, and the external branch lowered in its sheath. If the left sacro-pubic space is to be measured, the instrument should again be taken in the right hand; the fore and middle fingers of the other hand are introduced into the genital organs, and placed to the left of the pre- vertebral projection; then the extremity of the vaginal branch is passed up to the point indicated, and retained there by the fingers of the right hand; the button of the external branch is placed upon the mark over the left ilio-pectineal eminence, and the vice is tightened by the ring finger. The instrument, in its diagonal position, is withdrawn from the parts, and the distance between the two extremities ascertained by the scale. Having noted the latter, the vice is unfastened, and the two extremities of the callipers brought together. Then the fore and middle fingers of the left hand are again introduced into the vagina behind the left ilio-pectineal eminence, as also the extremity of the vaginal branch with its concavity forward; the branch is next grasped with the left hand, and the little finger introduced at the same time into the ring of the hook. The thumb, fore, and middle fingers of the right hand replace the button of the external branch upon the mark over the 560 DYSTOCIA. left ilio-pectineal eminence, whilst the ring finger presses upon the lever of the vice. The same precaution should be taken, as in the first instance, of turning the horizontal screw, if necessary, in order to withdraw the instrument, and to return it to its place, for the purpose of measuring the new distance between the extremities. The subtraction of this quantity from the other gives the dimen- sions required. The right sacro-pectineal distance is ascertained in the same way, except that the fingers of the right hand are then introduced into the vagina, the instrument being held in the left hand. * Finally, the measurement of the transverse diameter of the superior strait is accomplished in nearly the same manner. The callipers being prepared as usual and held in the right hand, two fingers of the left hand in a state of forced supi- nation, the thumb being directed downwards, are carried to the right side of the pelvis. The convexity of the vaginal branch is directed toward that point, and held there by the pressure of the introduced fingers, and by the left thumb, which is engaged in the hook. The free hand conducts the external branch beneath the left thigh, which is raised for the purpose, and places it upon the mark made upon the corresponding hip. The ring finger of the right hand fixes the instrument in its transverse position by pressing upon the lever of the vice, and the distance between the extremities is measured by the scale after the extraction. To make the second application, the vice is relaxed, and the external branch elongated beyond the extremity of the vaginal one; then, the fore and middle fingers of the left hand are placed in the genital organs on the left side of the pelvis. The extremity of the vaginal branch is conducted thither by the right hand, and kept there by the left hand, the little finger of which is inserted in the ring of the hook. The external branch is finally directed by the free hand beneath the left thigh upon the hip of the same side, and fixed as usual. The horizontal screw is next turned for the purpose of withdrawing the pelvimeter. When restored to its place, the distance between the extremities is again taken, and this, subtracted from the first measurement, gives the length of the transverse diameter. The diameters of the excavation may be measured in the same manner; it being only necessary to take the precaution to mark spots around the pelvis be- tween the limits of the superior and inferior straits. But, after all, the hand of an accoucheur, accustomed to practise the touch, is certainly the best and most satisfactory of all pelvimeters; for, with the excep- tion of a few rare cases, in which I would give the preference to the instrument last described, it is always possible to ascertain exactly by it the external form of the pelvis, and also, by its introduction into the vagina, the perfect or defective conformation of the cavity. By the exterior palpation, we are enabled to learn the external characters of the pelvis, to find out what interval exists between the two iliac crests, and to measure the depth of the anterior, the posterior, and the lateral walls of the pelvis; and this might possibly be all-sufficient; although, in our opinion, it is better to resort to the callipers of Baudelocque for the external mensuration. It is more particularly in the appreciation of the dimensions of the cavity, the DEFORMITIES OF THE PELVIS. 561 straits, and the excavation, that the hand introduced into the parts serves as a sure and faithful guide. It is not even necessary to pass the whole hand into the vagina, for the introduction of one or two fingers is usually quite sufficient; in fact, we ought to be satisfied with this, when the woman is not in labor, since the entrance of the entire hand would often prove very painful.1 The following is the proper mode of using the finger : the index having been passed into the vagina, is directed upwards and backwards towards the sacro- vertebral angle, which is easily recognized by its promi- nence, and by the transverse depression formed at the lumbo-sacral articulation. When the extremity of the finger is well applied against this part, the wrist is car- ried upward and forward, until the radial border of the finger comes into contact with the lower margin of the symphysis pubis; when the index of the other hand marks this point with the nail (the precaution having previously been taken to separate the labia externa and the nymphse); the finger is then withdrawn and placed on a scale, whereby the distance from the sacro-vertebral angle, upon which its extremity was applied, to the infe- rior part of the symphysis pubis, is very correctly ascer- tained. But this oblique line is longer than the antero- posterior diameter of the upper strait, which terminates The mensttrati<»n of the r . sacro-pubic diameter by the in front, on the posterior superior part of the symphysis; finger. 1 It is a great mistake, says M. Guillemot, to suppose that it is possible to measure the length of the sacro-pubic diameter, by the introduction of a single finger into the vagina. This result has never been effected when the diameter has exceeded two and a half or three inches in length; and the dimensions of the strait can only be correctly obtained by using the whole hand. Like M. Guillemot, we believe that the hand should be introduced, whenever this can be done without causing too much suffering to the patient; but we have elsewhere stated that this was often very painful, even at the moment of labor; and we will add, that at any other period it would appear useless, since the finger alone, by depressing the perineum, might measure as far as three and a half inches, unless there was an unusual resistance at this part, and beyond this a natural delivery is possible; or, at least, if the intervention of art should become necessary, it could always be terminated favorably to the lives both of the mother and child; and, therefore, nothing need be done until the time of par- turition. During labor, says M. Velpeau, we can, if necessary, introduce the entire hand into the vagina; the thumb and index finger are then separated, so as to place the one on the sacro- vertebral angle, and the other behind the pubis; the hand is withdrawn while in this posi- tion, and, by the aid of a measure, the dimensions of the sacro-pubic diameter are deter- mined within one or two lines. I have sometimes used the index and middle fingers, car- ried high up into the vagina, with advantage; and then, after having separated them as much as possible, and placed their extremities on the diameter that is to be measured, two fingers of the other hand are inserted between their bases, to prevent them from changing their relations while being withdrawn from the woman's parts. But these directions, given by M. Velpeau, appear to us impracticable at-the superior strait, and equally so as regards the bis-ischiatic interval. Ramsbotham's process resembles nearly Velpeau's. He introduces the fore and middle fingers into the excavation ; the bent extremity of the forefinger is applied closely against 36 562 DYSTOCIA. consequently, the excess must be deducted; and, by subtracting four or five lines for a large pelvis, and three to four for a small one, we shall have very nearly the extent of the sacro-pubic interval. With regard to the exact number of lines to be deducted, the attention should further be directed to the thickness, the length, and the more or less marked obliquity of the symphysis; which cir- cumstances can easily be determined by the touch. The finger introduced into the parts will also be able to appreciate the extent of the antero-posterior diameter of the excavation; for it can very readily pass over the whole front surface of the sacrum; and, consequently, can judge whether its anterior concavity is augmented or diminished. Lastly, its extremity being applied against the point of the coccyx, the accou- cheur should again elevate his wrist until the radial border of the hand is arrested by the lower part of the symphysis; then, marking this point with the other forefinger, he should withdraw the hand and apply it to a graduated scale, and he can thus ascertain very correctly the extent of the coccy-pubic diameter; further, by pressing gently on the point of this bone, he can judge very readily of the degree of mobility in the sacro-coccygeal articulation. In cases of deformity caused by the excessive length or unusual obliquity of the pubic symphysis, the direction of the vulvar opening will be so much changed as to attract attention ; it being then situated much more posteriorly than in well- formed women. Although the results furnished by the touch are perfectly satisfactory as re- gards the antero-posterior diameters, it is far otherwise with the transverse and oblique ones, particularly at the superior strait; for the extent of these can only be judged of approximately, and we can do nothing more than test with the finger the dimensions obtained by the external mensuration. The finger, when entered, is to be carried in the direction of those diameters, and the accuracy of the result thereby obtained will depend on the experience and tact of the accou- cheur. However, we shall soon have occasion to be more explicit on this point, by extracting from the works of MM. Naegele and Danyau the results of their researches. As to the transverse diameters of the inferior strait, their dimensions can evidently be ascertained by the aid of the fingers. Again, the educated finger will give a very just idea of the length of the sym- physis pubis, the spreading and height of the pubic arch, the depth and normal configuration or deviation in the lateral walls of the excavation, and of the in- ward prominence of the ischiatic spine. The existence of the various tumors that may obstruct the pelvic cavity, or greatly diminish the canal intended for the passage of the child, can be recog- nized by the finger alone; for it can detect their nature, their softness, or resist- the symphysis pubis and the end of the strongly-extended middle finger endeavors to reach the sacro-vertebral angle ; then withdrawing the fingers in the same position, the space be- tween their extremities is, he says, to be measured by a rule or a pair of compasses. He states that this process has the advantage of giving the exact dimensions, even when the head is engaged in the excavation, since one finger can be passed behind it and the other before it. (Obstetric Med. and Surg., p. 18.) We consider this procedure quite as unavail- able as that recommended by M. Velpeau. DEFORMITIES OF THE PELVIS. 563 ance, and their mobility, or adhesion to the osseous parietes, or to the soft parts which line the latter, far better than any other instrument. But .during parturi- tion, the touch, which is so often useful at other times, may not prove adequate to this measurement; for, if the contraction is not very extensive, the head, after being arrested for a long time, may finally engage at the upper part of the exca- vation, and form a considerable rounded tumor just below the superior strait, large enough to prevent the finger from passing up to the sacro-vertebral angle; and if the sacrum should then happen to be strongly pressed backwards, as is most commonly the case, so that the antero-posterior diameters of the excavation and of the inferior strait are increased, the cause of the head's arrest might be misunderstood, if the accoucheur does not bear in mind that, before engaging, it remained for some time above the symphysis pubis. The attention, however, will be awakened, if the finger, in traversing the anterior surface of the sacrum from above downward, detects the absence of its normal curvature. Our assertion, that the accoucheur's finger is the most perfect of all instru- ments, was, therefore, well founded, though its importance must not be Over- rated. In fact, many practitioners have erred in declaring, with Madame Lacha- pelle, that the best proof of a good conformation of the pelvis, is the impossibility of reaching the sacro-vertebral angle with the finger. Certain others, while admitting the imperfection of the other methods of exploration, equally err in supposing that an estimate, correct enough to guide us safely in practice, will be obtained by employing them simultaneously; because, there are some cases where the best known methods of exploration are inadequate, where the finger cannot reach the promontory of the sacrum, and yet where a mutilation of the foetus, and sometimes even the Caesarean operation, have been necessary. The oblique oval pelvis belongs to this class; and M. Naegele, who described it with so much care, after having experienced the inefficiency of the means of diagnosis usually employed, has made some researches, with the view of over- coming this difficulty; for which purpose, he has taken points on the pelvis different from those described by most authors, which are easily accessible and recognizable; and he has carefully measured the distances between them in the normal state, as already pointed out (page 550, Nos. 6, 7, 8, 9, and 10). " In forty-two pelves of well-formed females, we have found, says he, in a large ma- jority of cases, but little or no difference between the two sides of the same pelvis, as respects the above-mentioned distances." M. Danyau, responding to the wish expressed by M. Naegele, has repeated those researches in a great number of living and well-formed women, and the following are the conclusions at which he has arrived, namely, that in eighty females it appeared :— 1. That the distance from the tuber ischii of one side to the posterior superior spinous process of the opposite ilium, was the same on both sides in twenty-one persons; in fifty-one, the difference between the two sides was from one to three lines; and in eight only it amounted to four, five, and six lines; whilst, in the oblique-oval pelves, the smallest difference was found to be one inch, and the greatest two inches. 2. That the distance from the anterior superior spinous process of one side to the posterior superior iliac spine of the other, was the same in both halves of the pelvis in twenty-two females; in fifty-one there was a difference of one to six 564 DYSTOCIA. lines between the two; and in seven women only was this difference from seven to eleven lines. In the oblique-oval pelves, the smallest difference between these sides was three-quarters of an inch, and the greatest two inches. 3. That the distance from the spinous process of the last lumbar vertebra to the anterior superior iliac spine, was the same on both sides, in twenty-nine in- stances ; in fifty-one, there was a difference of oue to seven lines between the two. But in the oblique-oval pelves, the least difference was eight lines, and the greatest an inch and a third. 4. That the distance from the trochanter major of one side to the posterior superior iliac spine of the opposite one, was the same in eighteen cases; when measured comparatively on the two sides of the pelvis, a difference of one to six lines in this distance was found in fifty-seven ; and in five only it ranged from seven to nine lines ; whilst, in the oblique-oval, the smallest difference was half an inch, the greatest an inch and a half. 5. That the distance from the lower border of the symphysis pubis to the pos- terior superior iliac spine, was the same on both sides in thirty-two women ; in forty-six, the difference between the two halves of the pelvis, in this respect, was from one to six lines; and in two, from eight to nine lines; but, in the oblique- oval pelves, the least difference in this distance, taken on both sides, was seven lines, the greatest one inch. It will, therefore, appear that, by a proper degree of care, and the aid of the measurements just given, we would be able to recognize the deformity in ques- tion, by measuring the aforesaid distances on each side, and then comparing the results obtained from both. But there is yet another method for detecting the oblique-oval pelvis, says M. Naegele; that is, if a woman, having a well-formed pelvis, be placed with her back against any vertical plane, as a wall, for instance, so that the shoulders and upper part of the buttocks be in contact with this plane, and then two plumb- lines be dropped, the one from the point corresponding to the spinous process of the first sacral or the last lumbar vertebra, and the other from the lower border of the symphysis pubis, it will be found that the latter nearly or quite covers the first; that is to say, that a line perpendicular to the wall would intersect both of these plumbs at a right angle; but this is not th'e case in the oblique-oval pelvis. In fact, one of its essential characters is, that the symphysis pubis is deviated towards one side, and the sacrum towards the other, whence the middle of the pubic symphysis is opposite to the anterior sacral foramina, or even to the sacro-iliac articulation on the non-anchylosed side. Consequently, when a woman, whose pelvis is thus deformed, assumes the position just indicated, and the plumb-lines are dropped at the designated points, the operator will find, by bringing his view perpendicular to the wall, that the line placed in front does not cover the posterior one; for the latter will deviate to the right or the left, according to the anchylosed side, and this deviation will be the more con- siderable, as the pelvis is the more deformed. (M. Danyau's Translation.) DEFORMITIES OF THE PELVIS. 565 AKTICLE V. INDICATIONS PRESENTED BY THE DEFORMITIES OF THE PELVIS. It is not our intention to treat, in this place, of the measures that it would, perhaps, be advisable to employ for the purpose of remedying deformities of the pelvis when they exist, for this subject belongs exclusively to the surgery of the osseous system; besides which, the various mechanical and gymnastic means hitherto used for correcting the deformities of the skeleton have had no efficacy in changing the form of the pelvis. But, if nothing can be done by the physi- cian to cure, he is, at least, not wholly destitute of resources where there is still a possibility of preventing such deformities. Thus, during the earlier years of life, especially, he ought to watch over all the circumstances that might influ- ence the regular development of the skeleton, with the most tender solicitude ; he should relieve rachitic children from constriction or pressure of every kind, which might, in their variable attitudes, modify the pelvic circumference; they ought to be left in the recumbent position as much as possible; the nurse must not always have the child in her arms, as she is very apt to have, if not cau- tioned ; and great care is requisite not to permit them to walk too soon, not, indeed, until their bones have acquired a proper degree of solidity; and even then it should be by degrees, and only in proportion as their strength increases. We must not yield, says M. Bouvier, to the chimerical fears of augmenting the debility by depriving children of a necessary exercise; for repose, on the con- trary, is much better suited to that state of languor which they generally exhibit; and, besides, we may obtain, by passive motion, by exposure to sun- light, and by general movements in the horizontal position, a sufficient compen- sation for the state of inaction in which they are kept during a part of the day. The indications presented by the deformities in the pelvis, considered only with regard to the unfavorable influence they may have upon the puerperal func- tions, will evidently vary with the degree of deformity. When studying this influence, we classified all the malformed pelves in three categories, namely: all those having three and three-quarter inches, at the least, in their smallest dia- meter, were placed in the first; in the second, we have included those present- ing two and a half inches, at least; and in the third, those whose smallest dimen- sions are under two and a half inches; and, following the example of Professor Dubois, we shall still preserve this division in the study of the indications offered by the deformities.1 § 1. What is to be done when the Contraction is such, that the Pelvis measures at least three and three-quarter Inches in its SMALLEST DlAMETER ? In such a case, the child may evidently present either by the vertex, the pelvic extremity, the face, or the trunk. 11 am happy to state that most of the following considerations and practical views are deduced from the excellent thesis which M. P. Dubois sustained with so much credit in the concours, at the close of which he was nominated. I congratulate myself on being the first to give publicity to a work that is, unfortunately, but too little known. 566 DYSTOCIA. A. Where the Child Presents by the Vertex.—We have elsewhere stated that a spontaneous delivery is possible under such circumstances; and, consequently, that the wisest course is to wait and trust to the efforts of nature. But, where the uterine contractions are exerted in vain for a long time after the membranes are ruptured, and the amniotic waters are partially discharged without the head making any progress, an application of the forceps is the only remedy to which we can resort.1 But the exact moment for the employment of this measure is to be determined with greater precision. As a general rule, we may wait six, seven, or even eight hours after the membranes give way, and after the os uteri is fully dilated; and then, if energetic contractions have been uselessly exerted during all this time to overcome the obstacle, it will be necessary to interfere, and to apply the instrument; though it will be advisable to act a little more promptly where the head, after having been engaged for some time in the excavation, is arrested by a contraction of the inferior strait; and the same would be true, if this strait were regularly formed, and the arrest of the head were dependent on a feebleness of the uterine contractions occasioned by the previous efforts on the part of the organ to force it through the contracted superior strait. It is un- necessary to add, that if any accident whatever, grave enough to endanger the health of the mother or the life of the child, should occur during the labor, it would demand a more prompt intervention of art. Most generally, the fre- quently-repeated auscultation of the pulsations of the heart would be satisfactory as to the child's condition, though even here only a certain degree of confidence can be reposed in this sign. B. Where the Child Presents by the Pelvic Extremity.—When describing the mechanism of natural labor, we expressly recommended that no traction should be made on the pelvic extremity in breech presentations, with the view of avoid- ing the straightening out of the arms and an extension of the head ; and we still insist on the same precept here. Nevertheless, in the case before us, if the largest part of the trunk is delivered, and the expulsion of the head is unusually delayed, it would be proper to hasten the termination of the labor by a moderate traction on the body; for such attempts, if well conceived and well directed in the line of the pelvic axis, would prove sufficient in most cases to accomplish the delivery. If, however, they are ineffectual, it will then be necessary to apply the forceps. c Where the Child Presents by the Face.—Although face presentations may terminate naturally in the majority of cases where the pelvis is well formed, it is not the less true, as elsewhere demonstrated (pp. 430 and 465), that the labor is somewhat more painful to the mother, and is, besides, more dangerous for the child than in others. If, therefore, these difficulties, resulting from the posi- tion itself, are superadded to those which exist as a necessary consequence of 1 It is highly important not to confound in practice the constantly-increasing tumefac- tion of the hairy scalp with an actual descent of the head. For, when the labor is re- tarded, the sero-sanguineous tumor, formed by the soft parts, continually augments iu volume, and its summit gets nearer and nearer to the vulva; and, therefore, unless the precaution is taken to get an osseous portion of this region as a point of departure, the accoucheur might suppose that the head was traversing the excavation, and approaching the inferior strait, when, in reality, it did not move. DEFORMITIES OF THE PELVIS. 567 the contraction, there can be no doubt that a delivery, left entirely to nature would be attended with a very considerable risk to the foetus. Under such circumstances, M. P. Dubois recommends the conversion of the face position into one of the vertex, by flexing the head, and then the application of the for- ceps, if the uterine efforts remain fruitless after the change. It appears to us that this cephalic version would be quite as difficult as the pelvic, if attempted long after the membranes are ruptured, and we should give preference to the latter, which, generally, would enable us to dispense with the use of the forceps. (See Forceps.) D. Where the Child Presents by the Trunk.—If the contraction is discovered before the membranes are ruptured, or very shortly after, and- the foetus is very movable, we should endeavor to convert the presentation of the shoulder into one of the vertex, and then leave the expulsion to the efforts of the womb; but after the waters are discharged, the contraction of the organ renders the introduction of the hand and the cephalic version so difficult, that I consider turning by the feet much easier and less dangerous. The pelvic version, in the case before us, is attended with some peculiarities that ought to be mentioned. For instance, where an undue development of the sacro-vertebral angle is the cause of the narrowing, it often happens, as before shown, that the base of the sacrum is turned a little to the one or the other side at the same time that it is projected forward, thereby constricting one-half of the pelvis much more than the other; and hence, in performing the evolution of the foetus, and drawing on its pelvic extremity, under such circumstances, it would evidently be requisite to turn its posterior plane towards the larger half of the pelvis, so that, when the head presented at the superior strait, its large occi- pital extremity would correspond to the non-retracted side. It was stated above that when the foetus presented by its flexed cephalic ex- tremity, it would be necessary to apply the forceps, if the uterine efforts were incapable of terminating the labor; but the particular variety of malformation that we are now treating of may modify the rule laid down, which was perhaps a little too absolute; for, in this case, the position of the head must greatly in- fluence the accoucheur's determination. Let us take, for example, a pelvis whose sacro-vertebral angle while projecting forward is turned to the right, so as to diminish the sacro-cotyloid interval very considerably on this side; now, the intervention of art being judged necessary, if the head is placed in the left occipito-iliac position, an application of the forceps will be the only practicable measure; whereas, on the contrary, if the occiput is directed to the mother's right, we should preferably resort to the pelvic version. This last operation, by converting a second vertex position into the first of the feet, would have the ad- vantage of bringing the great occipital extremity of the head to the largest side of the pelvis, and would thus place the fcetus in a much more favorable position. The delivery has frequently been rendered comparatively easy by the pelvic version when resorted founder such conditions; and M. Velpeau relates a case which he terminated successfully by this manoeuvre, though other practitioners had deemed craniotomy to be indispensable in a former labor of the same woman The recommendations just made have the double object of sparing the mother from useless suffering, and more particularly of relieving the fcetus from the 568 DYSTOCIA. danger it would incur from a prolonged labor. Whence, it is evident, that the accoucheur's course^will be somewhat different in those cases where there is a certainty that the child is not living; for, having nothing to fear on its account, he might accord a much longer time to the uterine contractions, especially as the head, which is then softened and reducible, contributes far more to an easy ex- pulsion than under other circumstances. Consequently, he ought not to interfere in such cases, until he has ascertained positively, by a proper delay, the absolute inefficiency of the natural forces. The child's death may also modify the precept above given in the trunk pre- sentations, since the cephalic version was only recommended because it is more advantageous for the infant; therefore, after its death, the pelvic version would be preferred as being less painful to the mother. § 2. What is to be done when the Degree of Contraction is such that the pelvis measures three and three-quarter inches at the most, and two and a half inches at the least, in its smallest dia- METER ? If the foetus dies before or during the labor, and the uterine contractions are ineffectually prolonged, we should, doubtless, prevent the dangers the mother might undergo from the delay, by resorting to embryotomy, and the application of the ordinary forceps, or even of the embryotomy forceps. Again, if when the accoucheur is summoned to the patient, the membranes have been ruptured for some time, and the waters are partially or wholly evacu- ated ; if the uterine contractions are exerted on the child's body alone, or re- peated attemps at extraction have been made without success; if, in a word, the child's life has been compromised, either by the length of the labor or the useless intervention of art, in all such cases it may be regarded, though still living, as non-viable, and embryotomy is considered by most modern accoucheurs to be the only proposable measure. We, ourselves, held this opinion for a long time, but being rather less fearful of the probable consequences of pelvic version in contractions of the pelvis, we now think, that so long as any chance remains in favor of the child, the latter operation should first be attempted. Craniotomy can always be had recourse to, if, after the disengagement of the trunk, it should be found impossible to extract the head. But where the degree of contraction alluded to is detected at the commence- ment of the labor, before the membranes are ruptured, and consequently at a time when there is no reason for supposing that the viability of the fcetus has been compromised, what ought to be done ? Following the example of 31. P. Dubois, we shall here admit a further sub- division into two classes, namely : one, where the pelvis has an extent of three and three-quarter inches at the most, and three inches at the least; and the other, where it has but three inches at the most, and two and a half inches at the least, in its smallest diameter. In the former case, after having waited for all that can reasonably be expected from the uterine contractions, the forceps are to be applied when the vertex pre- sents favorably, and if moderate tractions are found to be insufficient, the instru- ment should be withdrawn, and pelvic version attempted, in the hope of extract- DEFORMITIES OF THE PELVIS. 569 ing a living child. (See Art. Forceps, Appreciation.) Should this attempt prove fruitless, the contractions may be allowed to continue for an hour or two longer, and if these are ineffectual, the instrument is again to be had recourse to. If no favorable result follows this second application of the forceps, we are in the con- ditions above mentioned, and the life of the child being certainly compromised, we are authorized in preferring craniotomy to an operation which might prove disastrous to the mother; I allude to symphyseotomy or the Caesarean operation. But should the presentation of the vertex be an inclined one, or should the child present by the face, trunk, or breech, turning is to be preferred. (See Ap- preciation of the Forceps.) When the pelvic diameters afford but from two and three-quarters to three and a quarter inches, the indications to be fulfilled remain the same; but the difficulty experienced in executing the manoeuvres, leaves no alternative but a bloody operation. The various degrees of contraction, when ascertained long before the termina- tion of pregnancy, present new indications to the practitioner ; these, in fact, are the cases in which the induction of premature labor is to be resorted to. The recommendation to subject pregnant women with contracted pelves to a restricted diet and repeated bloodletting during gestation, applies also to the degree of narrowing under consideration, and more especially, to those cases in which the smallest diameter amounts to at least three and a quarter inches. The value of these two methods will be discussed hereafter. § 3. What is to be done when the Dimensions of the Pelvis are under two and a half inches ? If the child is living, we have, evidently, only to choose between the Caesarean operation and the mutilation of the fcetus, for its spontaneous or artificial expul- sion is here physically impossible. (See Caesarean Operation.) But if it is dead, or if, in consequence of the duration of the labor, and the repeated attempts at extraction which have been made, there is reason to believe that its viability is so compromised that it might be considered as incapable of surviving after its birth, the indications will vary according to the degree of contraction. Where, under these latter circumstances, the pelvis offers two inches at least in its smallest diameter, and it is yet possible to hope, that, by reducing the size of the parts by craniotomy, the delivery can be accomplished without subjecting the mother to any very serious dangers, the mutilation of the fcetus should be resolved on, and its extraction effected by aid of the embryotomy forceps. But when the diameters are less than two inches, we can no longer think of extracting the child by the natural passages; and the Caesarean operation is then alone ad- missible. The extraction of the base of the cranium, after the perforation of its vault, and the evacuation of its cavity, requires such numberless gropings and violent efforts, such repeated and grievous pressures and distensions, that the chances for the mother's safety after these painful attempts, which are sometimes made without any benefit, are not more favorable than those which follow the Caesarean operation. In our remarks, thus far, we have supposed that the child always presented by its cephalic extremity; but, in order to fill up the outline we have traced, it is 570 DYSTOCIA. now necessary to point out what must be done when the pelvic extremity pre- sents, the pelvis affording two and a half inches at the most. Under such cir- cumstances, the head still adhering to the trunk after the escape of the latter, or entirely separated from it by decapitation, may become arrested above the supe- rior strait. If, then, the least diameter of the pelvis amounts to two inches, craniotomy, and the application of the embryotomy forceps, will evidently be indicated. But if the contraction be still greater, it would be necessary, after having diminished the volume of the parts, and attempted in vain every effort at extraction compatible with the mother's safety,—it would be necessary, I repeat, to separate the head from the trunk, by dividing the neck, and to abandon its expulsion entirely to nature; for, notwithstanding aH the dangers to which the woman would then be exposed, this would be better than the Caesarean operation, performed after the almost total contraction of the womb. If nothing has hitherto been said concerning a faulty direction of the axis of the pelvis, it was only because, like Professor Naegele, we do not attach to this particular variety of defective conformation all the importance that Lobstein and many other accoucheurs have attributed to it. The degree of inclination of the superior and the inferior straits may depart widely from the figure before given as expressing the average normal condition. Thus, the plane of the abdominal strait may be so inclined downwards as to be sometimes quite vertical, as in a woman described by M. Naegele; while, at others, there is no inclination at all, being then almost horizontal; finally, the upper part of the symphysis .pubis may be more elevated than the sacro-vertebral angle, the plane being inclined from above downwards, and from before backwards, as in the case reported by M. Bello. (Transactions Medicates, t. xiii, p. 285.) The plane of the inferior strait may present the same irregularities of inclination; indeed, the direction of both straits is most frequently changed at the same time. But excepting some inconveniences which the woman suffers during gestation, that are more particularly dependent on the wrong direction of the uterus, whose displacement is often a consequence of the faulty direction of the axis of the superior strait, the puerperal functions are scarcely troubled by the anomaly men- tioned; for, although this abnormal direction of the pelvis has appeared in some few cases to present a serious obstacle to the delivery, it was only because it happened to coincide with a deformity of the bones, and a contraction of the cavity. The facts reported by Moreau and Bello, when carefully examined, fully confirm the second part of this proposition, while the first is proved by the curious observations of M. Naegele. CHAPTER II. OF MALFORMATIONS OF THE VULVA AND VAGINA. The malformations of the genital parts may be either congenital or accidental; but, as both offer very similar indications for treatment, I shall include them in the same description. In treating of these, we shall successively take up the MALFORMATIONS OF THE VULVA AND VAGINA. 571 congenital or accidental adhesion of the labia externa and interna; the persist- ence of the hymen; contraction and rigidity of the vulva; the partitions, bands, and cicatrices that may exist in the vagina; and the narrowness of this canal. §. 1. Adhesion of the Greater and the Lesser Labia. This may exist at birth, or it may result from some wound or ulceration, the healing up of which has not been properly attended to. Denman has remarked that this abnormal union is quite frequent in little girls, though it is rarely ob- served at the age of puberty, as the free and constant use made of their limbs, when they begin to walk, most probably causes a spontaneous separation. This union, when congenital, may be more or less complete, intimate, or resistant. When resulting from an accident, it is never perfect, because the frequent pas- sage of the urine prevents adhesion from taking place at the point corresponding to the meatus urinarius; and the discharge of the menstrual fluid, when the courses come on before the cicatrization is completed, likewise prevents the adhe- sion of the labia for a considerable extent. § 2. Persistence of the Hymen. The hymen may occasionally persist even after copulation, and thus consti- tute an obstacle to the expulsion of the child. The varieties of form it may exhibit under such circumstances were pointed out in the anatomical description of this membrane. A persistence of the hymen does not always prevent concep- tion, since most authors relate instances in which they were obliged to divide it at the time of labor in order to make a free passage for the child. They have even detailed examples of pregnant women, in whom a second hymen was found some distance above the first. Again, this membrane has persisted after the delivery, as*proved in a case observed by Meckel, Sr., and reported by Tolberg. A woman, after having expelled a fcetus of five months, surrounded by all its membranes, still preserved her hymen intact, circular, and tense. § 3. Contraction and Rigidity of the Vulva. The rigidity of the external parts of generation, which is frequently observed in women who do not become pregnant until an advanced period of life, as also in very young, muscular girls, who are somewhat fat and of a plethoric habit, often causes a considerable delay in the progress of the head during the first labor. Most commonly, however, this narrowness and natural rigidity give way, and the parts become distended; but this distension is not always so complete as the volume of the head demands; and then the latter, being urged on by the vio- lence of the uterine contractions, breaks down the resistance before it, and a laceration of the posterior vulvar commissure and of a more or less considerable portion of the perineum results. In certain cases, as elsewhere described, the contraction is vainly exerted for a long time against the resistance of the soft parts, and it becomes enfeebled or ceases altogether; the intervention of artificial measures is then indicated, at first to restore the contraction if possible, and after- wards to replace it by moderate tractions with the forceps. In cases of this nature, where the labor had been abandoned for too long a time to the resources of the organism, the fourchette, being too firm to yield, has 572 DYSTOCIA. been known to remain intact; while the perineum, distended beyond measure, and thereby rendered thinner, was perforated at its centre, and the child ex- pelled through an accidental opening, bounded in front by the posterior commis- sure of the vulva, and behind by the sphincter ani muscle. At the present day, this fact is well determined. But it may happen that the perineum is perforated at its middle, and yet, notwithstanding this accident, the foetus pass out through the natural passage: this is particularly apt to occur when the accoucheur's hand, being forcibly applied on these parts, endeavors to press back the head in its normal direction, and thus replace the accustomed resistance of the pelvic floor. Therefore, it does not follow that the child has escaped through the central lace- ration of the perineum, simply because such an opening is met with after the delivery. Even when every precaution is taken, there are, as we see, cases in which extreme smallness of the vulva, and rigidity of the soft parts, make it impossible for the head to be expelled without greater or less rupture of the perineum. In order to prevent it, Michaelis advised, in 1810, incision of the posterior commis- sure. The example of Eichelbery might, however, be followed, and the incision be made on one or both sides of the vulvar orifice. This operation should be performed only when the head is at the vulva, and rupture of the perineum seems imminent. The blade of Pott's bistoury is to be glided on its side between the head of the child and the margin of the vulva, and an effort made to limit the incision to the extent just necessary to allow the head to pass. Eichelbery mentions a rapid and safe cicatrization of the wound, in recommendation of this incision of the thickest part of the vulva. The contraction and rigidity of the external parts may likewise be owing either to abnormal bands, or to resistant and inextensible cicatrices, which have resulted in consequence of the wounds or lacerations that often occur in the course of slow or difficult labors.1 1 To the numerous examples recorded in the books, I may add the following from my own experience: In the beginning of January, 1838, while I performed the duties of Chef de Clinique at the hospital of the Faculte, a woman of about thirty years of age was brought there, who was pregnant for the second time, and had reached her full term. She had been in labor since the previousFriday evening, and it was then Sunday morning. The patient informed us that the membranes were ruptured on Saturday at eight, A. m., and that the head appeared to descend rapidly in the excavation, but was arrested in the pas- sage. The accoucheur in attendance called one of his brethren in consultation, and they attempted an application of the forceps at two o'clock in the afternoon, without any bene- fit. At eight in the evening, everything being in the same condition, they renewed the use of the instrument, which still proved ineffectual. They then waited until Sunday morning, and had the patient transported to the hospital. As Professor P. Dubois was absent on her arrival, I examined the woman, and found that the head had entered the excavation and was resting on the floor of the pelvis, the inferior strait of which appeared to be slightly contracted. A transverse band, about the thickness of a large goose-quill, and composed of a very hard and apparently cartilaginous tissue, existed at the posterior commissure of the vulva. (The woman then told us that her former labor could not be terminated without resorting to the forceps, and that a considerable laceration of the peri- neum had resulted in consequence of its use.) At every contraction, which, however, was feeble and infrequent, the child's head pressed strongly against this bridle, but the latter did not yield in the least; and for two hours, during which we watched the progress of the labor before taking any part, the head did not advance a single line ; besides, the vulva MALFORMATIONS OF THE VULVA AND VAGINA. 573 It must not be supposed that all women, in whom the fourchette had been destroyed in a former labor, and in whom the band resulting from the cica- trix had constituted the obstacle to delivery, are as fortunate as she whose history I have just given ; for sometimes a fresh laceration has occurred, and at others the resisting band has not yielded, and the child has been expelled through a central rupture of the perineum. , § 4. Resistance of the Perineum. It is not at all unusual, particularly in strong and muscular primiparae, and in those possessing a considerable embonpoint, to find the labor progressing very regularly at first, the head clearing the cervix and descending into the excava- tion as far as the pelvic floor, and then its further progress to be entirely arrested; the uterus struggles energetically for a time against this obstacle, but, notwith- standing the force of its efforts, the head may remain there for several hours without advancing a single line. This resistance on the part of the perineum is evidently owing either to an excessive contraction of the muscular fibres that enter into its composition, or else to the presence of so great a quantity of adipose tissue as to render this portion of the pelvic wall too inextensible to permit the escape of the head. But whatever may be the cause of the resistance, it affects the ulterior course of the labor in two widely different ways, which it is highly important to distin- guish in practice, for they require the employment of opposite means. For instance, it may happen that the uterine contraction, which was originally strong and energetic, is sustained in the same degree during several hours, but then, being overcome by the resistance which it cannot surmount, it grows weaker, is exhausted, and finally disappears altogether. The indications here are obvious : to endeavor to arouse the pains again, by making the patient walk about her chamber, by rubbing the abdomen or titillating the cervix uteri, and by adminis- tering the ergot; and, if all these prove ineffectual, to apply the forceps. But a very different case is occasionally met with, in which the contractions, so far from being exhausted, are kept up as strong and vigorous as at the commencement of the labor; and yet, notwithstanding their energy, they are incapable of effecting did not dilate, and the band remained as hard, resistant, and inelastic as ever. I was about to make an incision on the anterior commissure of the perineum; but a new examination of the parts having satisfied me that the lower strait was somewhat contracted, that the pains were very feeble, and consequently that the head's arrest might be dependent on these two circumstances, as well as upon the resistance of the band, I resolved to attempt a new application of the forceps. The head was then in an occipito-pubic position, or nearly so, though the occiput was still a little to the left; the blades were applied and locked without difficulty, but the first tractive efforts proved to be wholly abortive; after trying for a quarter of an hour, I succeeded in fairly engaging the head in the osseous strait; the posterior part of the perineum began to bulge out, though the commissure still resisted, and the pressure thus made on the soft parts seemed to arouse the uterine con- tractions, for the woman, from that moment, aided my efforts with all her powers. Under the conjoint influence of these two forces, the head constrained the vulva to dilate, the band gradually yielded, it became thinner and more distended, and finally, after three quarters of an hour of constant tractions and almost continual pains, the head succeeded in clearing the vulva. The perineum was well sustained by an assistant, and did not ex- hibit the smallest trace of a laceration. 574 DYSTOCIA. the dilatation of the soft parts in the perineum ; this proving an insurmountable resistance against, which the most powerful efforts are spent in vain. Here the accoucheur should evidently avoid the use of means calculated to arouse the contractions—the ergot in particular would be exceedingly dangerous— since the tetanic and irregular contractions that result from its use, and which have so often been followed by the death of the child, and even by a rupture of the womb that has almost uniformly proved fatal to the mother, are then particularly apt to occur. The uterus is certainly doing all that it can, and the physician should not attempt to arouse any more energetic contractions, but should rather aid its expulsive efforts by tractions carefully performed on the child ; and an application of the forceps is clearly the only resource. Our view of its particular mode of action in the case before us will be studied hereafter in the article on Forceps. Now, in order to illustrate this distinction, which we believe very important in practice, we will suppose two women in labor, in both of whom the child's head is properly situated, and has rested on the pelvic floor for six or seven hours ; but, in one of them, the contractions, that were at first strong and frequent, have gradually become more feeble and rare, or even have almost entirely disap- peared ; while, in the other, on the contrary, they still maintain all their original power. In the latter case, we would apply the forceps immediately ; whilst, in the former, we should first have recourse to the various measures calculated to restore the pains, and we would only resort to the forceps when these excitations had proved ineffectual, or the pains caused by the ergot still appeared to be insufficient. It is also important to remember that the life of the foetus may be greatly endangered by the ergotic contractions. These, therefore, should not be allowed to continue too long. If the head is not expelled after the lapse of half or three quarters of an hour from the commencement of the ergotic contractions, I should think it prudent to terminate the labor by the forceps. This inefficiency of the pains brought on by the ergot is not very unusual in the case before us ; but, even then, the administration of this article will have been useful, though an application of the forceps be afterwards deemed neces- sary ; because the instrument will then be applied under much more favorable conditions; for the contractions produced by the secale cornutum will aid the artificial tractions; and, moreover, will prevent the consecutive inertia of the womb, to which the woman would have been exposed, if the instrument had been applied without previously exciting its contractility of tissue. § 5. Malformations of the Vagina. This canal may be wanting altogether, or only in its upper half; we have already mentioned a case (page 86) in which the lower fourth only of the vagina was present. This malformation often coincides with an absence of the womb, but the care of the accoucheur in such' a case is evidently unnecessary. Again, it may be obliterated wholly or in part in one portion of its extent, either by the partial or the complete agglutination of its walls, or by actual par- titions, passing from one side to the other. This cohesion may be congenital, and the vagina exist as a dense, solid cord, not traversed by a canal, but, on the MALFORMATIONS OF THE VULVA AND VAGINA. 575 contrary, reduced to a simple cellular tract; or it may be accidental, resulting most usually from lacerations or lesions during former labors, or else from wounds or injuries. Thus, in the cause of a woman, reported by M. Lombart, of Geneva, who used a pint of sulphuric acid as an injection, with the culpable design of procuring an abortion, the bladder was found to be fused immediately into the rectum, the vagina having been destroyed at the corresponding part; and M. Cruveilhier has known the vulvo-uterine canal to terminate in a cul-de-sac, about an inch from the meatus urinarius, in consequence of vaginal injections made with a solution of corrosive sublimate. The partitions spoken of as existing in the vagina may be transverse or longi- tudinal ; and most of the cases of double or triple hymen mentioned by authors can probably be referred to the former. These may be complete, that is, they may divide this canal into two distinct cavities, though more frequently they exhibit a small opening through which the liquids ooze ;* or incomplete, only obliterating it in part; consequently, their form is very variable in different cases. Where the septa are longitudinal, at times they only divide the vagina in a part of its extent; but at others, they separate it throughout. In the latter case, the continuity of the partition may be interrupted at some part, and then the two canals which it forms will communicate through this opening. The septum, when complete, is occasionally prolonged into the uterus, which it like- wise divides into two cavities, although this does not always happen. The vagina may have been originally very small, or it may have undergone a remarkable diminution or contraction. This, in some cases, has been carried so far as scarcely to permit the introduction of the female catheter. M. Morean observed a young woman in the fourth or fifth month of her pregnancy, in whom this canal was so contracted that it barely admitted the barrel of an ordinary 1 In.the course of the year 1837, a young woman, who was advanced to the last month of gestation, presented herself at the clinic of the Faculty. When the vaginal touch was resorted to, the finger was arrested, at the depth of one inch and a half or two inches, by a perfectly smooth septum, in which it could detect no sensible opening. By a resort to the speculum, it became evident that the obstacle to the entrance of the finger consisted of a membrane, which adhered to the walls of the vagina, and completely blocked up its cavity at this point. Its surface appeared to be nearly an inch in diameter; and, by push- ing and distending it with the extremity of the instrument, a small opening was detected towards the upper third and right portion of this partition, through which a few drops of a sero-purulent liquid were oozing. The extremity of a blunt probe could scarcely be made to penetrate the little orifice, which was directed obliquely from below upwards, and from before backwards; the in- strument then entered a kind of posterior chamber, formed by the upper wall of the vagina. Thus far, no accident had impeded the course of the gestation, but some diffi- culty was thenceforth anticipated at the time of labor. This patient was taken during the night with pains, but they were so feeble that a commencement of the labor was not sus- pected; though about five o'clock in the morning very strong and frequent ones came on, which effected the expulsion of the foetus. The lying-in was very favorable, and two weeks afterwards I found that the septum had been split into three distinct pieces; one inferior and two superior. I have examined this woman several times since, and am satisfied that the flaps still remain isolated. 576 DYSTOCIA. writing quill. Such a disposition, which gives rise to much uneasiness, nearly always yields to the natural progress of the gestation.1 A^-ain, the vulvo-uterine canal may be deviated from its usual course, and present no natural openings at the parts of generation. The points at which it then terminates are very various; thus it has been known to open below the navel by two small orifices, separated from each other by a strong membrane, one of which gave passage to the urine, and the other to the menstrual fluids; frequently, it discharges into the rectum. Portal states that a young girl, in whose vulva there was only a small opening for the passage of the urine, and whose menses were always discharged by the anus, became pregnant; yet the small opening enlarged sufficiently during the latter stages of gestation, and more particularly during the travail, to permit a spontaneous termination of the labor. M. Rossi reports that, having been called to a woman in labor, he discovered a total absence of the external genital organs. At first, he supposed there was a retention of the menses, and, under this impression, made an incision about two inches long in the direction of the vagina; when, instead of the menstrual blood, he encountered a male child, which escaped through this opening, and lived but seven hours after its birth. Whilst searching where the fecundation could have taken place, he discovered, after having interrogated the husband, a small orifice, near the sphincter ani and at the internal part, which would scarcely admit a fine probe. The various obstacles just studied are most frequently surmounted by the efforts of nature alone; and, therefore, as a general rule, there is no necessity for an early resort to cutting instruments. If, however, it be deemed advisable to have recourse to an operation before the labor, for separating the agglutinated parts, incising the hymen, or for destroying an abnormal septum or vaginal ad- hesion, it would be better" to wait until the first four or five months of the gesta- tion has passed over; because, after this period, there would be less reason to fear the unfavorable influence which the shock caused by the operation might have over its progress. As the hymen and the vaginal septum are nearly always perforated by an opening, a director might be introduced into it, along which a bistoury should be passed, so as to incise the parts; where it is necessary to divide the adherent labia, we might use the scissors, as their agglutination is always incomplete; but, in all cases, the incision must be carried as low down as possible, so as to open a free passage for the lochia. When it is desirable to destroy the hymen or a septum, it is usually recommended to make a crucial incision, and even to excise the flaps to prevent them from afterwards reuniting. A similar plan would be resorted to, at the time of parturition, excepting that 1 Plenck states that, being summoned to a woman in labor, he found the vagina so con- tracted that the little finger could not be introduced at all. Nevertheless, this canal was sufficiently dilated by the end of eighteen hours, and the child's expulsion took place without producing any laceration of it or of the external genital parts. (Elementa artis Obstetrician, p. 113.) Merriman states that the labor terminated spontaneously in thirty-six hours, in a case where the introduction of the finger was barely possible; but the patient died on the third day, and a small laceration of the vagina was found at the post-mortem examination. 'Synopsis, p. 59.) TUMORS OF THE EXCAVATION. 577 the same importance does not attach to the excision of the flaps, as the dis- charges of the lochia would prevent their reunion. As to the bands and partial contractions found at some part or other of the canal, we should delay our operation, for they most generally become softened and ultimately permit the delivery to take place; in the contrary case, they must evidently be incised. Finally, an accidental and complete obliteration of the vulva, occurring during the course of gestation, would require the creation of a new passage for the head, as soon as the latter distends the perineum; and it is advisable to make the in- cision in the place usually occupied by the vulvar orifice. § 6. Inversion of the Vagina. An inversion of the vagina occasionally takes place during parturition; that is, the mucous membrane of this canal being pressed down by the child's head, and consequently being more or less inverted, forms a livid and fungous cushion of considerable size between the labia, or beyond the vulva, which opposes the passage of the head. The pressure made by this part on the inverted mem- brane, often gives rise to gangrene; and, therefore, with a view of preventing this unfortunate result, the forceps ought to be applied at once. The causes that predispose the patient to an inversion of the vagina, are, a long and difficult labor, a large head, and a marked relaxation of the mucous membrane. If this affection is detected before the head is engaged, the accident might be prevented by pushing up the membrane at the commencement of the labor, and maintain- ing it there until its close. CHAPTER III. OF TUMORS OF THE EXCAVATION. The tumors that may obstruct the excavation are extremely numerous and varied; and, where they have acquired a considerable volume, they constitute one of the most serious difficulties in the practice of midwifery. It will not be in our power, in this work, to enter into all the details which the importance of the subject demands; besides, all that relates to the etiology, the pathological anatomy, and the symptomatology of these tumors, rather belongs to surgery than to the obstetrical art; and we must confine ourselves more particularly to pointing out to the practitioner those signs by means of which their diagnosis is established, as also to bringing into view the different indications they present for treatment. It is proper to state at the outset, that, in compiling this article, we have freely extracted from the learned dissertation of M. Puchelt on this subject, whose classification we retain. The tumors, whose influence over parturition is about to claim our attention, may have their origin either in the walls of the canal which the fcetus has to traverse, and therefore appertain to the soft parts or to the osseous parietes, or they may be a dependency of the neighboring organs. 37 578 DYSTOCIA. ARTICLE I. vf TUMORS DEVELOPED IN THE BONY WALLS. The ossific tumors, large enough to constitute an obstacle to natural labor, are exostoses, osteo-sarcoma, and those that result from old and badly consolidated fractures. § 1. Exostosis. If we lay aside, says M. Danyau, all those cases in which an unusual promi- nence of the sacro-vertebral angle has been mistaken for a true ossific tumor, as well as those where there is an uncertainty with regard to their character, from the insufficiency of the details in the written account, there positively remain but two examples of exostosis, the authenticity of which is incontestable, namely, those reported by Leydig and Mackibbin. Though some doubts may still exist, as to the value of many assertions that have not been subsequently confirmed by the autopsy, yet, I do not believe that we can thus strike out, by a dash of the peu, most of the observations recorded in our science. For example, it would really be difficult not to admit the authenticity of the one reported by Gardien, since Duret preserved the pelvis of the female who was the subject of it for a long time in his cabinet. The facts reported by M. Puchelt prove that most pelvic exostoses arise from the anterior face of the sacrum. Nevertheless, several other points of the pelvis have likewise been their seat; thus they have been known to spring from the sacro-vertebral articulation, from the last lumbar vertebra, or the first bone of the sacrum, aud from the posterior face of the pubis, either from its middle part, or on one of the sides, as also from the internal face of one of the ischia. What has been stated respecting the uncertainty of the published observations, forewarns us of the difficulty that is at times experienced in diagnosticating the pelvic exostoses, and in distinguishing them from the various prominences caused by deformities of the pelvis. The hardness of the tumor, and its original ad- hesion to the osseous parietes, are given as characteristic signs; its unevenness and immobility are also important to be ascertained. Being always covered by the vaginal wall, it projects into the interior of this canal, by pressing aside the organs situated before it. When arising from the anterior face of the sacrum, it impinges on the posterior wall particularly; and, if the rectum be then explored, the latter will be found slightly pressed forward by the tumor, which i3 itself located behind. This last sign is very important, for nearly all the other tumors are situated in front of the gut. The prognosis is necessarily dependent on the size and situation of the tumor, and on the earlier or later period of gestation, at which the labor takes place. It is evidently more serious when the abnormal growth is very voluminous; when it is so placed as to diminish one of the small diameters of the straits, and when the child's head is very large. The indications for treatment, which were so fully described in studying the deformities of the pelvis, present themselves anew, and demand the employment of the same means, namely: to abandon the labor to nature when the tumor is TUMORS OF THE EXCAVATION. 579 small, and so situated as only to diminish the large diameters; or to apply the forceps, resort to symphyseotomy, to the Caesarean operation, or to embryotomy, according to the degree of contraction. (See page 562, et seq.) § 2. Of Osteo-sarcoma. Osteo-sarcoma of the pelvis is a very rare disease; two instances, however, are recorded, in which the contraction produced by it was extensive enough to re- quire the Caesarean operation. The tumor can scarcely be distinguished from that of exostosis, unless, per- haps, by the inequalities it presents, and more particularly by the depressibility, the semi-cartilaginous softness, and the crepitation that it may offer at certain portions of its surface. It is evident that this depressibility of the tumor will render the prognosis less serious than in cases of exostosis; since we may indulge a hope that the head being urged on by the uterine contractions, will flatten it down, and make it disappear in part. Consequently, it is here permissible to wait a longer time; but as soon as the inefficiency of the efforts of nature becomes apparent, we must resort at once to the same measures as in cases of pelvic contraction. § 3. Bony Tumors resulting from Deformities. Ossific protuberances in the pelvis may likewise depend on the irregular con- solidation of an old fracture in this part; or may be formed by the head of the femur, which, in consequence of coxalgia, has traversed the bottom of the carious and perforated acetabulum, and projects into the pelvic cavity. I recollect having read in a medical journal (which I cannot now find) an account of the Caesarean operation having been performed in a case where the sole obstacle to delivery was thus formed by the head of the thigh bone. A representation of a .fracture is given in the atlas of Professor Moreau, taken from the Musee Dupuytren, in which the bottom of the right cotyloid cavity has been driven in, the internal wall forming a rounded tumor that projects nearly an inch and a half inwards; the ilium was at the same time divided beyond the right sacro-iliac symphysis; but, in consolidating, the exterior part of the iliac fossa has been carried inwards in such a manner as to approach towards the sacrum, whereby the tumor formed by the cotyloid wall is brought near to the sacro-vertebral angle. The Journal des Progres, t. xv, 1828, contains another curious instance of a fracture of the pelvis, with a consecutive deformity in the excavation followed by mortal symptoms; this woman had previously had five fortunate deliveries. The Caesarean operation has frequently been performed for obstacles of this na- ture ; thus Burns, Lever, and Barlow have each reported a case of the kind. In conclusion, it is evident that, from whatever point the osseous tumors of the pelvis may arise, this cause of dystocia will still present the same indications for treatment. 580 DYSTOCIA. ARTICLE II. TUMORS APPERTAINING TO THE SOFT PARTS. The tumors appertaining to the soft parts may either be attached to the vulva or vagina, or they may arise from the neck and body of the uterus. Those which are seated in the vulva or the vagina are very variable in their character; thus we may enumerate an oedema of the labia externa, a thrombus of these parts, cysts, abscesses, fibrous tumors with or without pedicles, together with cancerous degenerations and vegetations of every kind; while those appertain- ing to the neck and body of the womb are caused by an induration of the os tincae, an elongation, hypertrophy, and tumefaction of the anterior lip, abscesses, cancers, or other degenerations with which they may be affected; or lastly, on polypous masses, arising from the cervix or body of the womb, and projecting into the excavation. § 1. (Edema of the Labia Externa. The ozdema of the greater labia, already alluded to, when treating of the complications of pregnancy, is sometimes so considerable at the time of labor as to obliterate the entrance of the vagina almost completely; and, by opposing the necessary distension of the vulva, it may render the parturition very difficult, as well as exceedingly painful. The child's head may produce a gangrene in the parts thus tumefied, by the pressure on them during its passage, or, at least, it may cause an extensive rupture. These accidents are to be prevented by making punctures with the lancet in all the swollen tissues; the number of the punc- tures will necessarily vary with the extent of the swollen parts, and the degree of their engorgement. § 2. Sanguineous Tumors, or Thrombus. The tissue that constitutes the lips of the vulva, and lines the entrance of the vagina, is composed of venules, arterioles, cellular filaments, and fatty masses, so interlaced and held together, that an effusion of blood there is almost always abundant; besides which, the stagnation of the fluids in the external genital parts, and the varicose state of the vaginal veins, so frequent in pregnant women, predispose all these organs to what is denominated thrombus. In fact, during gestation, and more particularly in the course of its latter months, these large veins are apt to give way, either spontaneously, or in consequence of some exter- nal violence, and the blood is extravasated into the cellular tissue, whereby a considerable tumor is developed; and, in the course of a variable period, gan- grene attacks the distended parts, and a hemorrhage, which is occasionally very profuse, and sometimes even fatal, takes place.1 Thrombus of the vulva does not appertain to pregnant women exclusively, since it may also appear in the non-gravid condition; indeed, according to Vel- 1 This accident was described quite accurately, in 1647, by Veslingius. "I have twice." says he, " witnessed an effusion of blood between the vaginal tunics, in cases of difficult labor. The labia presented a considerable tumor, which, when opened, discharged quite a large amount of blood." TUMORS OF THE EXCAVATION. 581 peau, it is even more frequent then than during gestation. However, it must be acknowledged that the obstruction to the circulation in the lower extremities caused by the development of the womb, must necessarily favor the production of this tumor; and, consequently, that, in the non-pregnant state, a thrombus of the vulva is far less dangerous than in the opposite condition. This tumefaction most generally affects the great labia, though it has also been observed in the lesser; in most cases a single lip only is involved, though at times there is a double tumor, caused by a simultaneous effusion into both of the labia externa. Wherefore, Boer was wrong in supposing that the right one was its exclusive seat, for it may appear indifferently on either side. It is rarely present in the earlier months of gestation, but is more frequent in the latter periods, and particularly so during the labor, or after the delivery. The most common causes of thrombus during pregnancy, are blows, falls, violent concussions, &c, &c. In some cases it can be traced to no external violence, and then the spontaneous rupture must evidently be referred to an excessive disten- sion of one of the vaginal veins. When occurring during labor, this affection is nearly always manifested just as the head or breech endeavors to clear the vulva, after having reached the inferior strait. The rupture of the veins is then cer- tainly caused by the distension, which they, like all the other parts, are subjected to (a distension to which they yield with more difficulty), and by the great accumulation of blood produced by the obstruction to the circulation from the presence of the child's head. Therefore, an excessive size of the latter, or its unusual delay at the inferior strait, a narrowing of the pelvis, and the consequent immoderate efforts on the part of the patient to overcome the resistance, are its most common causes. Certain authors have likewise supposed that the obliqui- ties of the womb, and the frequent rough examinations of the parts of genera- tion, might produce them; but it is evident that such circumstances cannot have the attributed effect, unless a varicose predisposition exists at the same time. Ordinarily, these tumors only appear after the delivery, when, indeed, they are the more dangerous ; first, because they may the more readily escape unperceived, and then, because the relaxation of the parts permits them to acquire a very con- siderable volume. The remark of M. Deneux should be borne in mind, that most of the cases of thrombus which are not detected until after delivery, really commence during the labor, or, at least that the rupture of the vessels, if not the effusion, takes place during the first expulsive pains. Often, indeed, when a vein is ruptured, it is so compressed by the head in the excavation as to prevent any effusion, a free escape of blood taking place only after the labor is terminated. It being rarely necessary to introduce the hand into the vagina after the delivery of the placenta, the tumor will not be discovered until it has become so large as to incommode the patient, or the physician is alarmed by the general symptoms of hemorrhage. Therefore, considerable time may elapse between the commencement of the acci- dent and its detection. Still another condition may postpone the appearance of the thrombus, namely, the stoppage of the small opening in the vein by a coagulum. Finally, it may happen, as supposed by M. Dubois, that the badly contused, and, perhaps, even mortified walls of the vessels, do not give way until when, at 582 DYSTOCIA. a later period, the part which has suffered the pressure becomes detached. The mucous membrane, being more extensible than the walls of the veins, recedes, so to speak, before the violence which affects the distended vessel, and is not. therefore, so much injured by it. Thus is explained the late effusion of the blood into the submucous cellular tissue, and the consequent formation of a tumor. Such, doubtless, is the usual way in which a thrombus is formed after delivery, the effusion only being consecutive to the expulsion of the fcetus. We can imagine, however, that the phenomena may take place differently; for, as the walls of the veins are often very much weakened, either by extreme distension or the stretching to which they are subjected during the labor, it is possible that a sudden movement, a violent inspiratory effort, or a fit of coughing, might sud- denly cause such an afflux of fluid into them, as to produce their spontaneous rupture even after the lapse of several hours from delivery. The development of a sanguineous tumor is generally announced by a severe pain in the affected part, caused, doubtless, by the rupture of some of its vessels; then one, or sometimes both of the greater labia, or, perhaps, only the nymphae, soon swells up, becomes rapidly distended, and forms a more or less voluminous tumor. This tumor may acquire a considerable size, and the quantity of effused blood be great enough to debilitate the patient, and, possibly, to produce syn- cope. In some instances it acquires its full volume at once, while in others it goes on augmenting for twenty-four hours; it may be limited to the external parts, or it may extend deeply into the pelvis, and, possibly, as far as the iliac fossag. In 1846, I had occasion to witness a case in which the effusion had extended much farther. The autopsy revealed a layer of coagulated blood between the muscles and peritoneum, spread over the whole lower half of the anterior walls of the abdomen on the right side. The layer was nearly a quarter of an inch thick, and extended from below upward to about two fingers' breadth below the umbilicus, besides occupying transversely the entire space between the linea alba and the crest of the ilium. At the latter point, the layer of blood was continuous with a clot about three- eighths of an inch thick, also situated beneath the peritoneum, and lining the entire iliac fossa. Below and inward, it turned over the edge of the superior strait, and was lost in a large collection of coagulated blood, which formed the tumor that during life had especially attracted our attention. The clot in this place was at least five-eighths of an inch thick at the centre, but it grew thinner ( as it spread out over the entire right side of the excavation : the remaining cel- lular tissue of the pelvis was highly colored by infiltrated blood. The disaster was not, however, limited to what we have described, for in as- cending, and separating the peritoneum upon the posterior and right lateral side of the abdomen, the coagulated blood was found to extend as far as the right hypochondrium, and to imbue the entire cellular tissue surrounding the kidney; it also passed between the folds of the peritoneum forming the origin of the mesentery, and finally extended to the attachments of the diaphragm to the false ribs of the right side, which connections seemed to have been the only barrier to its further progress. The thickness of this large coagulated layer varied from TUMORS OF THE EXCAVATION. 583 one to two-eighths of an inch. The total amount of effused blood was estimated at two pounds by those who witnessed the autopsy.1 Again, it not unfrequently happens that the effusion commences within the pelvis, and subsequently approaches the exterior. The tumor shortly assumes a violet or livid hue ; and when the thrombus is seated high up, this discoloration of the skin rarely permits it to be mistaken; when lower, and in the substance of the greater labia, on the contrary, it may neither be accompanied by ecchy- mosis, .pulsation, nor throbbing. Where the blood infiltrates into the meshes of the cellular tissue only, the tumor is hard ; but it becomes soft and fluctuating when this texture is torn, and there is an abnormal cavity formed. Again, it is not unusual for the skin, or mucous membrane covering it, to give way in con. sequence of being gradually rendered thinner; thereby giving vent to a consi- derable discharge of blood, with an instantaneous cessation of the pain; and this hemorrhage may be so profuse as to speedily terminate in death, especially if the tumor be voluminous, and the rupture occurs during the efforts of parturition. Cases have been known in which the rupture was followed by a projection of a jet of blood with such force and abundance, as to fall at a distance of several feet from the patient, and to be mistaken by the attendants for a rupture of the membranes, and discharge of a large amount of water. Whenever the nature of the accident was mistaken and the proper measures were not employed, the pa- tient succumbed in a few minutes. A copious bleeding has occasionally taken place during the formation of a thrombus. In fact, this circumstance may occur whenever the mucous mem- brane and one or more of the veins are lacerated at the same time. Should the two openings not correspond with each other, one part of the blood will escape into the vagina, and the other be infiltrated into the cellular tissue. Where the thrombus has acquired a considerable size, it may evidently impede the passage of the head, and after the delivery, that of the placenta and lochia. Madame Lachapelle relates a very curious instance, in which a thrombus, that had first commenced during the labor, underwent a rapid development after the child's expulsion. The tumor obstructed the vagina so much, that it prevented the escape of the lochia, whence the latter accumulated in the womb, and be- came, somewhat later, the source of a profuse hemorrhage. Fortunately, she continues, in the attempts to introduce my hand into the uterus, for the purpose of extracting the clotted blood, I ruptured the tumor involuntarily, near the entrance of the vagina, when a large quantity of coagulated blood immediately escaped, its size diminished, and all the attendant symptoms disappeared without any particular treatment. Finally, the pressure of the tumor on the neck of the bladder may cause re- tention of the urine and fecal matters. When the thrombus appears early in pregnancy and has been emptied by incision and the patient cured, it may reappear some time after and at the same place. A relapse of the kind is reported by Montgomery. The tumor, which showed itself in the left labium in the seventh month of gestation, caused so much pain as to induce the author to puncture and empty it on the 18th of June. 1 For the details of this case, see the Gazette Medico-Chirurgicale (February 28th, 1846). 584 DYSTOCIA. He was sent for again on the 13th of July, and discovered a much larger tumor than the preceding, and was again obliged to puncture it in order to relieve the patient. It did not return until the 24th of August, at which time the young woman was delivered. The diagnosis of these tumors is, in general, quite easy; for their sudden appearance, their rapid development, their hardness when the blood is simplv infiltrated, and fluctuation when it is collected in an abscess; the violent pains they give rise to, and the bluish discoloration of the skin, are always sufficient to detect them. Nevertheless, they have sometimes been confounded with certain other tumefactions, such as the simple varicose ones, an inversion of the vagina, the descent or inversion of the womb, and with the vaginal herniae formed either by the intestine, the omentum, or the bladder; but as we shall have occasion hereafter to treat of each of these tumors, and their peculiar signs, it seems use- less to enter here into their differential diagnosis. The prognosis is usually unfavorable; thus, "in sixty-two cases brought to my knowledge," says M. Deneux, "the mother died in twenty-two of them, either during the gestation, or else during or after delivery; and with the exception of a single instance, all the children of these twenty-two females were likewise lost. The profuse hemorhage is the most frequent cause of the patient's death, though the latter may also be occasioned by the gangrene and suppuration which often follow the primary symptoms. These tumors may terminate either by resolution, suppuration, rupture, or gangrene, but, as the progress of the disease exhibits nothing peculiar in any of those cases, we shall merely mention them in passing. The treatment of thrombus necessarily varies according to its size, and the sufferings thereby occasioned to the female, as also to the period at which it is manifested. If the patient be in labor when the tumor is developed, and the latter be large enough to seriously impede the passage of the head, the effused liquid should evidently be evacuated by a free incision, made on the most de- pendent part of the swelling, the extent of which must be proportioned to its volume. If this operation is performed some time before the head engages in the excavation, it would be advisable, after having emptied the sac, to make use of the tampon in order to prevent hemorrhage; but if, on the contrary, the tnmor is only opened when the head is fully engaged, the application of the tampon may be dispensed with, for the child's head will sufficiently compress the divided vessels to prevent a further discharge of blood. In the latter case, it would be requisite to attend to the precautions described below, after the delivery. The question is not, however, so easily decided when the thrombus appears during pregnancy or after delivery, and authors are far from being unanimous as respects the course to be pursued. To give greater precision to our therapeutic recommendation, we shall distinguish the cases in which it is necessary, 1, to incise immediately; 2, to incise at a later period; and, 3, to omit incision alto- gether. 1. When it is necessary to Incise immediately.—The tumor is sometimes so large as to fill a great part of the excavation, and seems capable of obstructing the discharge of the lochia. Careful examination then shows the skin or the mucous membrane covering its internal surface, to be so greatly thinned by dis- TUMORS OF THE EXCAVATION. 585 tension and to present so deep a violet hue that gangrene or spontaneous rupture seems likely to occur at any moment. On the other hand, the quantity of fluid effused, and the disorder which it necessarily produces in the cellular tissue in which it has formed a large cavity, renders its absorption very improbable; the evident fluctuation discoverable over the greater part of the tumor induces the reasonable belief that it does not contain a large clot, and that there is nothing, therefore, to prevent a continuance of the internal discharge. The patient ex- periences acute pain, and, lastly, her increasing weakness, the feebleness of pulse, pallor of the skin, &c, lead to the opinion that the disorder is not limited to the tumor of the excavation, but that in all probability the blood is making its way to the upper part of the abdomen. Under these circumstances, it would cer- tainly be nothing short of folly to depend upon the efforts of nature alone, and immediate incision appears to us indispensable. 2. Postponement of Incision.—If, however, the tumor is small, being no larger, for example, than an egg; if the walls are of considerable thickness and of a natural color; if it is but slightly painful, and does not appear to increase in size; if, from the coagulation of the effused fluid, fluctuation becomes more and more obscure; if, in a word, there is every reason to hope that the internal hemorrhage is not only arrested, but its recurrence rendered impossible through the compression of the ruptured vessels by the coagulum, I have no hesitation in believing that everything should be done to assist resolution, and, consequently, that the instrument should not be used, unless rendered necessary by certain accidents, which may occur under the circumstances. This method, I am aware, has both its advantages and disadvantages; still I regard the former as of greater importance than the latter. As advantages, I would mention: 1, the possibility of absorption, which we certainly have occa- sion frequently to observe as taking place with much larger effusions; 2, the rarity of consecutive hemorrhages. This latter point we shall discuss hereafter. The partisans of immediate incision reproach expectation with exposing the tumor to suppuration and gangrene, besides thinking that a late incision does not always protect against hemorrhage. Let us examine the worth of these objections. The attempt to bring about resolution does not dispense with the necessity of a careful oversight of the case: now, before becoming affected with gangrene, the walls of the tumor present to the attentive eye of the surgeon certain changes which forewarn him of the danger. On the other hand, when the blood, which, extravasated in the tissues, acts as a foreign body, and excites around it first an irritation and then an intense inflammation, suppuration does not take place without having been preceded by heat, redness, greater or less tension of the tumor, and more or less pain to the patient: now we can hardly expect the phy- sician to be so negligent as to allow all the phenomena of a suppurative inflam- mation to pass undiscovered. Therefore, as soon as the tumor, so far from progressing toward complete resolution, presents some of these preliminary symp- toms, it will be time enough to have recourse to the operation. But, would it not have been better to have practised it at once? Certainly not; for, indepen- dently of the chances of obtaining resolution, you have now the advantage of performing incision under circumstances the best calculated to prevent consecu- tive hemorrhage. 586 DYSTOCIA. Indeed, it seems to me undeniable, that, when the hemorrhage has ceased for several days, and the greater part of the blood is converted into a solid clot. which, either by direct compression, or by extending into the opening of the ruptured vessel shall have obliterated the latter, the cavity may be incised with- out probability of hemorrhage. I am acquainted with the observations relied on by M. Deneux and others, as showing that secondary hemorrhage is not an impossible occurrence; but, in my opinion, they are far from being conclusive against the opinion which I hold. If hemorrhage is ever to be feared as a consequence of opening sanguineous tumors of the vulva and vagina, I certainly maintain that it is especially so when practised immediately; for, as the rupture of the varicose veins is then recent, there is nothing to prevent the blood from flowing externally: the determination of blood to the parts, which may have contributed to the production of the rup- ture, still exists, and during pregnancy, the obstruction to the return of the circulating fluid by the large venous trunks, in consequence of the pressure of the uterus, highly developed as it is, and situated above the superior strait, is remarkably well calculated to produce venous hemorrhage. I am well aware that the tampon may be applied, as also that the partisans of immediate incision rely chiefly upon it; but whoever has used the tampon, knows what suffering it occa- sions when it has to be left in its. place for several days, and how difficult it is, notwithstanding all the means proposed for the purpose, to maintain a free dis- charge of the lochia. It appears to me that M. Velpeau, who treats the fears of some authors on the subject of hemorrhage as chimerical, has had reference rather to cases of throm- bus frequently witnessed by him in non-pregnant women, than to those which ■ appear in the puerperal state; for, according to him, there is no vessel in this region large enough to become a source of anxiety. This last proposition I esteem erroneous, if it be intended to apply to pregnant females; it is well known that the arteries and veins of the vagina share in the development of the entire generative apparatus, and all practitioners have felt the varicose veins projectiug beneath the vaginal mucous membrane during pregnancy, and also the pulsations of large arteries. The latter sensation is so evident as to have been styled, by Osiander, the vaginal pulse. Finally, it may be said that, by deferring the incision of the tumor, we incur the risk of an extension of the effusion, and a separation of the peritoneum over a large surface, all of which would have been avoided by providing a free exit externally. This, doubtless, is possible; but when we come to reflect upon the conditions by which we would limit the expectant method, and the attempts to obtain resolution, it will be seen that we are protected from any such danger. Besides, if it is necessary to apply the tampon after immediate incision, may not this have the same effect by obstructing the discharge of blood outwardly? Unfortunately, this is no hypothesis, for it is supported by one of M. Deneux's own observations. 3. The Omission of Incision altogether.—It is evident that whenever the means employed to assist nature in effecting resolution seem to affect favorably the size of the tumor, and its consistency, by which we mean its becoming more compact and solid, their employment should be continued, and cutting instru- ments abstained from. TUMORS OF THE EXCAVATION. 587 At whatever period the incision is practised, it is best not to insist upon the removal of all the clots; but, at the first dressing, to respect all that seem to adhere to the surrounding parts; for while their immediate detachment would risk a return of the hemorrhage, they would come away gradually at the subse- quent dressings. If necessary, their separation might be assisted by daily injections. Another question has reference to the part of the tumor to be operated upon. Most authors agree to make the incision external, that is, through the integu- ments ; for they find that the dressing is thereby rendered easier, that it does not require the introduction into the vagina of foreign bodies, which might ob- struct the discharge of the lochia, and that the wound is not subject to irritation from the uterine fluids. I would add that the cicatrix would be less dragged upon in future labors, and, therefore, less exposed to rupture when the external parts are greatly distended by the fcetal head. I therefore adopt the external incision, but upon one condition, namely, that it shall be possible, which is not always the case; for when the tumor is situated in the greater or lesser labia, it presents two surfaces, one mucous and the other cutaneous, and unless there exists a very thin and altered point,1 which of itself deprives the surgeon of the power of choosing, it may be incised either outwards or inwards. But the thrombus is not always situated so low down; in such cases, and I would recall the one the details of which I have already related, the tumor being altogether within the excavation, and limited outwardly by the bony walls of the pelvis, presents none other than a mucous surface to the instrument. Therefore, should incision be deemed necessary, it can then only be practised upon the wall of the vagina. I make this remark, because it forms, in my opinion, an additional reason for recommending late incisions. A large wound in the walls of the vagina is not, under ordinary circumstances, a serious affair; but, in the case of a newly-de- livered female, it would be attended with great inconvenience ; for, not to speak of the serious consequences which might result from the introduction of the uterine fluids into the cavity, it is evident that a dressing which should be at once sufficiently protective and suitable, and at the same time permit the free discharge of the lochia, would be of very difficult performance. When incision is decided upon, it should be practised freely; for a simple puncture would allow only the fluid blood to discharge, whilst clots of consider- able size would certainly be left in the cavity. A too small incision would have the same inconveniences, in part; therefore, the opening should be large, and made upon the part most favorable to the discharge of the fluids. Though the incision be every extensive at the moment it is practised, on account of the great distension of the integuments, it diminishes much by the retraction of the walls of the tumor after its contents are discharged. It will, besides, have the very great advantage of facilitating the extraction of the clots. After the incision and the partial evacuation of the clots, it is very common for inflammation to be set up in the cellular tissue in which the effusion had 1 It were useless to state that if the integuments upon any point of the tumor are ex- ceedingly thin, or affected with gangrene, the incision should be through the affected parts. 588 DYSTOCIA. taken place. This inflammation is to be opposed by the appropriate means; but, like M. Deneux, we should place in the first rank attentions to cleanliness, fre- quent washings, and injections, at first emollient, and afterwards containing a small amount of chlorine, to be thrown gently within the cavity. § 3. Sanguineous Tumors or Thrombus of the Lips of the Neck of the Uterus. We shall learn hereafter that the anterior lip of the cervix sometimes becomes considerably swelled during labor, and that the swelling may sometimes be occa- sioned by an infiltration of blood. This infiltration, which may become a mecha- nical obstacle to the expulsion of the head, is certainly the first degree of a much more serious accident; for the blood, which is merely infiltrated at the outset, may, by separating the meshes of the tissues of the neck, collect in a cavity, which, by opening afterward in the same way as the thrombus of the vulva, may give rise to mortal hemorrhage. A case of this kind was communicated to the Obstetrical Society of Dublin by Dr. Johnston, and its character was so remark- able as to justify our giving a short analysis of it. A woman, who had already given birth to six children, was delivered for the seventh time, after four hours of easy labor. The child presented by the breech. The after-birth came away without difficulty, and the patient was perfectly well for the first three days; about the fifth day, however, she was seized suddenly, and without apparent cause, with profuse flooding. The uterus was thoroughly contracted, and yet, notwithstanding the employ- ment of the most appropriate means, she died in about an hour and a half. All the abdominal and thoracic organs were found, at the autopsy, to be perfectly healthy. The uterus was well contracted, but upon the left side of its neck, at about an inch from its orifice, there was discovered a rupture, with irregular and blackened edges. This opening, which was large enough to permit the easy in- troduction of two fingers, conducted into a cavity formed in the substance of the neck, large enough to contain a small orange. Five or six open vessels, of a size sufficient to admit the introduction of a small bougie, were observed upon the internal surface of the cavity, and were proved by insufflation to commu- nicate with the uterine sinuses. "A careful examination of the specimen," says Mr. Montgomery, " convinced me that it was a case of thrombus, whose external envelope formed a thin layer of the uterine tissue, became gradually thinner, and finally ruptured. The fluid and coagulated blood escaped through the rupture, and th\e hemorrhage continued." (Dublin Quarterly Journal, 1851.) The thrombus is, in all probability, developed during labor, under the follow- ing circumstances. When the neck is half dilated and the waters discharged, the anterior lip is found to swell, thicken, project, and descend beneath the pre- senting part, usually the head, to the disengagement of which it sometimes pre- sents an insurmountable obstacle. An infiltration of blood, which may become converted into a sanguineous collection, is soon formed in the substance of the lip. The cavity increases in size, until its walls rupture and give rise to hemor- rhage. The discharge may then take place during the labor itself, though far more frequently it does not appear until some time after delivery. In the latter TUMORS OF THE EXCAVATION. 589 case, it is more likely to prove dangerous, as the complete retraction of the uterus makes it difficult for the accoucheur to divine the true cause. The introduction of a tampon into the vagina is certainly the most useful measure that can be employed. § 4. Various other Tumors. The other tumors met with on the external parts of generation, are cancers, phlegmons, cysts in the thickness of the labia externa, together with various ex- crescences and syphilitic vegetations. But whatever may be the nature of these tumors, the course of the practitioner is always the same; that is, to do nothing, so long as, by their size and character, they do not oppose the dilatation of the vulva; but, in the contrary case, to puncture the cysts, to open the abscesses, and to extirpate the vegetations or degenerated parts. As to the modus operandi in these cases, it is too simple to require a particular description. Prompt action is not requisite in cases of polypus, for, unless it be very large, it will seldom offer an insurmountable obstacle to the expulsory efforts of the womb; because, when adherent to the vagina, these abnormal growths are often pressed beyond the vulva. But if their size should be deemed too great to per- mit delivery, the tumor might be removed. In a case where M. Gensoul was obliged to apply the forceps, he seized the head and the fibrous body, whose pedicle adhered to the upper part of the vagina, at the same time, and brought them away together. The polypus weighed twenty-two ounces after it was extracted. § 5. Tumors appertaining to the Neck or Body of the Uterus. Besides the indurations, the oedematous swellings, and the cancerous degene- rations affecting the cervix uteri, which will be described in the following chapter, there are certain tumors, which, though filling up the excavation, really have their origin or seat in the proper tissue of the neck; others, that arise from the body of the womb, to which they still adhere by a long pedicle, are found hang- ing down in the lesser pelvis. A. Fibrous Tumors of the Cervix Uteri.—These tumors may be developed in the neck as well as in the tissue of the uterine walls. In a case described by Madame Lachapelle, the pelvic excavation was almost entirely occupied by a tumor that seemed enclosed in the lateral and posterior portions of the neck; it was as large, she states, as the head of a foetus at term, and would have been the more likely to deceive an inattentive person, from the fact of its presenting a depression similar to a fontanelle. The child was very small, and had been dead for a long time; so that, notwithstanding the size of the swelling, it was enabled to flatten it down and pass through the narrow passage that still remained free. Madame Boivin and M. Duges found; when making a post- mortem examination of a woman who died of peritonitis, after a very painful though natural labor, a fibrous body about the size of the fist in the substance of the neck; the child had a fractured cranium, and was stillborn. In another case of the kind, Ramsbotham was obliged to resort to embryotomy; but the woman recovered. M. Danyau reported to the Academy (1851) a case in which he was much • 590 DYSTOCIA. more fortunate, for he succeeded in enucleating a tumor of considerable size which had been developed in the posterior lip of the cervix. Encouraged by the idea that, although he might not be able to remove it altogether, he might, at least, extirpate a portion large enough to give passage to the fcetus, he deter- mined to operate, and was successful in bringing it away completely. The appearance of the tumor was precisely that of a fibrous tumor of the uterus; it weighed about twenty ounces, and its greatest diameter was six inches. AVhen enucleated completely, the tumor was drawn down, but could not be extracted until after it was divided into two parts. I was called, in February, 1853, to take charge of a young woman at term in her third pregnancy, and whose waters had been discharged four days previously. Upon practising the touch, I was astonished to find the excavation filled by a tumor apparently of the size of a full-grown fcetal head. At first, I was unable to discover the orifice of the womb, and it was only by carrying the finger very high up in front and to the left, that I succeeded in introducing the index into something like the finger of a glove, which appeared to me to be the cervix retaining its full length. Penetrating still deeper, I at last reached the internal orifice, above which I distinguished the foetal head. What, now, was the nature of the great tumor which had thus turned the neck aside, and prevented the effacement that it should have undergone during the last few weeks of gestation ? Where, also, was it situated ? My first hope was, that it would prove to be merely an exaggerated anterior obliquity of the neck, and I asked myself, whether what sometimes happens to the anterior lip, had not occurred in the present instance^o the posterior one, and whether the latter, forcibly depressed by the foetal head, did not alone form the tumor which filled the excavation. But the tumor had a peculiar consistence and an apparent fluctuation, by no means resembling the hardness of the head, besides which, the hypothesis did not explain the persistence of, and the increased length of the neck. A fresh examination induced me to conclude that a solid tumor had become developed in the substance of the neck. The waters had continued to discharge for the past four days without any pain, and I resolved to wait. The next day, the condition of things remaining the same, I requested M. Dubois to examine the patient. A long investigation induced M. Dubois to suppose that a cyst containing fluid had formed in one of the lips of the orifice, and therefore he recommended waiting, and finally puncture, if the tumor should appear to present an insur- mountable obstacle, after labor had continued for a certain time. At first I did not coincide with this diagnosis, but it also seemed tome wisest to wait for the pains. The latter appeared decidedly on the evening of the next day, five days after the membranes were ruptured; they continued all night with- out effecting any change either in the tumor, or in the situation or length of the neck. To clear up the diagnosis, I introduced the entire hand into the excava- tion, and grasping the whole tumor, I declared joyfully to my friend, M. Par- chappe, that I had been deceived, that M. Dubois was right, and that, most happily, we had to deal with a cyst. With a long trocar, of at least an eighth of an inch in diameter, I made a puncture, but, to my great surprise, nothing escaped. I endeavored to remove obstructions from the tube, if there were any, but in vain; nothing appeared. • TUMORS OF THE EXCAVATION. 591 My sensations were so decided, and so convinced was I that I had to deal with a cyst, that I had no hesitation in puncturing anew; but the same result fol- lowed, and I was obliged to relinquish the idea. M. Dubois being absent, I requested my professional brother and friend, M. Danyau, to assist me with his advice. I related to him all that had passed, and insisted especially upon the result of my two punctures, but notwithstanding all this, M. Danyau, after examining the patient, was convinced of the existence of a cyst. He made two successive punctures, but not a drop of fluid escaped. There was no avoiding the conclusion; it was not a cyst. What, then, was to be done ? We could no longer hear the pulsations of the foetal heart. After proving our incapacity of making an exact diagnosis of the nature of the tumor, we thought that its soft and apparently fungous character would enable us to incise it throughout its extent, and thus create a passage to the foetus, which we then might extract. The tumor was therefore divided into two lateral parts, and we were able to reach the head. The forceps were at first applied with much difficulty, but notwithstanding the diminution that the tumor had undergone, it obstructed the entire excavation and rendered the extraction of the head impossible. Craniotomy and the appli- cation of the cephalotribe forceps were equally unsuccessful. Blood flowed freely from the incised tumor, the patient was pale and pros- trated, and the uterine contractions became weaker and weaker. But a single feeble hope remained, namely, pelvic version. It was performed immediately, and the trunk of the fcetus, bringing with it the entire tumor externally, enabled us at last to extract rne child. The operation had lasted two hours, and the unfortunate lady was exhausted. Before extracting the placenta, ergot was administered, the uterus rubbed, and the after-birth was expelled almost spontaneously. Notwithstanding all our precautions, and the use of all kinds of tonics and stimulants, some blood still escaped from the womb, which in a patient already exhausted by the hemorrhage from the operation, was sufficient to cause a fatal termination. She died about half an hour after her delivery. The autopsy showed that the tumor, which was larger than the head of a child at term, had formed in the anterior lip of the cervix. By its weight, which was considerable, it had during life so twisted the neck around, as to bring the pos- terior lip in front, which explains the situation of the orifice, as the seat of the tumor accounts for the persistence of the length of the neck, notwithstanding the progress of gestation. The tumor was constituted of a soft and spongy tissue, resembling rarified placental tissue, the meshes of which circumscribed numerous cavities, in which no fluid was to be found. No abnormal element could be discovered by the most careful examination, no newly-formed pathological product; it was simply an enormous hypertrophy of the tissue of the neck. Such was the opinion of several professors who examined the specimen at the School of Medicine. There is every reason to believe that this tumor was developed during the last pregnancy, for, eighteen months before this last delivery, I attended her on account of a miscarriage, and did not at that time detect any anomaly either of structure or form affecting the neck. * 592 DYSTOCIA. These examples show what may be feared or hoped for in such cases. Thus, we should wait when the tumor is very small and so situated as to correspond with one of the large diameters of the pelvis, or extirpate it, if the bistoury can reach it without danger, which seldom happens; on the other hand, where its size no longer permits us to attempt the extraction of a living infant, to resort to embryotomy; and, if the excavation is completely obstructed, to open a passage for the child by the Caesarean operation. b. The polypous, or pediculated fibrous tumors that arise from the body or neck of the womb are seldom very serious; for, when their size appears to constitute an insurmountable obstacle to the delivery, an extirpation of them is nearly always feasible. As a general rule their diagnosis is readily made out, though several singular errors on this head are recorded by authors; for example, Dr. Merriman relates a case in which an experienced physician mistook a polypus for the head of a child; and Smellie furni&hes two similar instances; consequently, we must not trust to a superficial examination. The influence of uterine polypi over the progress of labor will be modified by a number of circumstances; thus, when the tumor is small, it may be compressed against one of the walls of the excavation by the child's head, and the latter then passes before it; or, where the pedicle is very long, the fibrous mass is pushed by the head entirely out of the vulva, and therefore only retards the foetal expulsion in a slight degree. This occurred in a case reported by Dr. F. IT. Ramsbotham; who says, " I was summoned to a woman in labor, and found a tumor of the size of a goose's egg hanging in the vagina.* " I had no difficulty in determining it to be a polypus, whose pedicle was at- tached to the internal wall of the organ above the neck. Dilatation took place rapidly, and the membranes ruptured; then, in less than an hour, the head, urged on by powerful contractions, forced the body of the polypus outside of the vulva and became disengaged." (Obstetric. Med. and Surg., p. 237.) After having consulted with his father, whether it was advisable to remove the polypus at once, the ques- tion was determined in the negative. In many cases, therefore, we may trust to the re- sources of the organism, remembering, at the same time, that too great a delay is not without danger both to the mother and child; and, where the inefficiency of the uterine contractions has been fully ascertained, a divi- sion of the pedicle appears to us to be the only resource. If the subsequent extraction of the tumor is rendered very difficult by its volume, it might be cut up into several pieces, as I have seen done on two occasions, or be firmly grasped with a small serrated forceps. Pelvic version, which is recommended by some authors, could be performed in those cases only in which the length of the pedicle gives great mobility to the tumor, and allows it to be pushed above the superior strait. It is un- necessary to add that, if the existence of this tumor in the canal be ascertained This figure, taken from Ramsbotham's work, shows the situation of the polypus described by him. TUMORS OF THE EXCAVATION. 593 during the latter months of gestation, it should be excised immediately, if it be of a sufficient size to render the parturition difficult or tedious. C. Fungous, or Cauliflower Tumors, &c.—These tumors, which resemble a cauliflower in their appearance, may arise from either lip of the womb ; and then by acquiring a considerable size, they mask the orifice and render it nearly in- accessible. As they often give rise to hemorrhage, and as the spongy tissue that constitutes them has some analogy with the placental structure, they have occa- sionally been mistaken for a placenta praevia. Both Madame Lachapelle and Denman relate errors of this character ; and I witnessed the following still more singular case. The internes of the Hospital de l'Oursine sent for M. Nelaton, who was surgeon to the establishment, to turn in a supposed case of hand pre- sentation. M. Nelaton desired me to accompany him; and, on our arrival, we ascertained that these young gentlemen had mistaken an enormous cauliflower excrescence, that sprung from the anterior lip of the cervix uteri, for the hand; its pedicle was at least an inch and a half long, and its base presented five or six little vegetations that had been mistaken for the fingers. It frequently happens that these tumors are small enough to admit of the child's spontaneous delivery; indeed, such was the fact in the case just men- tioned ; but there are many others where the accoucheur is less fortunate. Take, for instance, the seven cases reported by Puchelt; in one of which it was neces- sary to make incisions upon another part of the hard and scirrhous neck, so as to secure the introduction of the hand, and in a second, to remove the tumor, that was 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 was saved; in another, the extraction of the child was im- possible, notwithstanding the perforation of the cranium, and the woman died before delivery. Only a single mother survived. D. Encysted tumors, adhering to the cervix uteri, or to the vaginal walls, may also exist in the excavation. As a general rule, they are rounded, well-defined, movable, elastic, yielding a little under a moderate pressure, and sometimes fluctuating; the mucous membrane covering them remains unaltered. A small puncture, in the way of exploration, will always dissipate any doubts concerning their true nature, especially if containing a liquid; and where they enclose a solid, cheesy, or fatty matter, some portions of it will adhere to the canula. An attempt should be made to push the tumor above the superior strait, before the head becomes engaged; and the membranes must be ruptured early, so as to determine the engagement of the fcetus. In the opposite case, it will be requisite to evacuate the liquid by a simple puncture, or even to make an in- cision large enough to allow the contents to be pressed out. ARTICLE III. OF TUMORS IN THE NEIGHBORING PARTS. These are very variable, both in character and location; and may appertain either to the ovary, the Fallopian tube, the rectum, the bladder, or to the cellular tissue of the pelvis. 38 594 DYSTOCIA. § 1. Tumors of the Ovary. This organ may be affected with a number of diseases, nearly all of which have the effect of singularly augmenting its volume; thus cysts, distended with solid or liquid matters, are frequently observed there, and abscesses have also been met with; or this body itself may become hypertrophied, or be affected with scirrhous or encephaloid cancer. But we shall not treat of these latter affections, further than to examine the influence they may have over the puer- peral functions. In this respect, it is highly important to ascertain the exact seat of the tumor; for sometimes the diseased ovary remains in the abdominal cavity above the superior strait; and, again, it is very often displaced, and falls into the pelvic excavation. In the former case it may, doubtless, obstruct the development of the uterus, 'by its bulk, and thus bring on a premature labor; or it may produce an obliquity of the womb by pressing the latter to the opposite side, and thus prove a source of dystocia; but it particularly claims the attention of the accoucheur when situated in the lesser pelvis ; for it may then so obstruct the passages, that a natural delivery of the child becomes wholly impossible. The tumors, constituted by the displaced ovary, nearly always fall down into the cul-de-sac, formed by the peritoneum, it being reflected from the posterior surface of the uterus to the anterior one of the rectum. In a single case only, reported by Jackson, has it been found behind the rectum, which latter was then pressed forward. This singular anomaly merits attention. The ovarian tumors vary greatly, both in their volume and form—from the size of a small orange up to that of a child's head; sometimes they only occupy a part of the excavation, while, at others, they fill it up so completely that the finger can scarcely be introduced between them and the pelvic walls. It is im- portant in practice to ascertain these differences of size and location, and equally so to detect the nature of the tumor, and the kind of material that forms it. In some cases of ovarian dropsy, the fluctuation is so evident that no possible doubt can exist concerning its character, but, in others, this sensation is not so clearly recognized; though here the smooth and polished surface of the tumor, and its rounded form, compared with the irregularities, and the nodules exhibited by cancerous degenerations of this organ, will facilitate the diagnosis. The density of the fluid tumor, its elastic resistance and fluctuation, are singularly modified during the contraction; because, being then strongly compressed by the child's head, the sac, that was at first soft and yielding, becomes hard, tense, and resis- tant; consequently, it is advisable to examine both during and after the pain, for the differences then presented will likewise aid in making out the diagnosis. The exploration should be made both by the vagina and rectum, singe this is the best method of distinguishing the enlargements of the ovary from those belong- ing to the uterus or the vagina. This double exploration only admits of their being confounded with the tumors existing in the recto-vaginal septum; but this error would be of little consequence, since the two cases present the same indi- cations for treatment. The presence of such tumors is always a very unfavorable complication of the labor; but the prognosis will necessarily vary with their volume, seat, nature, and mobility, as also according to the period at which the physician is summoned. TUMORS of THE EXCAVATION. 595 Thus, in thirty-one cases recorded by Puchelt, fifteen were fatal to the mother and twenty-three to the child. Twenty-one children and one woman died during the labor. As regards the treatment, the same course is not always to be pursued in the cases under consideration. There is evidently nothing to be done where the size and locality of the tumor afford a well-grounded hope of a spontaneous delivery; but when it is movable, and the head has not yet engaged, it is recommended to attempt to press up the former above the abdominal strait; and, should the tumor still have a tendency to fall back, after having been carried up, it ought to be supported, while the feet are sought after, or an application of the forceps is resorted to. But, in some grave cases, the engagement of the head or the adhesions of the tumor render a return of the latter impossible; here it is particularly important to be certain of its nature; and if the signs above indicated have not proved sufficient to settle the diagnosis, a puncture should be made in it, which would determine the question of its fluidity or solidity. If it proves to be an ovarian dropsy, it is to be evacuated by a trocar somewhat larger than the one used for the exploratory puncture; but if the cyst be multilocular, or if it contain a cheesy matter that cannot escape through the canula of the trocar, a free incision will evidently be requisite. By allowing the fluid to escape, the incision would have the double advantage of facilitating the labor when the tumor is very large, and of preventing conse- cutive inflammation of the cyst, when the latter, though too small absolutely to prevent the expulsion of the foetus, is yet large enough to delay it greatly. Under the latter circumstances, indeed, the compression it undergoes during labor may excite in it a violent inflammation, and, in some cases, even produce a rupture. As a consequence of this rupture, the fluid may be discharged externally through a perforation of the vagina, or be effused into the cavity of the peritoneum. The incision or the puncture is usually made by the vagina, as the evacuation of its contents is more easily effected through this canal. Some persons, how- ever, fearing lest an incision made through the vaginal wall might become enlarged at the moment of the passage of the head, have recommended the introduction of the instrument through the rectum; and although this mode of operating ought, in general, to be rejected, it should certainly be followed in those cases in which the tumor is located between the posterior part of the rectum and the anterior surface of the sacrum. Again, the tumor is solid, it cannot be pushed up, and its size is so great as to render an extraction of the fcetus altogether impossible. The case is then most serious, and we have only to choose between an extirpation of the tumor, or a resort to embryotomy or to the Caesarean operation. Under such circumstances, if it were possible to ascertain that the abnormal growth had not contracted inti- mate adhesions to the neighboring parts, I would willingly adopt the views of Merriman, who recommends its extirpation; but if this latter be deemed im- practicable, a mutilation of the child might be resorted to, when there is room enough between the tumor and the pelvic wall to afford a passage to the fcetus grasped by the embryotomy forceps; otherwise, the Caesarean operation seems to be the only resource. 596 DYSTOCIA. The following summary, which will serve to illustrate the danger of the opera- tions just recommended, is extracted'from M. Puchelt's statistics: In five eases, where the delivery was abandoned to the resources of the organism, four of the mothers died, and but two children were born living. The simple pushing up of the tumor was only followed up by the safety of both individuals in a single instance, while in another case the infant was stillborn. Version was performed twice, after having previously pushed up the tumor, but this double operation was only once successful for the woman; the child, though born living, died immediately afterwards; but in the other, both mother and child perished. A simple puncture of the tumor was attended with success in one case, though in two others it did not obviate the necessity for embryotomy, and both women died. The incision of the mass, which was practised in three instances, was favorable to both individuals in a single case only, while in the other two the children perished; in a fourth, version was effected after the incision, but both mother and child were lost; the same result attended the application of the forceps in one case; a perforation of the cranium was found necessary in six, and only three of the women recovered; and, finally, both parties survived in those in- stances where the blunt hook could be employed. § 2. Tumors appertaining to the Fallopian Tube. As the tumors of the tube are much more rare than those of the ovary, they very seldom constitute a mechanical obstacle to the delivery. In fact, only one case of the kind is on record, that related by Chambry of Boulaye, in the old Journal de Medecine, Chirurgie, et Pharmacie. It appeared as a round, hard, irregular, and partly osseous tumor, the true seat of which was subsequently as- certained by the post-mortem examination. If a similar case should be met with, it would offer the same indications for treatment as the ovarian tumors. § 3. Tumors of the Rectum. a. Fecal matters may accumulate and harden in the rectum, and give rise to unpleasant symptoms, which sometimes simulate a regular disease of the intes- tine ; and if such an accumulation takes place towards the end of pregnancy, it may render delivery difficult, or even impossible, by obstructing the passages the fcetus has to traverse. In several of the reported cases, injections could not be made, and laxatives given by the mouth proved ineffectual. For instance, Guillemot says, "We were constrained, before delivering her, to extract all the excrements which distended the said large bowel;" and Lauverjat likewise re- marks, " I introduced my finger into the vagina, and pressed on the matters, with the view of diminishing their solidity; I then gave two injections, which soon emptied the intestine; the pains, which had been completely suspended for six hours, reappeared, and the labor was terminated in less than fifteen minutes." Under like circumstances, I know of nothing better than to follow the example of these practitioners. A curious case, in many respects, is reported by Fournier, who says: "I was sent for by three surgical students, who had been ineffectually attempting to de- liver a woman for five days. Having ascertained, on my arrival, that she was costive, and had not had a passage for a week, I immediately directed an injec- TUMORS OF THE EXCAVATION. 597 tion. The student, charged with this duty, endeavored in vain to find the anus; and, on going to his aid, I discovered that it was imperforate, and that no vestige whatever of an orifice remained; but, instead, a line similar to the raphe extended from the coccyx to the vulva. I introduced my finger into the vagina, where I found the rectum floating, and as it was filled with excrement, compress- ing the womb, the canula was introduced there, and the injection penetrated into the intestine, from whence a prodigious quantity of cherry-stones, mixed up with fecal matters, came away at once; and after this evacuation, I terminated the labor." (Diet. Sci. Med., torn, iv., p. 155. Cas rares.) B. Scirrhus.—Dr. Lever relates having met with a case where the labor was rendered difficult by the presence of a cancerous tumor situated three inches above the anus. But such tumors rarely acquire a large size, and the applica- tion of the forceps would nearly always prove sufficient to overcome the obstacle. § 4. Tumors of the Bladder. The tumors in the pelvic cavity, dependent on the bladder, may be caused either by a procidentia vesicae, a cancer of this organ, or a urinary calculus. In addition to which, we have elsewhere spoken of the unfavorable influence that an excessive distension of the bladder might have over the puerperal functions. A. Procidentia Vesica- (Falling of the Bladder).—Under this title, certain authors have described an inconsiderable displacement of the bladder, but which does not the less constitute a true hernia of the organ; and we shall, therefore, refer our remarks on this subject to the article in which hernial tumors are treated of in detail. B. Cancer of the Bladder.—Puchelt extracts one case of this disease from Herteufer, and Dr. Lever reports another; both of which would seem to prove that the vesical walls, when attacked by cancer, may form a tumor in the exca- vation large enough to obstruct the course of parturition. As to its treatment, this tumor evidently presents the same indications as all the other solid ones before describe'd. C. Urinary Calculi.—Instances of a stone in the bladder descending into the excavation, and thereby obstructing the free passage of the head, are not very unusual. The numerous cases of the kind on record prove that they are always situated below the head, or else are placed between it and the symphysis pubis. In a single instance only, reported by Lauverjat, the calculus was above the pelvis, though, as M. Velpeau remarks, it is difficult to understand how it could then arrest the expulsion of the foetus. Calculi vary very much in their size, and the same is true of their shape, which fact modifies the prognosis. The diagnosis is not always an easy matter, though, if the tumor felt behind the symphysis pubis is hard, circumscribed, and gives rise to pain when pressed upon by the finger or the child's head, if it is situated without the vagina, and if it is firmly fixed during the con- traction, but is movable during the relaxation of the womb, there is every rea- son to suspect the existence of a calculus; which suspicions would naturally lead us to the use of the catheter, whereby the foreign body can nearly always be detected. 598 DYSTOCIA. Treatment.—An attempt should be made to press up the stone above the superior strait, before or even during the labor, and prior to the engagement of the head; or, if the latter is still movable—although it may be. engaged—it should be raised up from the strait, and the calculus be pushed above it. But, unfortunately, it is not always possible to do this, either because the head has descended too far to be pressed back (the stone being below it), or because this latter is forcibly wedged in between it and the symphysis. In such cases, an extraction of the calculus seems to be the only resource; however, this need not be attempted at once, for some of the reported facts would seem to prove that its spontaneous expulsion may take place, even where its great size might preclude all hope of such an event, as occurred in the following case reported by Smellie' The wife of a coal-porter, who had long been suffering from the presence of a stone in the bladder, became pregnant. The midwife, summoned at the time of labor, was surprised to find a hard resistant body lying before the head, but, as the means of the patient did not admit of her sending for a physician in consul- tation, the midwife could only keep up the spirits of her patient during the long and painful parturition. At last, she felt something coming away, which proved to be a stone about the size and shape of a goose's gizzard, and which weighed from five to six ounces. Immediately after its escape, the child was expelled and the woman recovered in due time, but she afterwards suffered from inconti- nence of urine. Some surgeons have been encouraged, probably by facts of this kind, to attempt an extraction of the calculus through the previously-dilated urethra; but this operation requires too much time to admit of being performed during the progress of parturition. If there should be no hope of succeeding by the forceps or pelvic version, on account of its large size, it would be necessary to resort to the operation of vaginal lithotomy, and incise the urethra directly on the stone through the anterior vaginal wall. § 5. Of Tumors developed in the Cellular Tissue of the Pelvis. We have yet to treat of the fatty, the fibrous, and the cancerous masses, and of the abscesses, or encysted tumors, that may be developed in the cellular tissue of the lesser pelvis, nearly all of which are situated in the substance of the recto- vaginal septum, though they are occasionally found on the sides of the vagina. In one instance, reported by Ed. Meier, the delivery was rendered impossible by the existence of a cyst, about the size of a child's head, between the uterus and the bladder. The steatomatous and cancerous tumors are usually found in con- tact with the osseous or ligamentous walls of the pelvis, to which they seem to appertain. It must be apparent that there is an identity of nature and seat between the tumors of the cellular tissue and those of the ovary ; the reducibility of the one, when non-adherent, and the irreducibility of the others, constitute the only marked difference between the two. Consequently, the diagnosis is not easily made out after the engagement of the head, or when the ovarian tumor is re- tained in place by old adhesions; but, fortunately, that would be an error of little importance, since both present the same indications for treatment. It is more easy to distinguish the tumors of the cellular tissue from those appertaining to the organs before spoken of, and we refer to the signs already given, as charac- teristic of each of them. TUMORS OF THE EXCAVATION. 599 The reader will understand that the prognosis varies according to the size, nature, density, and seat of the tumors. When small, compressible, and situated in the direction of one of the long pelvic diameters, it will most frequently per- mit a spontaneous termination of the labor; and this may also take place, if, not- withstanding its hardness and size, it still retains a certain degree of mobility. Even in those cases where it is impossible to push it above the superior strait, we may still hope that, being forcibly compressed by the child's head, it will permit the latter to pass. During my sojourn at the Clinique, I saw a woman, in whom the child's head was arrested at the superior strait for a long time, by a tumor, which was probably fibrous in its character, and was situated in front of and on a level with the sacro-iliac symphysis. An application of the forceps had been seriously thought of, but the tumor, located in the recto-vaginal septum, was gradually forced down by the head, under "the influence of strong contrac- tions, as far as the floor of the pelvis, where it was pressed backward, at the same time distending the perineum, and the labor terminated by the birth of a living child. In many cases, the volume and permanence of these tumors do not permit us to anticipate so happy a result, and it will then be necessary to interpose. The indications to be fulfilled will vary according to the particular case ; that is, where an abscess or an encysted tumor is detected, it is to be punctured, so as to eva- cuate the liquid, or it is to be incised when the contents cannot be removed by a simple puncture; but where the tumor is solid, is easily accessible, and has contracted no intimate adhesions with the vagina or rectum, it ought to be extirpated. Two modes of operating have been recommended for this purpose ; in the one, the vaginal wall only is incised, while in the other the tumor is reached by making an opening in the perineum. The success obtained by Drew and Burns pleads in favor of the latter procedure. In the worst cases, where the situation of the tumor, or the numerous and firm adhesions which it has formed, render its extirpation impracticable, our only resources are in the obstetrical manipulations, properly so called; namely the application of the forceps, or tractions on the feet, if the tumor is not very large, and the Caesarean operation, or embryotomy, if the excavation be so obstructed that the extraction of a living child is impossible. § 6. Of Hernial Tumors. A considerable portion of the intestine, omentum, or bladder, may become engaged in one of the culs-de-sac formed by the peritoneum, in being reflected from the bladder to the womb, and from the latter to the rectum, and thus con- stitute a true vaginal hernia. But when the parts that are displaced and engaged between the rectum and the vagina descend still more, and cause a prominence in the perineum, the term perineal hernia is applied. Under the title of vagino-labial hernia, a tumor has been described, which is situated in the substance of the labia, or in the lowest and most projecting part of the fold which it forms with the skin. A. Intestinal or Omental Hernia.—The seat of a vaginal enterocele, or epiplo- cele, is sometimes between the vagina and bladder, but oftener between the rec- tum and posterior wall of the vulvo-uterine canal, and always on one side of 600 DYSTOCIA. it, in consequence of the vaginal adhesions both behind and in front. The mis- placed organ forms a tumor there which is very variable in its size, and which either presents the clammy softness of epiplocele, or the elasticity and rumbling of an enterocele. Though easily recognized, these tumors have, in some in- stances, given rise to serious mistakes, which might have proved disastrous to the patient. I was summoned, says Levret, to a case of this kind, where the question was actually discussed whether a large portion of the tumor should be removed or not; but I demonstrated, in a satisfactory manner, that some part of the in- testine had slipped down into the substance of the septum, through the bottom of the cul-de-sac that is found between the neck of the womb and the upper part of the rectum. (Levret, Abus des regies.) The prognosis is unfavorable, not only from the obstacle thereby created to the expulsion of the child, but also from the pressure of the head on the hernial sac; because an inflammation, that is always serious, and which might sometimes even terminate in gangrene, may result in consequence. All authors have, therefore, recommended the reduction of the hernia as soon as possible. To accomplish this, it is better to place the woman on her knees and elbows, so as to facilitate the return of the intestine and the engagement of the head; this position was followed by the happiest results in the case above reported. In another instance, Stubbs, by compressing the hernial tumor, succeeded in redu- cing it, and the head then engaged. In my estimation, the taxis should be pre- ferred to Levret's method, taking care to sustain the head at the same time with the other hand, if the hernia be voluminous. Where the reduction is impossible, it is necessary to terminate the labor as soon as possible by the aid of the forceps, or by turning. B. Vulvar or Perineal Hernia.—We may be allowed to speak in this place of vulvar or perineal hernias, which, although they do not present a mechanical obstacle to parturition, may give rise to special indications during pregnancy and labor. These tumors, which are situated in the lowest and most posterior part of the greater labia, may be formed by the escape of a loop of intestine, and sometimes of a portion of the bladder. They have been oftener observed during pregnancy than at any other period, and may ultimately acquire a very con- siderable size. Papus mentions having dissected one which had the form of a large bottle, hanging to the right of the anus, and descending as far as the leg. In one of the cases observed by Smellie, the tumor, which toward the end of gestation was as large as the fist, became strangulated and gangrenous. The seat of the tumor, which is always situated in the lower part of the greater labia, between the edge of the anus and the tuberosity of the ischium, the ease with which it is reduced in the horizontal position, and its sudden re- appearance when the patient rises or makes the least exertion, serve to indicate its nature. Enterocele may be distinguished from cystocele by the gurgling which accompanies the reduction of the former. The latter often diminishes in size after urinating, or using the catheter, and desires to urinate are produced by pressing upon the tumor. It is evident that the exertions of labor have a tendency to increase the size of the hernia greatly, and even to produce strangulation. It should be kept reduced by pressure properly applied. TUMORS OF THE EXCAVATION. 601 c. Vesical Hernia, or Cystocele.—It sometimes happens during labor that the fundus of the bladder descends below the head, and constitutes a tumor of vari- able size at the anterior superior part of the vagina; the descent being probably caused by the pressure made by the child's head or the inferior part of the womb, on the fundus of this organ. The patient has a feeling of weight or fulness in the pelvis, and a dragging sensation about the um- bilicus ; she has a constant desire to urinate, without the power of emptying her bladder, though, some- times, each uterine contraction is followed by the emission of a small quantity of urine; besides which, a more or less oval tumor, that is smooth, soft, and fluctuating between the pains, but hard and tense whilst they last, is detected by the touch at the upper front part of the vagina; and above this the head can often be distinguished; indeed, the finger may easily vaginal cystocele, taken from slip behind the tumor, and reach the cervix uteri; but Ramsbotham. it cannot pass between the former and the pubic symphysis. The tumor formed by a cystocele is occasionally quite large. Madame Lacha- pelle says, "The first thing that attracted our attention was a pediculated tumor, about the size of an egg, which projected a little from the vulva, and seemed to be attached to the right anterior wall of the vagina near its middle. The pedicle was about an inch and a half in thickness, and the tumor contained a liquid, all of which could be pressed back through the pedicle; an opening with a thick margin was then detected, which appeared to communicate with the bladder. In fact, according to the woman's account, the tumor augmented in size in the erect position, though it often disappeared after the emission of urine, and always when using the cold bath. The uterine pains increased the size of the hernia, and the head in descending compressed, and rendered it very tense; after having emptied the bladder, I reduced it, and recommended the students to support it with two fingers during each contraction of the womb. The head soon cleared the passage, sustaining the hernia itself, and the labor terminated favorably." The tumor is nearly always seated at the anterior part of the vagina; but, in a case reported by Sandiford, it was located between this canal and the rectum. There is one variety of tumor, formed in the pelvic cavity, which is the more worthy of attention, as its true nature might be misunderstood from its singular situation. It depends on a lateral displacement of the bladder, and M. Christian assigns to it the following characters, namely, a remarkable fulness on one side of the pelvis, more especially during the uterine contractions, which give to the tumor an evident elasticity and tension; it is generally circumscribed, though its base is somewhat spread out, and extends along the side of the pelvis as far as the sacrum; its volume varies, of course, with the quantity of fluid contained in the sac, occasionally equalling one-third of the transverse diameter of the pelvis. The tumefaction completely disappears after the use of the catheter; and, by directing the concavity of the instrument downwards, its point can be felt through 602 DYSTOCIA. the walls, and can readily be moved from before backwards in a horizontal direc- tion. As the tumor is covered by the vagina, and its base is diffuse, there is no danger of mistaking it for. the bag of waters, since it does not prevent the finger from reaching the uterine orifice. Cystocele may sometimes be removed by pressure, and almost always by the catheter; its size will vary with the extent of displacement, and with the quantity of urine contained in it. Cases of this kind merit serious attention, for they may be confounded with other tumors ; and such an error of diagnosis might lead to the performance of a useless and perhaps dangerous operation. Dr. Merriman (Synopsis, page 202) speaks of a surgeon, who, supposing he had to treat a case of hydrocephalic head, thrust a sharp instrument into the bladder; and a similar mistake, according to Hamilton, was committed by another practitioner, who imagined he was opening the bag of waters. In all these obscure cases, a resort to the catheter is the best possible means of diagnosis; nevertheless, it must be observed, that, for this measure to be conclu- sive, it should be done in such a manner as to plunge the beak of the instrument into the liquid contained in the cavity of the tumor; that, is, after the instrument has once entered, it should be turned over, so as to make its concavity look down- wards and backwards. As a remedy, this is the only one requisite, and the instrument ought to be left in the bladder until after the head is engaged. Unfortunately, its introduction is not always an easy matter, particularly where the head has been wedged in the pelvis for a long time; under such circum- stances, an attempt should be made to press up the former during the intervals; but if this is impracticable, and there is reason to fear a rupture of the bladder from its over distension, I know of no other resource than to puncture the organ with a very delicate trocar. CHAPTER IV. OBSTACLES PRESENTED BY THE NECK AND BODY OF THE UTERUS. ARTICLE I. OBSTACLES DEPENDENT ON THE NECK. The obstacles to delivery which the cervix uteri may present, are due either to a rigidity or spasmodic contraction of the orifice, or to its obliquity, to an agglutination or complete obliteration of the lips, or to a scirrhous or other dege- neration of its tissue. § 1. Rigidity of the Neck. Under certain circumstances, the fibres of the uterine neck seem to possess an extraordinary degree of resistance; and although they have none of the charac- ters we are about to indicate as appertaining to an inflammatory or spasmodic contraction, yet their dilatation is not effected. According to Dewees, this resis- OBSTACLES PRESENTED BY THE UTERUS. 603 tance of the cervix uteri is particularly apt to be met with in very young girls, or in middle-aged women in their first labors, and also in those cases in which par- turition takes place prematurely. There is one symptom that would lead us to suspect rigidity of the os uteri, even before an examination; we allude to what is ordinarily termed the pains in the loins. These have always appeared to Madame Lachapelle to be a conse- quence of the rigidity of the external orifice, either from its experiencing a kind of cramp, or that, because of its having to sustain the whole force of the uterine contraction in consequence of its firmness, it suffers more than when soft and yielding. Prolonged baths, employed from the beginning of the labor, and bleeding from the arm, if not contra-indicated by the general condition of the patient, are the only measures which need be used under these circumstances. However, as this extreme slowness appears from the beginning of the labor, that is to say, at a period in which the membranes are still intact, the life of the fcetus is by no means endangered thereby, and its only effect is to fatigue the mother greatly. Therefore, unless some dangerous complication should super- vene, there is nothing to do but recommend patience. Still, if the labor should be extremely prolonged, and, by its duration, seem likely to endanger the life of the mother, it would be right to make a few incisions upon the lateral parts of the cervix. § 2. Spasmodic Contraction of the Neck. Again, it may happen, that after having attained a considerable degree of dila- tation, the cervix becomes affected with spasmodic contraction, whereby its subsequent expansion is retarded, or suspended altogether for several hours. The orifice then presents a thin, cutting edge, and is warmer, drier, and more sensitive to pressure of the finger; in short, is much more irritable than usual. This condition, which has been designated as spasmodic contraction of the external orifice, may be confounded with the simple rigidity just spoken of, and with the natural retraction of the neck, when the presenting part of the child does not engage in its opening immediately after the rupture of the membranes. In the latter case, however, the thick, soft, and easily dilatable edges of the orifice will always enable us to avoid error. In the former case, the diagnosis is often more difficult if all the phenomena of the labor have not been watched, and the extreme sensibility of the neck, which is not generally met with in rigidity, will be the only evidence that we have a case of spasmodic contraction to deal with.1 This state of spasm does not generally last for a great while; but so long as it exists, the dilatation is extremely slow, and sometimes hardly takes place at all. Usually, however, the efforts of the body of the womb overcome the resistance at last, and the head of the foetus clears the orifice; but, in some cases, it happens that being no longer supported, the neck retracts immediately, and grasps the neck of the foetus more or less forcibly, so that a new dilatation is required to 1 Rigidity is a passive force, by which the fibres of the orifice resist the dilatation they have to undergo. Spasmodic contraction is an active force, by which the fibres contract and diminish the size of the opening previously exhibited by the mouth of the womb. 604 DYSTOCIA. allow the shoulders to pass; nor is this second dilatation as easy as might be expected. This spasm of the external orifice may be met with in strong and plethoric women, but also in lymphatic, nervous, and very irritable individuals, of a pale and relaxed fibre. In the former case, general bleeding is one of the first mea- sures to be had recourse to, but in the latter it might prove hurtful. Under both circumstances, however, recourse may be had with advantage to emollient injections, fumigations, baths, and the administration of laudanum by clysters, or, preferably, the application'of belladonna to the uterine neck itself. Chaus- sier, who has particularly recommended the use of this latter remedy, was in the habit of using an ointment prepared by mixing and triturating one drachm of the extract or juice of belladonna with an ounce of lard. But as the application of this ointment is quite difficult, Professor P. Dubois prefers the ordinary dry extract. He places a little pellet of it, about the size of a pea, on the nail of the index finger, which latter is then carried up to the cervix, where, in the course of a few minutes, the heat and moisture of the parts soften the extract, which is then readily smeared over the external and internal surfaces of the neck. The belladonna, so highly lauded by some accoucheurs, is by others thought to be useless. It seems to me that this difference in opinion has arisen from confounding simple rigidity with spasmodic contraction. Though without action in the former case, I think it very useful in the latter. If all these measures prove unsuccessful, or if an accident, which endangers the life of the mother or child, should demand a prompt termination of the labor, the accoucheur will have to choose between a forcible introduction of the hand and multiple incisions upon the neck. (See Difficulties of Pelvic Version.) But it is not the external orifice alone which may retard the delivery of the fcetus by retracting on its neck, for very often the internal one, or rather that portion of the uterine walls which corresponded to it in the non-gravid state, retracts forcibly on the neck of the child, even before the head has cleared the external orifice; so that the latter, being retained in the portion of the organ that appertains to the neck after delivery, can advance no further. This inter- nal contraction only takes place where the waters have escaped for some time, and it evidently results, as Dewees has remarked, from the double tendency of the womb to regain its primitive form, and to accommodate itself to the shape of the parts contained within its cavity. There is every reason to suspect that the delay in the progress of the head is dependent on this cause, when, notwithstanding the energy of the pains and the absence of all other sources of dystocia, it is found to make no advance at all, or, even if it approaches the vulvar orifice during the contraction, it returns to its primitive position immediately afterwards. Besides which, if the finger is slipped above the head, the latter will be found free in the excavation; but one of the orifices (the internal one, most usually) will be strongly retracted around the neck. Bleeding, general bathing, and laudanum injections may be employed use- fully under these circumstances also, though it sometimes happens that the con- OBSTACLES PRESENTED BY THE UTERUS. 605 traction of the internal orifice persists notwithstanding. Under these circum- stances, should version be judged necessary, the most serious difficulty may be anticipated in passing the hand through the retracted part; and if the application of the forceps be deemed requisite, as it would be if the head were already engaged, but delayed by the retraction of the internal orifice, this latter circum- stance, by arresting the shoulders, would render the delivery impossible. It is then we must have recourse to the measures so much vaunted, and so often em- ployed by Dewees with success, namely: to bleeding in the arm, pushed ad deli- quium animi. But, in order to avoid drawing too'great a quantity of blood, the patient should be directed to stand up, if possible, and, as soon as fainting occurs, she is to be replaced on the bed; when, according to the American accoucheur, the relaxation in the retracted orifice, produced by the syncope, will be such that the pelvic version, or the extraction of the head by the forceps, can always be performed. Finally, in those cases where the woman's general condition does not permit a resort to bloodletting, we may employ the opiates in a full dose, either by the mouth or by injection, with great advantage. The reader will also understand that, in a natural labor by the pelvis, the retraction of one of these orifices may likewise arrest the head. Under such circumstances, if the source of difficulty is confined to the external one, nume- rous incisions might be made in the ring of the'os uteri; but, if it is at the internal orifice, Dewees's plan should certainly be followed. It is likewise impor- tant to ascertain, at once, whether the child is still living; for though it be diffi- cult to admit that a strangulation of the fcetus can occur from direct pressure, yet it is not the less true that the umbilical cord, from being nearly always com- pressed in these unfortunate cases, exposes the child to a speedy death; and, if the infant is already lost, we may employ, beneficially, either belladonna, or the opiates internally, according to the orifice retracted. In cases of this kind, the use of anaesthetics might prove serviceable, by pro- ducing relaxation of the partial spasm of the uterine fibres. § 3. Obliquity of the Orifice. In consequence of the usual direction of the uterus, the neck is slightly turned downward and backward. This posterior obliquity may, in some cases, be much greater, whilst in others, the orifice may be directed strongly forward, or toward one of the sides of the pelvis. When treating hereafter of malpositions of the body of the womb, we shall have occasion to speak of the effect of re- troversions and lateral obliquities upon the direction of the neck. We would treat at present of the posterior obliquity of the orifice, which is by far the most frequent. The posterior obliquity of the neck may be due to an extreme anteversion of the body of the organ, though it may also be very well marked, even when the fundus of the womb projects no farther forward than usual. This deviation of the orifice may also take place during labor; but it may also exist in the latter stages of pregnancy. In the former case, the obliquity is due to the fact that the dilatation of the orifice is effected more at the expense of the posterior than of the anterior lip, and, consequently, the plane of this opening would naturally be found, in most 606 DYSTOCIA. cases, behind the long axis of the organ. Wherefore, this irregular dilatation may, independently of any deviation in the fundus, produce such an obliquity of the neck, that the plane of its orifice, instead of being horizontal, has very nearly a vertical direction ; that is, the opening looks directly towards the anterior face of the sacrum, its anterior margin has become inferior, and its posterior one is now the superior. When existing before the commencement of labor, its mode of production is altogether different. We know that in vertex presentations the head of the foetus engages in the excavation in the latter months, pressing the lower part of the uterus before it. Now, in the normal direction of this organ, it is evident that the head must press more especially upon the portion anterior to the orifice, which anterior portion it must carry before it. Hence, it is plain the external orifice of the neck must necessarily be situated altogether posterior to the projection formed by the head in the lesser pelvis. But, whatever may be the manner and time of its production, its effect upon the progress of the labor is always the same. Consequently, when the child's head is urged on by the uterine contractions, it presses the anterior inferior wall of the uterus before it, and thereby evidently retards the delivery. In fact, the dilatation of the neck must necessarily be very slow and imperfect; besides, the expulsive efforts are spent against the anterior part of the cervix, which part, corresponding to the void in the pelvis, and being distended by the head, is sometimes forced down nearly to the vulva, and threatened with a rupture. Most generally, there is time for rectifying this unfavorable situation of the cer- vix ; nevertheless, the patient must remain in bed as much as possible; for it is very apparent that, in the erect position, the body of the womb constantly aug- ments this posterior obliquity in the neck by being carried forwards. The termination of the labor may also be facilitated by placing the orifice in its natural position with the finger; this is done, during the interval, by hooking the anterior lip, and carefully bringing it to the centre of the vagina, and then sustaining it in this position until a new contraction comes on; when the head is forcibly pressed down and engages in the opening, and no longer permits the lip to regain its abnormal position. The labor is sometimes speedily terminated after this little manoeuvre. It occasionally happens that the cervix uteri is well dilated, though not as yet sufficiently so to permit the parietal protuberances to traverse it; and this con- dition of things lasts for a considerable period, notwithstanding the long and acute sufferings of the patient. In such cases, the engagement of the head may be singularly facilitated by making a slight pressure on all the periphery of the orifice with the extremity of the index finger. Again, the dilatation may often be completed and the head be down in the excavation, but, notwithstanding the expulsory efforts of the womb, it is retained there by the anterior lip of the neck, which is pressed before it; the head can- not overcome the resistance thus made by the band formed by the anterior lip, and several hours may elapse without any advance in the progress of the labor. When this happens, the following course should be adopted in order to promote a prompt engagement at the inferior strait: taking advantage of an interval, the accoucheur hooks the anterior lip with his finger and draws it towards the sym- physis pubis, where it is retained until the pain comes on ; then the extremity of OBSTACLES PRESENTED BY THE UTERUS. 607 the finger, placed under this portion of the neck, pushes it above the descending part of the head, until it gets beyond the occipital boss; when the occiput is found to engage almost immediately in the pubic arch, and the labor terminates two or three hours sooner than it would have done without this little manipula- tion. It is occasionally necessary to repeat these attempts several times; but as they are attended with no inconvenience, when properly performed, they may be renewed without fear. We will add, that the most favorable period for this pur- pose, is that when the head, after having reached the pelvic floor, is on the point of clearing the inferior strait; provided the pains are energetic, and the cervix uteri is sufficiently dilated to permit the passage, if the axis of its orifice were parallel to the axis of the head. § 4. Agglutination of the External Uterine Orifice. This is a very rare complication, and but few examples of it are reported in the books; though, perhaps, as M. Nasgele remarks, from whom I extract the following details, this rarity is owing to the fact, that the various degrees of agglutination have escaped the notice of the physician; the powers of nature alone triumphing over the accident in most cases. Its existence may be suspected when the inferior uterine segment descends low down in the excavation at the commencement of the labor, and presents no trace of an orifice; or when the latter presents as a fold or a hollow, which is slightly depressed at its centre, and very often not corresponding to the pelvic axis. The middle of this little depression is usually occupied by a filamentous web, some fleshy tissue, and a cellular network, in the centre of which a small narrow opening is found; sometimes the lips are held together by a consistent mucus. As the contractions become more energetic, the lower segment of the womb is forced into the excavation, and becomes so thin that, at the first explo- ration, the finger appears to be separated from the head by the membranes alone ; but, notwithstanding the strength of the pains, the uterine orifice is not only tightly closed, but even seems to ascend somewhat, and to be carried towards one side. The orifice may open spontaneously under the pressure of the ener- getic contractions; but if it resists, and the accoucheur does not early recognize the source of the difficulty, a rupture of the womb, or a paralysis of it, which is not less dangerous, might result in consequence. The question arises, what is the nature of this agglutination ? It has probably followed an inflammation of the cervix uteri, and the upper part of the vagina; since the pseudo-membranous or fibrous tissue that composes it, is similar, says Naegele, to that substance which serves as the bond of union between the pla- centa and womb, or that uniting the pleura pulmonalis to the pleura costalis, or the intestines with each other and with the abdominal wall, when an inflamma- tion of these parts terminates by adhesion. In a case where a woman died during labor, the adhesion of the neck was found, at the post-mortem examination, to be so resistant that it could neither be lacerated nor broken by any moderate force, and the membrane that blocked it up was of an aponeurotic character. The precise period at which its formation commences cannot be determined. In a woman who presented this peculiarity during labor, the orifice was patulous six weeks before her delivery. 608 DYSTOCIA. The agglutination of the orifice has been remedied in most cases without much difficulty, the membrane having been easily ruptured either by the finger or some blunt instrument, and the operation has generally been followed by the loss of only a few drops of blood. The index finger should be preferred to everything else, for if this is not sufficient to break down the obstacle, we can expect but little aid from an instrument. It is really difficult to understand how this agglutination, which almost always yields to the pressure of the finger, can resist the impetus of the strong contractions of the womb. § 5. Swelling and Elongation of the Anterior Lip. It is not at all unusual to find the head descending in the excavation long before the complete dilatation of the os uteri, whereby the anterior lip is neces- sarily compressed between the former and the symphysis pubis. As a general rule, this compression, and the consequent pain, disappear on the prompt termi- nation of the labor; but if the latter be prolonged, and especially if the pelvis scarcely reaches its normal dimensions, the compression is very severe, a consi- derable tumefaction will result in that part of the anterior lip found below the constricted point. Duclos, of Toulouse, has met with three instances of this kind, two of which were in the same woman; M. Naegele has published another, Dr. Leve» two more, and M. Danyau one, making seven in all. M. Blot men- tions a case in which the tumor formed by the anterior lip was an inch and a quarter thick, and forced down to the vulva. The labor had to be terminated by the forceps. The following case is one of those reported by Duclos: A woman, thirty-four years of age, who was in labor with her fifth child, was suddenly attacked, after twenty-four hours of moderate pains, by acute sufferings, which called forth loud cries; an elongated body appeared between the lips of the vulva, and its appari- tion was accompanied by a slight hemorrhage, pallor, and feebleness. On his arrival, he found a cylindrical tumor projecting four fingers' breadth beyond the parts; it was two inches broad near the vulva, and was irregular, resistant, and of a wine-like color. After a careful examination, he ascertained that it was formed by the elongated and tumefied anterior lip of the cervix. He first thought of applying the forceps on the child's head, but afterwards concluded to aid its delivery by drawing on the occiput, and operating on the forehead by means of the index finger previously introduced into the rectum. In the cases observed by Naegele and Danyau, as also in one of the women reported by Lever, the labor terminated spontaneously. There is, therefore, nothing to be done in most instances; though if the tumor be of a large size, very tense and black, and apparently threatened with gangrene, the example of the English surgeon, just named, might be followed; that is, to make a number of punctures, for the purpose of evacuating the infiltrated liquids and diminishing its volume. On the whole, then, I may remark, with M. Danyau, that this species of tume- faction can scarcely be considered as a mechanical obstacle to the delivery; and that the unusual length of the labor must rather be attributed to the extreme pain it occasions, and to the disorder and irregularity of the uterine contraction caused thereby. The cases recently mentioned by M. Montgomery under the name of thrombus OBSTACLES PRESENTED BY THE UTERUS. 609 of the lips of the cervix, and which we have already noticed (see page 588), are evidently instances of this affection. The observations of the Irish accoucheur appear to us similar to those just mentioned. As regards the prognosis, how- ever, it is important to distinguish simple infiltration from a true effusion. M. Montgomery thinks that this condition of things might be mistaken for a case of insertion of the placenta upon the neck, the tissue of the infiltrated lip bearing considerable resemblance to the placental tissue. Still, as he observes, it may always be readily ascertained that the tumor is not only applied to the internal surface of the womb, but that it is also situated in the substance of the latter. The finger can never be made to penetrate between the tumor and the internal surface of the uterus. § 6. Abscesses in the Lips of the Cervix Uteri. Genuine abscesses are occasionally developed in the substance of the lips of the os tincae, which, independently of the unfavorable influence they may have over the gestation, must necessarily disturb the regular progress of the labor; because, where they invade a considerable portion of the neck, its dilatation is thereby rendered very slow and very painful; besides which, their size may be so great as to retard the passage of the head. The reader will find in Bonet (Sepulchretum, vol. ii, lib. iii, sect. 38, Obs. 2) the history of a woman, who died without having been delivered, after five or six days of suffering, in whom a large abscess, filled with putrid pus, and occupying the neck of the womb, was found at the post-mortem examination. If the presence of fluctuation should establish the diagnosis, the proper course would evidently be to incise the tumor. § 7. Induration, with Hypertrophy of the Cervix Uteri. This affection is more frequently observed in the anterior than the posterior lip, though it may affect both; but, in no case has the volume of the indurated part been great enough to impede, mechanically, the expulsion of the child; but the alteration very often retards the dilatation, and sometimes even renders it impossible. Venesection and tepid bathing may be resorted to with advantage. Certain English practitioners highly extol the use of tartar emetic, given in nau- seating doses, but I have not had an opportunity of testing its efficacy. If these means prove ineffectual, or if some more grave complication requires the prompt termination of the labor, we might have recourse to repeated incisions made on the neck of the womb. § 8. Of the Cancerous Neck. Like all the organs of the economy, the cervix uteri may be affected with scirrhus, or may form an encephaloid tumor; and when this does take place the prognosis is very unfavorable, both for the mother and child. For example, of twenty-seven females reported by Puchelt, five died during the labor, nine shortly after the delivery, and but ten recovered; the fate of the other three is not stated. However, if the disease is still in its firststage; if the patient's general condition is not seriously altered; and especially if the malady has made but little progress, or the tumor is small, the danger is not so imminent, and the 39 610 DYSTOCIA. expulsion of the child may then take place regularly. But, even where the delivery is effected spontaneously, its influence over the subsequent progress of the tumor is not the less disastrous; for the pressure to which the diseased part is exposed seems, in most cases, to hasten its development; and, whether the labor be terminated naturally or by the recourses of art, its progress afterwards is much more rapid. The child, likewise, is very often lost in the cases under consideration; thus, of the twenty-seven women above cited, fifteen were delivered of a stillborn child, and ten only of a living infant; nothing is said of the fate of the other two. The indications for treatment, when the cervix uteri is affected with cancer, will necessarily vary, according to the seat and size of the tumor ; for, if it is not very voluminous, or if it is located on the posterior lip, or the pelvis be of large dimensions, there is every reason for hoping that the efforts of nature will prove adequate to the dilatation, and the expulsion of the foetus. I have seen the former process effected at the expense of the sound anterior lip, where the other was invaded by a cancer throughout, which also extended to the posterior vaginal wall.1 Wherefore, there is no occasion for immediate action; although it must not be forgotten that, if the degeneration of these parts is more extensive, the powers of nature alone are nearly always inadequate to the accomplishment of the delivery. Some authors have recommended copious bleedings; but sanguineous emis- sions, though advantageous in cases of rigidity, or of simple induration of the neck, would here only enfeeble the patient without producing any change in the condition of the orifice; and the only available resource of our art is still in the repeated incisions on the periphery of the cancerous mass; because turning, and the application of the forceps, which have been advised by certain accoucheurs, are evidently only practicable where the bistoury may have previously facilitated the entrance into the womb. Without this precaution, one or more fissures dividing the lobes of the scirrhus would necessarily result from the introduction 1 This case appears to me too remarkable not to be reported, at least in a condensed form. A female, aged forty-five years, who had previously had several children, came to La Clinique about the commencement of the last month of her gestation; when, by resorting to the touch, it was ascertained that the posterior vaginal wall was occupied throughout by an elongated tumor, which was curved in a serpentine form, and extended from the poste- rior lip of the cervix, to within a finger's breadth of the vulva. The lip was nearly an inch thick in all its transverse extent (which latter was more considerable than usual), and it had contracted adhesions with the vagina by its posterior face. The tumor presented nearly the same thickness in all parts; its anterior surface was irregular and nodulated, as was also the posterior lip of the cervix uteri; but its hinder surface adhered to, or rather was con- founded with, the recto-vaginal septum. When this woman arrived at full term, the labor began, and the dilatation was effected very slowly, though completely, at the expense of the anterior lip. The tumor whose volume seemed to offer an insurmountable obstacle to the delivery, only rendered the second stage of the travail a little more tedious than usual; for, being pressed back by the child's head, it became nearly transverse in the excavation, and formed on the perineum a pad, or a kind of crescent, the convexity of which looked down- ward, but its concavity was directed upwards, and arrested the head; finally, under the influence of the powerful contractions, the head pushed the tumor still more backwards, by forcibly depressing the perineum, and then passed in front of it, and soon cleared the external parts. OBSTACLES PRESENTED BY THE UTERUS. 611 of the hand or instrument, which, at the moment of the head's passage, would extend still further, and encroach perhaps on the body of the womb. Or, if the fissures should not form, the neck, by not dilating, would create an obstacle to the delivery, and the patient would be exposed to a rupture of the organ, to convulsions, and to all the consequences that attend labors rendered difficult by mechanical impediments; unless, indeed, there happened to be a rupture of the subvaginal portion of the womb itself, and the child's passage was effected through this accidental orifice. Lastly, in those cases where the application of the forceps is still impossible, even after the incisions have been made, a grave question is offered for our solu- tion. Supposing the child is still living, we have only to choose between its mutilation and the Caesarean operation. Though this last operation be serious under all circumstances, it nevertheless seems preferable here to the first, because it affords a considerable chance of saving the child; and the mother's life is already so greatly compromised by the disease with which she is affected, that we should not, in my estimation, hesitate to sacrifice all to the safety of her infant. § 9. Complete Obliteration of the Cervix Uteri. At the present day, it is an ascertained fact that the neck of the womb may be entirely obliterated at the time of labor; and, where a case of this kind does occur, the vaginal Caesarean operation should doubtless be performed. But it is an exceedingly rare occurrence, and the accoucheur must not permit himself to be deceived by a great obliquity of the cervix, rendering the orifice of difficult access, nor by an agglutination of the lips of the os tincae, since it is possible for an overlapping of the two latter to be mistaken for an absolute obliteration of the orifice. "Several times," says Duges, "we have found the anterior lip covered and embraced by the posterior one, which thus masked the opening, so that the finger could only penetrate it in a very oblique direction; though, when effected, this introduction furnished a means of rectifying the error promptly, and of reducing the parts to a more favorable state." A complete obliteration of the cervix, when certainly detected, evidently de- mands the vaginal Caesarean operation. ARTICLE II. obstacles dependent on the body of the womb. § 1. Of Uterine Obliquity. When studying the phenomena of gestation, we enumerated the various causes that forced the uterus to depart more or less from the direction of the pelvic axis; and we demonstrated that, under the influence of those causes, the womb very often inclines forwards and to the right during the latter months of preg- nancy. It is not, therefore, of this right antero-lateral inclination we are about to speak, in treating here of uterine obliquity as a cause of dystocia; because, where it is slight, and where it may be considered as a normal result of the deve- lopment of the womb, it affords no obstacle to the parturition; but, when the 612 DYSTOCIA. obliquity is more extensive, it may impede the spontaneous expulsion of the child, and will, therefore, claim our attention. Deventer, and most of the writers on this subject since his day, have described four varieties of it, namely, the anterior, the posterior, the right lateral, and the left lateral obliquity. But the modern accoucheurs, such as Baudelocque, (Jar- dien, Desormeaux, and P. Dubois, believe that a posterior obliquity cannot take place; for the prominence of the sacrum and of the lumbar vertebrae, they say, prevents the uterus from being carried backwards; however, from the facts re- ported by Deventer, Levret, Merriman, Duges, and Velpeau, we feel warranted in still retaining these four varieties. 1. Of the Anterior Obliquity.—As a natural result of the resistance presented by the posterior abdominal plane, the womb inclines forward, where it only encounters the abdominal muscles, which form a soft and an extensible wall. When this obliquity is inconsiderable, the physician has only to remain a simple spectator of the efforts of nature; but, when it exists in a higher degree, it be- comes a source of annoyance and pain during the latter months of gestation that demands attention; and it also gives rise to difficulties in the course of the labor that should either be prevented or corrected. An unusual inclination of the plane of the superior strait, or a well-marked laxity of the abdominal walls, favors the obliquity; and, where this laxity is carried to an extreme, the ventral muscles gradually relax and yield, the womb inclines more and more forwards and downwards, its fundus gets above the pubis, and then falls anteriorly, like an inverted sack, on the thighs. This displace- ment has been designated as the ventre en besace, and by the Latin authors it is described under the name of the venter propendulus. This displacement gives rise to acute pains in the groins, in the fore part of the thighs and loins, when the abdomen is not supported by a proper bandage during pregnancy; and, at the time of labor, the cervix uteri is carried so far back against the anterior face of the sacrum, that it dilates with the greatest difficulty; and, if the membranes be prematurely ruptured, or if the pelvis is unusually large, it nearly always hap- pens that the child's head presses the anterior inferior part of the uterine wall before it; which part appears at the vulva while its orifice is directed consider- ably upwards and backwards. But, if the pelvis be small, this engagement of the head does not take place, and the anterior uterine wall is then forcibly com- pressed between it and some portion of the superior strait. The enormous dis- tension in the former case, and the pressure on the lower part of the uterus in the latter, expose this portion of the organ to laceration or gangrene. Under such circumstances, the abdominal exploration and the vaginal touch can alone explain the cause of the difficulties and pains which the patient experiences. The obliquity in the body is readily recognized by the external examination; and if the head be engaged in the excavation, the finger introduced into the vagina will find a voluminous, smooth, and rounded tumor, filling up the whole cavity of the lesser pelvis, and upon which no opening similar to that of the cervix uteri can be detected; but, when carried further upward and backward towards the sacro-vertebral angle, it will reach (though at times with great difficulty) the anterior border of the cervix; but, most generally; it will be impossible to recog- nize the posterior lip. This circumstance has several times been mistaken for an OBSTACLES PRESENTED BY THE UTERUS. 613 imperforation of the womb, or a complete obliteration of the neck, and, as a con- sequence, the vaginal Caesarean operation has occasionally been performed, where nothing more than an obliquity of the uterus was to be remedied. If the head has not yet engaged, the tumor will not occupy the excavation, but the same difficulty will still be experienced in finding the cervix. Both of these modes of exploration should be employed ; for we have already learned that the cervix may be oblique, while the body retains its natural position; and it is evident that, under such circumstances, a resort to the touch alone might lead us to suspect an obliquity that did not really exist; and, on the other hand, the internal ex- ploration would guard against the errors that the deformed appearance of the woman's abdomen might possibly make us commit; for it alone can enable us to distinguish the obliquity from that deformity already alluded to, under the name of anteflexion, in which the womb is shaped like a retort. In the former case, the cervix will be detected high up towards the posterior plane of the pelvis; in the latter, on the contrary, it will correspond to the centre of the excavation, notwithstanding the great forward inclination of the body of the womb. 2. Of the Posterior Obliquity.—This variety of obliquity (which is denied, as above stated, by most modern authors) must be attributed to an excessive re- sistance on the part of the abdominal walls, which prevents the uterus from fol- lowing the direction of the axis of the superior strait, when it rises out of the pelvis; that is, from inclining forwards, and therefore it is almost exclusively met with in women bearing their first child. The direction of the uterine axis is not to be judged of in reference to the axis of the body, but to that of the superior strait. Now, it is undeniable that the womb, in some cases, instead of being directed from above downward and from before backward, has its long axis directed from behind forward, and sometimes even in a direction parallel to the plane of the superior strait, so that, while its fundus reposes on the posterior inferior plane of the abdomen, its neck is situated above the pubis. I cannot better describe the signs appertaining to this particular obliquity than by relating a few examples of it; and these citations will have the further advantage of verifying the fact, and of establishing its possibility. I have twice had, says Merriman, from whom I extract the following case, an opportunity of observing this singular and unusual position of the uterus, in which the os uteri is carried so far above the symphysis pubis that it is inacces- sible to the finger, and the posterior part of the pelvis so completely filled by the body of the womb that it is impossible to touch the sacrum. A case of the kind has been published by Dr. S. H. Jackson j but it occurred in a woman who had not reached full term. In the first of my cases, the woman was at term, and the labor continued for several days; but the uterus regained its ordinary position after severe efforts, and the labor terminated spontaneously: the child was still- born, but the mother recovered. The other was published a long time ago, in a dissertation on retroversion of the womb, which has been sharply criticised by Dr. Dewees. The following is an abstract: " Mrs. F----was taken with symp- toms of labor, on Monday, June 16, 1806, at which time a discharge of the liquor amnii was perceived, and severe and apparently strong pains recurred at distant intervals. In the course of the day, the patient was examined per vagi- 614 DYSTOCIA. nam, when there appeared to be a singular condition of the parts. The whole of the back part of the pelvis was filled up by a globular tumor, which prevented the finger from passing in the direction of the coccyx and sacrum, but it was obliged, in tracing the tumor, to take a direction towards the ossa pubis, above the crest of which it could be passed; but neither here nor anywhere else could the os uteri be felt. " By introducing the finger into the rectum, it appeared that the tumor was uterine, and that some bulky part of the fcetus was contained within it; but whether the nates or the head could not be clearly distinguished. "On Tuesday, the 17th, the discharge of liquor amnii continued; the pains were frequent and excruciating, and the tumor was pressed down closer upon the perineum. A rigor, terminating in convulsions, and followed by fever and deli- rium, took place this day; but a prompt bleeding and evacuating the bowels re- lieved these symptoms. " Wednesday, 18th, and Thursday, 19th, no material alteration was observed. The pains continued regular and distinctly marked through these days, but were much less severe and distressing than at first. " Friday, 20th, another very careful examination of the parts was made. The uterine tumor presented the same shape and bulk, quite obstructing the passage towards the sacrum, for even the coccyx could not be felt, except the finger was introduced into the rectum; when the finger in the vagina was carried forward, in the only direction in which it could pass, namely, anteriorly, it reached above the pubes, but still the os uteri could not be felt; yet, on withdrawing the finger from above the symphysis pubis, there was now, for the first time, perceived upon it the true appearance of a show, which'furnished a convincing proof that the os uteri was situated in that direction, and encouraged us to hope that an alteration in the state of the uterus was at hand. "Our hopes were not vain; for, on the next day, Saturday, 21st, a consider- able alteration was discovered in the pains, and in the situation of the globular tumor, which occupied the pelvis. The pains were more powerful and effective, and the tumor, which had been contiguous to and pressing upon the perineum, was found to have a little receded, while a flattened mass (which proved to be the head of the child in a state of complete putrefaction, with the bones sepa- rated, and the brain almost dissolved) was forced down from above the pelvis. between the ossa pubis and the uterine tumor. "After a few hours of active pains, the tumor ascended above the brim of the pelvis, and was no longer to be felt; but now the os uteri was easily distinguish- able, though still very high. "It was judged right to make an opening into the head, and about a pint of grumous blood and brains was evacuated; this allowed an opportunity of grasp- ing the scalp, and, by means of this, so much assistance was afforded, in extract- ing the child, that the labor was terminated in a few more pains. " The patient perfectly recovered, and lived many years afterwards in good health, but never had another child." (Synopsis.) "In a woman," says M. Velpeau, "who came to be confined at my amphi- theatre, in the month of May, 1828, the fundus of the uterus was rather inclined backwards than forwards. The head of the fcetus formed above the strait a con- OBSTACLES PRESENTED BY THE UTERUS. 615 siderable projection, which descended in front of the symphysis pubis nearly to the vulva. Besides, the walls of the abdomen were so thin that the head, fonta- nelles, and sutures could readily be detected through them: the occiput was to the right, and the face to the left. The right parietal bone rested against the anterior face of the symphysis pubis, and the left remained in front. The os uteri, which was on a level with the superior strait, seemed to be scooped out of the substance of the posterior wall of the womb, which made it much longer behind than before. In order to reach the orifice, and penetrate towards the head of the child, I was obliged to bend my finger, so as to make it pass al- most horizontally above the pubis. After seven days of pain and pretty strong contractions, the os uteri, although very soft and very dilatable, was scarcely opened at all. M. Desormeaux agreed with me, that by means of position, and the assistance of the hand properly combined, I ought to try to carry the head to the centre of the superior strait, by making it slide from below upwards, and from before backwards over the pubis. I began to execute this manoeu- vre at half-past eight o'clock, and continued it, alternating with several of the students, until nine o'clock: From this time there was no longer a tumor in front of the symphysis, and the labor progressed so rapidly that iu less than an hour the child was born, and the placenta itself expelled." (Meigs' Transla- tion, p. 404. Dr. Billi, Professor at Milan, reports a case (Ann. de Chir., 1^45, p. 113) in which the retroversion was so complete, that the orifice was situated five fingers' breadth above the pubis, whilst the posterior part of the excavation was occu- pied by the head of the foetus. The fundus of the uterus, in the shape of a hard and rounded tumor, was situated between the vagina and the rectum, which it compressed violently. I might also add similar examples from Duges ; but these two are probably quite sufficient to render what is meant by the posterior obliquity of the womb fully understood. •By summing up the symptoms so well described by Merriman, we shall have : 1, a very considerable elevation of the os uteri, which is carried high upward and forward above the symphysis pubis; 2, a tardy dilatation of the cervix; 3, the tumor, constituted by some part of the fcetus (the shoulder, probably) pressing before it the posterior inferior portion of the womb that envelopes it, is strongly engaged in the excavation, and occupies all the cavity of the lesser pelvis ;* and, 4, the head situated above the symphysis pubis. By collecting in the same way the principal characters of M. Velpeau's case, we shall find a remarkable eleva- tion of the presenting part; a very unusual elevation of the cervix uteri, the orifice of which, being turned directly forward, is placed above the symphysis, and is scarcely accessible to the finger; and, lastly, a considerable tumor formed by the child's head, just in front of the anterior face of the symphysis. And we 1 It is highly probably that the engagement of the shoulder in the excavation is owing to the putrefaction of the foetus. Merriman has not noted the prominence formed above the symphysis pubis by the head ; the absence of this projection, which was so remarkable in M. Velpeau's case, was certainly due to an engagement of the shoulder, and the head was probably thrown back on the opposite one, so that a spontaneous cephalic version took place. 616 DYSTOCIA. may add, that such a tumor had previously been described by Duges, in several of his observations.1 The posterior obliquity of the womb is rarely so disastrous in its consequences as Merriman's case proved to be ; for, most generally, the strong contractions of the organ, the energetic efforts of the patient herself, and a sufficient amplitude of the pelvis, succeed in overcoming its unfavorable influence, without extraneous aid ; and, besides, it often happens that, at the time the membranes are ruptured, the head descends into the excavation along with the discharged waters. But on the other hand, as in the instance of the author just quoted, the deviation of the foetus, and of its presenting part, goes on increasing, and then it may require version. 3. Lateral Obliquities.—For the reasons formerly given (page 605), the right lateral obliquity is far more frequent than the left; indeed, but very few examples of the latter are ever met with. These variations in the direction of the uterus are rarely.of such a nature as to constitute a serious obstacle to parturition ; they act more particularly in modifying, and sometimes even in altogether changing, the presenting part of the foetus. Let us suppose, for instance, says Duges, that the womb be oblique enough to carry the child's head towards the border of one of the iliac fossae, as I have seen in two cases; but it can hardly remain at this point, for it will either be pressed back into the excavation, or else it will slip further forward and Outward, and the child, by thus becoming more and more oblique, wall ultimately present one or the other shoulder at the superior strait. Treatment of Uterine Obliquity.—In a large majority of cases, the obliquity of the womb, whatever may be its variety, presents no special indication for treatment; it constitutes a source of delay in the progress of the parturition, but it scarcely ever becomes a serious cause of dystocia. Consequently in these, as in all other slow labors, the first duty of the practitioner is to wait. In some very rare instances, where it happens that an excessive degree of obliquity is not rectified under the influence of the powers of nature, the intervention of art becomes necessary; and the indications then presented are,—to restore the womb to its normal position, to sustain it there, and to remedy any accidents that may happen. The measures whereby the first two indications may be fulfilled, are 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 down until after the displacement is remedied. If these means are not sufficient, it will be necessary, while thus operating externally on the body, to act at the same time on the neck ; for that purpose introducing two fingers into the uterine 1 It has been remarked, in many cases, that the child's head presented, after birth, a red longitudinal mark between one of the parietal protuberances and the sagittal suture. This long narrow track seems to be owing to the contusion made on the scalp by the upper border of the pubis. In a case of this kind, reported by Paisley, the midwife could not detect the child's head until after the discharge of the waters. The head would not descend, and the woman died of exhaustion ; and, at the autopsy, the frontal and parietal bones of the right side were found applied against the pubis, which had made a depression there of one or two inches in extent. OBSTACLES PRESENTED BY THE UTERUS. 617 orifice, and taking advantage of an interval between the pains, to draw it gently towards the centre of the pelvis, whilst the other hand is employed in pressing the fundus of the organ in the opposite direction. These measures generally succeed, and their use should be continued as long as the double interest of the mother and child will permit; but if they prove unsuccessful, and the reduction of the obliquity and the delivery become impos- sible, our only resource is to open an artificial passage, by making an incision into that portion of the uterine wall which projects into the vagina (the vaginal Caesarean operation). Still this ought to be considered an ultimate resource, and one not to be resorted to until after the impossiblity of introducing the hand into the uterus to effect the pelvic version has been fully ascertained. In the posterior obliquity, the woman ought to remain seated or standing, or, if possible, even inclining a little forward. If the head forms a projection above and in front of the pubis, as in the case of Velpeau, and those reported by Duges, the hand should support the hypogastrium, and, by perseverance, it will succeed in pressing back the head to the centre of the excavation. This ma- noeuvre will be rendered more easy by the vertical position, by walking, or, if necessary, by the woman's resting on her hands and knees, so that the fundus of the womb will hang forward, as it were. A kind of see-saw movement then takes place, which, by depressing the part of the child that occupies the fundus, elevates that near the neck. Finally, should all these plans fail, the pelvic ver- sion must be resorted to. § 2. Of Hernia of the Womb. Most of the cases of hernia of the womb may be referred to what we have described under the name of anterior obliquities of this organ. These are true eventrations;1 and it is exceedingly rare for the uterus, by escaping through one of the natural openings of the abdomen, such as the inguinal or the crural rings, to constitute a hernia, properly so called. Some well-established examples of it, however, are found in the books; for instance, Simon, in his Memoir on the Caesarean operation, and Sabatier, in his work on the displacements of the womb and vagina, both of which are found in the valuable collection of the Academie de Chirurgie, have related several very curious instances of the kind. In most cases, the displacement of the womb had existed prior to the fecunda- tion, and the organ thus situated without the abdominal enclosure, continued to be developed until full term. In some others, which are more difficult to admit, this organ having attained a certain degree of development, gradually dilated one of the crural or inguinal rings, and constituted an external hernia. These latter have been admitted by Desormeaux, but they are rejected by M. Moreau, who considers them as genuine eventrations, and we are disposed to adopt the latter view, at least so far as regards the case reported by Ruysch. Sometimes, however, the existence of an old hernia has -occasionally seemed to favor the development of a hernia of the uterus.3 1 A term applied to the hernias following any accidental opening in the abdominal walls; as also the falling of the belly, resulting from an extreme relaxation of the anterior ventral walls.—Translator. 2 One Ramus, aged twenty-four years, and having borne six children, had a right inguinal enterocele, which appeared some time before her marriage. At the third month of a seventh 618 DYSTOCIA. The characters of this latter, during the gestation and labor, are too well marked to require a detailed account of the signs of recognition. But, at the time of the parturition, the inefficiency of the efforts of nature should be fully tested by a prolonged delay, before resorting to the Caesarean operation, which is the only resource recommended by very many accoucheurs; for, in some cases, the labor has been known to terminate spontaneously. In a case related by Ruysch, a midwife, by raising the tumor, succeeded in returning the fcetus into the abdomen,'and the delivery was effected as usual. § 3. Of Prolapsus Uteri. It is possible for a prolapsus of the womb to exist in a non-pregnant woman, and yet the latter may conceive, as is fully proved by the following observation of Marrigues, reported by Chopart. " A female, who was affected with a pro- lapsus, had been impregnated by the direct and immediate introduction of the fecundating principle into the uterus, through its gradually dilated orifice." The conception having once taken place, the uterus may go on developing until term, and at the time of labor may present an enormous tumor hanging between the thighs; or this falling may only occur during the gestation; and again it may suddenly come on in the course of the parturition, where the patient is aban- doned to herself, or is attended by inexperienced persons, who allow her to remain standing or walking for a long time, or who permit her to make strong bearing-down efforts, with a view of hastening her delivery before the os uteri is sufficiently dilated.1 The prolapsus may prove a source of serious difficulty in the progress of the parturition, for experience has shown that this accident may not only be produc- pregnancy she was attacked by an annoying, dragging sensation on the left side of the hypo- gastrium. The tumor hitherto observed in the latter region disappeared, and she dis- charged blood by the vagina. By placing her hand over the inguinal hernia, she discovered there a hard and strange body, that was painful on pressure, and which she several times attempted to push back again, without success. Seven weeks afterwards she felt some movements at that point, and sent for a physician, who detected at the lower and right portion of the abdomen a tumor, that descended on the thigh of this side, covering the pubis, and even extending across as far as the left thigh ; this tumor was twenty-six in circumference at the middle, and twenty-four inches at its junction with the abdomen. Several attempts at reduction were made without effect. The pains came on at the eighth month, and hysterotomy was then performed, but the reduction was still impossible after the delivery, and the uterus was left on the exterior. Both the mother and child were saved. (Ledisma de Salamanca; Gaz. de Mid., 715, 1840.) 1 According to M. Moreau, the patients are particularly exposed to this kind of displace- ment in the five or six weeks following the delivery. The uterus, which has been distended by the product of conception, still infiltrated by fluids, hypertrophied in a measure, has a much larger size and a far more considerable weight than usual; the ligaments that were stretched have regained as yet neither their consistence nor habitual strength. Now if, on the one hand, there is more weight in the organ to be sustained, and, on the other, greater weakness of the ligaments which should sustain it, it is very apparent that a cause which, in the ordinary conditions of life, would be insufficient to bring about a displacement, will produce it under the circumstances just indicated. For these reasons, therefore, we can- not too strongly urge the patients to keep in the horizontal position during the early part of their lying-in, and to avoid all kinds of violent exertions for the first six weeks follow- ing their delivery. OBSTACLES DUE TO THE FOETUS. 619 tive of long delays, but likewise of real danger; perhaps, it may even render the spontaneous expulsion of the fcetus altogether impossible, either (as has long since been remarked) because the womb, which has descended to the lowest part of the abdomen, and possibly even beyond the abdominal enclosure, is removed as it were from the influence of the contractions of the abdominal muscles; or because, being wedged in between the surface of the child's body and the walls of the pelvis, it has lost a great part of its energy in consequence of the long-continued pressure. The difficulties to be overcome will also vary according to whether the pro- lapsus be recent or of long standing; for, in the latter case, the prolonged con- tact of the organ with the internal face of the thighs, and with the dress, may have produced a state of induration of the cervix which opposes its ready dilata- tion ; indeed, this has often been impossible, and the physician has been obliged to incise it to overcome the resistance offered by the indurated parts. On the contrary, where the accident has recently occurred, or, still better, if it is only manifested during the labor, the dilatation of the os uteri is sometimes effected spontaneously; and the duty of the accoucheur is then limited to facilitating it by the use of the appropriate means. The special indications presented by a falling of the womb, when it occurs du- ring pregnancy, have already been treated of. (Page 312.) All attempts at reduction would be dangerous during the labor; and, conse- quently the accoucheur must then be satisfied with hastening the dilatation of the os uteri as much as possible, and with preventing the lacerations it would suffer by suitable incisions, in cases of induration. The delivery of the placenta likewise demands much circumspection, since it is evident that we cannot trust its expulsion to nature, and still less can we draw on the cord in the usual manner; hence, the after-birth must be artificially sepa- rated. Immediately after its delivery the uterus retracts, and then the reduction of this organ is often quite easy. CHAPTER V. OF OBSTACLES DEPENDENT ON THE FCETUS OR ITS APPENDAGES. For the delivery to be effected spontaneously and without danger, it is not only necessary that the mother be well-formed, and the labor not complicated by any of the accidents that we shall hereafter have occasion to study, but also that the conformation of the fcetus, and the size of its different parts, do not destroy the just relations that should exist between it and the canal it has to traverse. It is further requisite that the child present by one extremity of its long axis; for, with the exception of a few rare cases, a natural delivery is only possible when it presents by its cephalic or its pelvic extremity. But, unfortunately, these favorable conditions are not always met with; for the fcetus may be affected with various diseases at the time of its birth, or may possess some deformity, 620 DYSTOCIA. which sensibly augments its dimensions; and it may likewise be badly situated, relatively to the canal it has to pass through. Therefore, we must successively consider the indications presented by these diseases, deformities, and unfavorable positions. ARTICLE I. DISEASES OF THE FffiTUS. The diseases of the child, to be mentioned in this connection, are those which, by sensibly augmenting the size of one of its parts, create an obstacle to its pas- sage through the pelvic canal. We have, therefore, to treat of hydrocephalus, hydrothorax, ascites, and the accidental tumors that may have been developed on various portions of its body, during intra-uterine life. § 1. Hydrocephalus. Under this term are included all the dropsies of the head, and all the effusions or infiltrations of serum within or exterior to the cranium. Hydrocephalus has been described by authors as external or internal, accord- ing to the seat of the effusion; placing under the former variety all the serous or sero-sanguinolent infiltrations that are found beneath the scalp or pericranium. This latter affection has never hitherto been considerable enough to constitute an insurmountable obstacle to parturition. In fact, it is usually associated with a state of general oedema that destroys the fcetus at an earlier period of gestation; and, consequently, its expulsion is effected without difficulty, whatever may be the thickness of the scalp. I saw a seven-months' child, at La Clinique, in 1838, in whom this part was a finger's breadth in thickness, and the mother, also, was quite oedematous ; the labor terminated without difficulty. Desormeaux speaks of two very similar cases. I do not know that the records of science furnish a single case of external hy- drocephalus formed by a true collection of fluid, yet I have seen two cases of this kind of effusion. The subject will be referred to, presently, in greater de- tail. Hydrocephalus internus, the only variety requiring a particular description, is such a rare disease, that Madame Lachapelle observed but fifteen cases of it in forty-three thousand five hundred and fifty-five labors. In the estimation of pathologists, this is always a grave affection, on account of the danger to which it exposes the child after birth; but more particularly so, in the eyes of the accoucheur, from the difficulties thereby entailed on the labor itself. Moreover, these difficulties and dangers vary with the quantity of liquid effused into the cranium; because, where this is inconsiderable, the delivery is still possible, owing to the flexibility and the softness of the head, the walls of which are nearly all membranous; so that, by gradually moulding itself to the passage, the head becomes lengthened out, and the labor is either terminated by the powers of nature alone, or else is effected without much difficulty by the application of the forceps, or by the pelvic version; but where the water exists in great abundance, the dimensions of the head exceed those of the diameters of OBSTACLES DUE TO THE FCETUS. 621 the pelvis1 so much that the delivery is absolutely impossible, unless the fluids be evacuated by an artificial puncture, or by a spontaneous rupture of the sutures, or fontanelles. The following, according to Duges, are the signs whereby a dropsy of the head may be recognized during the parturition: the finger falls upon a large and slightly convex surface, which covers every part of the superior strait without engaging, and has a variable consistence at different points; for, although hard and resistant while the pain lasts, it is, on the contrary, soft and fluctuating in some places during the interval between the contractions. Then, by passing the index regularly over it, the accoucheur can recognize pieces of bone separated by membranous interspaces, or soft commissures, as broad as the finger; and, at times, the fontanelles, equal in extent to the hollow of the hand. If the child has presented by some other part than the vertex, and the head is only accessible to the touch by its base, the separation of the bones detected by the finger will be much less, though it is often easily appreciable. Finally, if the dropsy be incon- siderable, the same characters will be observed, though they are less evident; and besides, the head being then more convex, and not so soft, will engage better in the pelvic excavation. The diagnosis is sometimes rendered difficult by the elevation of the head; but when the latter is ascertained to be presenting, and the pelvis found to be well formed, the presence of the pulsations of the fcetal heart on a level with, or even above the umbilicus, may excite a suspicion of hydrocephalus. (Blot.) According to Duges, the signs furnished by the touch are not always to be met with, and I have seen two cases iu which they were entirely wanting. These two cases which, if my investigations are to be relied on, are unique, present instances of hydrocephalus with double effusion, viz., intra-cranian and extra-cranian. - A well formed woman who had once been safely delivered was again in labor under the care of Dr. Bassereau. Thirty:six hours had elapsed when the Doctor called me in consultation. By this time the neck was completely dilated and the membranes ruptured, but the pains which were for a long time power- ful had gradually lessened, so that the labor was almost suspended. I discovered at the superior strait a large and soft tumor, offering none of the characters of the head, but suggesting rather a presentation of the breech. During the contractions it became tense and elastic, but was devoid of bony resistance. Upon introducing the entire hand within the vagina and grasping the tumor, I was able, by making unequal pressure upon various points of its surface, to perceive here and there a sense of fluctuation, and I knew that I had to deal with the head covered by a sac containing fluid. I then remembered having ten years before met with a similar state of things, and confidently diag- nosed external hydrocephalus coincident, doubtless, with effusion within the cranium. 1 In a case reported by Wrisberg, the child's head was ten and a half inches long, and thirty-two inches in circumference. Meckel has the skull of a hydrocephalic infant whose transverse diameter is sixteen and a half inches, and its height, taken from the occipital foramen to the vertex, measures sixteen inches ; and Burns gives a case of hydrocephalus, where the circumference of the head amounted to twenty-three inches. 622 DYSTOCIA. Nothing was revealed by auscultation. The child had ceased to live. An incision, one-eighth of an inch in length was then made upon the top of the tumor, and about a glassful of liquid escaped. The soft and fluctuating tumor disappeared and the scalp alone remained between my fingers and the bones of the head. The forceps were applied but without effect, and three-quarters of an hour afterwards I decided to make another puncture; this time a quart of liquid escaped, and shortly after, the head engaged and delivery was spontaneously accomplished. Ten years before, I was called by Dr. Saint Ange to a woman who had been in labor thirty-six hours, and in whose case various stimulants, amongst them, ergot, had been vainly employed. At the commencement of the labor my con- frere had detected a vertex presentation, but feeling a large and soft tumor, I at first thought of a presentation of the breech. During an interval between the pains I pressed suddenly upon the tumor, and clearly distinguished the resisting surface of the bones of the head. The forceps were twice applied in vain, when a puncture was made, giving issue to two glassfuls of liquid. The forceps were applied once more, and a dead child easily brought away. The sutures were large, and within the cranium there was a collection of fluid which escaped upon an incision being made through a suture. There was, therefore, in this case, both internal and external hydrocephalus. It were unnecessary to say how greatly this anomaly must modify the diagnostic signs pointed out by authors. Nothing but a sudden pressure upon the tumor, dispersing the extra-cranian fluid, will enable us to feel the bones of the head. How, next, are the two collections of fluid to be explained? 1. It may be supposed that both are formed separately, one by pressing away the subcutaneous cellular tissue and the other taking place in the intra-cranian cavities. This, however, is hardly probable; but, 2. It is possible that before labor the internal hydrocephalus alone was present, and that under the influence of the various kinds of pressure undergone by the head, necessarily unequal and partial as they must be from the very form and dimensions of the pelvis, it is possible, that under these circumstances a fissure might occur somewhere in a suture or fontanelle, allowing the liquid to pass from within outwardly and to form a tumor upon the external surface of the cranium. The latter theory receives confirmation from the fact that, in the second case, M. Martin Saint Ange had no difficulty in detecting the head early in the labor, whilst at a later period I discovered it with difficulty, masked as it was by a soft and fluctuating tumor. But, supposing a communication between the two col- lections, how explain why the evacuation of the first was not followed by the emptying of the latter ? how account for the necessity of a double puncture in the first case and the persistence of the internal hydrocephalus in the second, even when the head was subjected to strong compression by the forceps? The fact merits further examination; but however the mode of its formation be ex- plained, it is not less curious in respect both of diagnosis and of operative indications. The indications for treatment presented by this affection vary with its extent, OBSTACLES DUE TO THE FCETUS. 623 and according to whether the child is living or dead. Besides which, as Duges justly remarks, the physician must not only base his determination on the size of the head, but also on its flexibility and its inclination to engage in the exca- vation. When the cranium is of moderate size, is soft, reducible, and, from the influ- ence of the strong, energetic contractions of the womb, gradually approaches the inferior strait, we should temporize, and be satisfied with favoring a spontaneous termination of the labor by the employment of the proper means. But if the delivery is delayed, and the pains are weakened or uselessly spent against insur- mountable obstacles, the forceps should be at once applied. Nevertheless, the pressure and tractions on the head ought to be slow and gradual, with the view of preventing a rupture, which pan always be avoided by proceeding with gentle- ness, and under a fear of the instrument's slipping. Breech and trunk presentations are much more common when the fcetus is hydrocephalic, as shown by statistics furnished by Scanzoni; of 152 cases 30 presenting some other part than the head, or 1 in 5. Now, under these circum- stances, it is evident that the difficulties will not be felt until after the sponta- neous exit or the artificial extraction of a great part or even the totality of the trunk, for then it is that the occipito-frontal circumference considerably enlarged engages in the superior strait. The pelvic version would doubtless be resorted to in presentations of the trunk; but if the operator has been fortunate enough to detect the large size of the head before searching after the feet, he should, in my opinion, endeavor to bring the cephalic extremity to the superior strait. When the size of the head is such that a spontaneous delivery is wholly im- possible, and the application of the forceps or the pelvic version is not practi- cable, there is no other resource for saving the mother than to puncture the cranial vault, which alone can afford an outlet to the serum accumulated in its cavity. This operation may be performed with the trocar, the bistoury, or with any pointed knife whatever, after having taken the precaution to envelope its blade with tape, so as to leave only the point uncovered. This simple puncture of the membranous intervals is always preferable to the mutilation of the child. For, although the sudden collapse of the brain, which usually follows the eva- cuation of the liquid, nearly always occasions the death of the foetus, still the latter may possibly survive such an operation; since a puncture of this kind made after birth has occasionally been followed by a complete cure. Smellie's and Stein's scissors should, therefore, be proscribed in these cases, and we ought to decide on plunging them into an intact brain only, when the opening made with a smaller instrument has not been free enough to permit the escape of the liquid. It may happen, in cases of double hydrocephalus, that when the ex- ternal fluid has been evacuated through a puncture, the labor may terminate either spontaneously or by the use of the forceps. Should it be otherwise, another puncture through the sutures or fontanelles will evidently be called for. In no case is a bloody operation on the female permissible, because the life of the infant is then too seriously compromised, by the mere fact of hydrocephalus, to think of sparing it at the expense of that of the mother. Where the child is dead, cephalotomy would appear to us preferable, unless some serious difficulties in its performance were likely to be met with. 624 DYSTOCIA. If cephalotomy be decided upon in cases of pelvic presentation, some difficulty may be experienced in perforating the cranium. Though it is often possible to pass the instrument through the arch of the palate, I would prefer repeating what I have already done in a case to which I had been called in consultation by M. Ducros, namely, to introduce the blunt hook into the orbit, and enter the cranium through the optic foramen. This process had been before recommended by M. Dujardin in a note addressed to the Academy of Medicine in 1851, but is evidently practicable only when the child is dead. § 2. Hydrothorax and Ascites. Ascites is even more rare than hydrocephalus, though it is met with somewhat oftener than hydrothorax. The signs indicative of dropsy of the chest are a considerable enlargement of the thorax, a widening of the intercostal spaces, and an evident fluctuation in these enlarged intervals. On the contrary, the extra- ordinary size of the belly, the distension of its walls, and the fluctuation detected there, characterize ascites. The foetus, being retained by the amplitude of one or the other of these cavities, is arrested in its progress through the pelvis, and the accoucheur finds the excavation filled up by a large, soft, and fluctuating tumor. In some cases of extreme distension of the abdomen, the walls of this cavity have been found to yield, so that a great part of the tumor remained above the superior strait, whilst the rest of the trunk gradually descended into the excavation; and when one portion of the abdomen had reached the exterior, the liquid gravitated towards this point, where the resistance was less, the portion remaining internally progressively diminished in volume, and the labor termi- nated naturally. Frank speaks of a dropsical child that presented by the breech, in whom a quantity of the serum had escaped from the abdomen into the scro- tum; and an evacuation of all the liquid was secured by making an incision into this part, which course should be repeated, if a similar case were to occur. But when the aqueous tumor of the chest or abdomen is large enough to be arrested by one of the straits, we should have recourse to puncture with the trocar. A peculiarity which might readily be mistaken for ascites, consists in the accumulation of a large amount of urine in the bladder of the foetus. When treating of the secretions of the fcetus, it was stated that a certain amount of urine was doubtless secreted during its intrauterine existence, and we mentioned in support of the opinion, some instances in which obliteration of the urethra had given rise to enormous distension, and even rupture of the bladder. In a case communicated to the Academy of Medicine by M. Depaul, the bladder was so distended as to prove an insurmountable obstacle to the extraction of the foetus. Whether aware of the true cause of the difficulty or hesitating between as- cites or extreme distension of the bladder, it is evident that if properly directed tractions are ineffectual, an evacuation of the fluid is the only recourse in either case. We would merely add, in accordance with M. Depaul, that since the per- meability of the urethra may sometimes be re-established after birth, it is strictly indicated to perform the puncture as carefully as it would be done in the adult. The insertion of the cord would be a sure guide in choosing the most favorable point. OBSTACLES DUE TO THE FCETUS. 625 In a case observed by M. Moreau, ascites and considerable distension of the bladder existed simultaneously. The first puncture, though it discharged a large amount of peritoneal fluid, did not enable the extraction to be made, and a second one was necessary to evacuate the urine contained in the bladder. The delivery of the child was effected without difficulty immediately afterward. § 3. Emphysematous Condition of the Fcetus. Merriman has remarked that, when the fcetus has been dead for some time, a large quantity of gas may be created in consequence of the putrefaction it has undergone; thereby greatly augmenting the volume and the distension of the belly, and consequently retarding the expulsion. " I have known," says he, " two instances of rupture of the vagina, arising from the rashness of mid- wives, who forcibly dragged the children enormously swelled with putrid air, into the world. In one case, the vagina was torn completely through. Both the women died in a few hours. Had the bellies of the children been punc- tured, to give vent to the air, these fatal occurrences would have been avoided. (Synopsis.) M. Depaul has recently published a case, in which not only was a large quan- tity of gas developed in the abdominal and thoracic cavities, but the limbs of the child were so greatly infiltrated as to present nearly double their natural size. After extracting the head by the forceps, it was deemed necessary to apply the cephalotribe forceps, and close them with such force as to reduce the size of the trunk considerably, and at the same time obtain a firm hold for traction. Whilst proceeding thus, a large amount of exceedingly fetid gas escaped with a report, and very strong tractions were required to disengage the chest and deliver the child. The uterus in contracting expelled a similar kind of gas. Supposing the diagnosis to be well established, we agree with Merriman in the opinion that a previous puncture of the abdomen and chest would certainly have facilitated the use of the cephalotribe, or perhaps have even rendered its em- ployment unnecessary. § 4. Tumors of the Fcetus. The tumors, of divers sorts, with which the fcetus may be affected at the time of birth, and the size of which is occasionally so great as to impede its sponta- neous expulsion, are not susceptible of being included under any general head, and the measures to be employed vary for each. Where they are pediculated, it not unfrequently happens that the pedicle is broken, either by the influence of the expulsory efforts of the womb, or the tractions made by the accoucheur. When their induration is not very great, they temporarily disappear, at times, from being compressed between the foetal surface and the uterine parietes, or the osseous walls of the pelvis. The proper course is to remove them, when acces- sible, or to discharge their contents by means of a puncture where they contain a liquid. But, unfortunately, we can seldom even suspect their existence until the labor is already so far advanced that it is hardly possible to act. If their volume be excessive, the child's death will nearly always result from the delay 40 626 DYSTOCIA. and difficulty in the parturition, and then the conduct to be followed is clearly evident. Certain tumors are also sometimes present in the great cavities, especially that of the abdomen, which may render spontaneous delivery difficult, and occasion- ally even impossible. A very curious case is mentioned by MM. Guilleton and Oilier, in which the obstacle to delivery was occasioned by an abnormal enlarge- ment of both kidneys, due to an hydatiform hypertrophy of the glandular cle- ment of the Malpighian bodies. Tractions so strong as to tear away the lower extremities of the child failed to deliver it; but, fortunately, the pains returned, and the labor terminated spontaneously in a few hours. In another case, quoted by Siebold, the child had presented by the pelvis, though the head was the first to appear, and was expelled without much trouble. The delivery of the body, however, required strong and long-continued tractions. The size of the abdomen was enormous; it measured seventeen inches in cir- cumference, and eight inches from the xyphoid cartilage to the pubis. At the autopsy, the kidneys appeared as two large tumors, weighing two pounds; each one was six inches long, four inches wide, and three inches thick. (See, in the Journal Hebdomadaire, 1855, the bibliographical reference to several similar cases.) Still another case of dystocia, due to the enormous bulk of a cancerous liver, is reported by M. Noeggeralt. Though the forceps were applied, the extraction of the head required the entire strength of the operator; and even then the pains, though very powerful, failed to deliver the shoulders; so that, having dragged fruitlessly upon the head, it was necessary to hook the fingers in the axillae, and draw upon them forcibly. The principal bulk of the foetus was due to the abdomen, which had four times its normal size. An immense tumor, the liver, filled its cavity; it weighed two and a quarter pounds, measured eight and three-quarter inches in width, six inches from below upward, and three inches in thickness. The tissue proper of the liver was met with here and there, but the greater part of it was replaced by a heteromorphous mass resembling the gray substance of the brain. In cases like these, the difficulty cannot be foreseen, nor even suspected, until it begins to exert its influence upon the labor. Tractions upon the head, arms, or axillae, when the head presents, and upon the lower extremities under other circumstances, should be made at first moderately, and afterwards strongly; but, should they fail and the child be dead, it were better to perform embryotomy than to continue them so long as to risk laceration of the maternal organs. § 5. Anchylosis of the Fcetal Articulations. Dr. Busch has recently had an opportunity of observing a very singular case of dystocia, dependent on an anchylosis of the articulations of the child's limbs, in which the forceps was applied, but, after the extraction of the head, the trunk could not be delivered. Being unable to discover the cause of the difficulty, repeated tractions were made, at first moderate, but afterwards more powerful, when a cracking noise was Heard, and the upper part of the trunk cleared the external orifice; but the lower portion of it likewise became ar- rested, and, as the child was dead, it was dragged out without hesitation, and OBSTACLES DUE TO THE FCETUS. 627 the same cracking sound was again heard. At the autopsical examination, it appeared that the articulations of the limbs had been anchylosed in the ordi- nary flexed position exhibited by the fcetus in the womb, and that the bones of the arms and thighs were fractured. (British and Foreign Med. Review, p. 579, April, 1838.) ARTICLE II. DEFORMITIES OF THE FCETUS. Under this title we shall include foetuses of an extraordinary size, those pre- senting certain defects of formation, and known as acephalous or anencephalous fcetuses, &c, and twins connected together by one or more points of the surface of their bodies. We shall conclude the article with the special indications pre- sented by twin labors. § 1. Of Excess of Volume. However voluminous we may suppose a child to be at the time of birth, it is impossible to believe that its volume alone can constitute an insurmountable ob- stacle to a spontaneous delivery, without supposing a simultaneous contraction of the pelvis; since the largest children are never more than twenty-three inches from the vertex to the heel; and, as Duges remarks, if the head presents in its state of habitual flexion, the sub-occipito-bregmatic diameter, which corresponds to the oblique one of the superior strait, is but four and a quarter inches at the most, that is, half an inch less than the oblique diameter. Nevertheless, for this to occur, it is necessary that the flexion of the head be carried to the extreme; for, otherwise, the occipito-frontal diameter, which has occasionally amounted to five and a quarter inches, in very large children, would come into relation with the oblique diameter of the pelvis, which is less. But, fortunately, this demi-flexion will always be completed in the vertex presenta- tions by the force of the uterine contractions; and the same will be true in the spontaneous expulsion by the breech, unless ill-directed tractions interfere un- favorably with the efforts of the womb. Therefore, it will only be in cases where a presentation of the trunk will have rendered the pelvic version imperative, that an unusual development of the fcetus can render its extraction difficult. Con- sequently, in all these cases, the precautions to draw only while the pain lasts, to turn the child's anterior surface towards the sacrum, and to avoid the crossing of its arms behind the neck, should be redoubled. (See Version.) Finally, if the spontaneous expulsion of the head be difficult, we should resort to an appli- cation of the forceps, the same as if it were an original presentation either of the cephalic or the pelvic extremity. § 2. Of Monstrosities. As the cyclopes, the anopses, the acephalous and anencephalous fcetuses, are delivered as easily as those having a normal conformation, we need not dilate upon them here. 628 DYSTOCIA. § 3. Of Multiple and Adherent Fcetuses. We pointed out the signs, in the article on gestation, by which the presence of two or more children in the uterine cavity might be recognized, during preg- nancy; but these characters equally belong to separate and distinct twins, and can in no wise aid in ascertaining the adherence, or the more or less intimate fusion, of two living beings into each other. The diagnosis is likewise very difficult at the period of labor; for, even after the twin pregnancy has been recognized, it is only by negative evidence that we can suspect the adhesion of the two children. If two bags of waters are detected by the finger, if it is necessary to rupture the membranes twice, if the waters are discharged at two separate and distinct periods, the presence of independent twins in the womb may be regarded as cer- tain ; for there are never two envelopes for a double monster, and two perfect twins are very seldom enclosed in the same amniotic pouch. Again, if two feet or even a single one descend with the head, more particularly if the feet yield to the tractions made on them, and appear at the vulva without the head having a tendency to reascend, we may affirm there are two infants; because a monster is never composed of two individuals so united that the head of the one is along- side of the feet of the other; but if several limbs present simultaneously, we can only ascertain whether the children to which they respectively belong are joined together or are independent, by carrying the hand up into the womb. (Duges, Mem. de V Academic) Is it proper to interfere in all cases, whether the monstrosity be recognized or not, or should the delivery be abandoned to nature for a certain length of time ? The recorded instances, which prove that a spontaneous delivery may take place, are too numerous at the present day to warrant an active intervention until after a sufficient length of time has been accorded to the uterine contractions to effect the expulsion. The mechanism by which the delivery is finally accomplished will also vary according to the particular kind of monstrosity. When the two fcetuses are united by the breech or head, their expulsion takes place without any marked difficulty, and they generally escape one after the other, more particularly when they happen to be joined at the breech. But if connected at the occiput, the point of union is seldom flexible enough to permit the two heads to descend simultaneously, and if the patient is at her full term the intervention of art will become necessary. Where there are two heads for a single trunk, the mechanism varies according to whether the monstrosity presents by the vertex or by the breech; but the delivery is still possible, if the twins are slightly adherent and so movable as not to be invariably parallel, for then the two heads may engage successively and not simultaneously. In the vertex presentations, the anterior head, which is the most inferior on account of the obliquity of the body of the child situated in the line of the axis of the superior strait, engages first; and then the other, which had been primitively arrested by the sacro-vertebral angle, follows it. On the contrary, where the infant is delivered by the breech, the posterior head will engage the first, in consequence of the inclination impressed on the trunk by the axis of the pelvic canal; and the anterior one, which was hitherto delayed by the symphysis pubis, will engage immediately afterward. obstacles due to the fcetus. 629 When each head has its own body, but the two trunks are united by their lateral, anterior, or posterior faces, whether throughout their whole extent, or only in a partial degree, a spontaneous delivery is more difficult than in the former cases ; but, when it does occur, it takes place just in the same way. If there is only one head for two bodies, the latter are expelled simultaneously, and the only difficulties which can then present, depend on the unusual size of the head, which is sometimes very large. The process does not always advance as favorably as we have just stated, since it is not at all unusual for one of the heads (where the double condition involves the whole body, or is limited to the head) to be arrested above either the sacro- vertebral angle or the symphysis pubis, and thus delay the subsequent descent of the one that is already engaged, or on the point of engaging. What has just been stated concerning the mechanism by which the expulsion of the bicephalous fcetuses is effected, would naturally lead us to suppose that, whenever one of the heads shall have been arrested above the superior strait, the pelvic version should be resorted to, if the monstrosity presents by its cephalic extremity or trunk; and if the breech descends first, to draw on the lower extremities. But, in either case, when the greater portion of the body is de- livered, it would be necessary to carry it up in front of the symphysis pubis, so as to favor the engagement of the posterior head, prior to the anterior one. Again, if the head that presents first shall have been engaged too long in the pelvic excavation to admit of being pressed back, and of the feet being brought down, it would be proper to make an application of the forceps, if the fcetus were still living; but, under such circumstances, this latter measure will often prove ineffectual, for the tractions made by the instrument will not overcome the resistances offered by the second head. We have, therefore, in this case only to choose between a bloody operation on the mother, and a division of the child's neck, which would permit the head that offered first to be removed, and thus render the pelvic version practicable. And here, notwithstanding the high autho- rities to the contrary, I do not hesitate to advocate the mutilation of the fcetus; for, in cases of this nature, I would have no scruple in sacrificing the infant's life to the safety of the mother. § 4. Of Multiple and Independent Fcetuses. Although the expulsion of the child often takes place in twin pregnancies with as much facility or sometimes even with greater rapidity than in ordinary labors, yet it must not be supposed that the whole duration of the labor is always shorter; for very often, on the contrary, the parturition will be found to drag along, and become tedious. Indeed, by reflecting on the circumstances which then complicate the process, it will not be a difficult matter to explain this un- usual delay, since it is well known that an excessive distension of the womb greatly diminishes both the force and frequency of its contractions; and, as the labor often comes on before the end of the ninth month, the cervix uteri has not yet undergone those modifications which usually render its dilatation at term quite easy; besides which, the elevation of the presenting part, whose engage- ment is impeded by the presence of the second fcetus, also assists in retarding this dilatation. The stage of expulsion, which the small size of the twins would 630 DYSTOCIA. at first sight seem to facilitate, is often delayed by the feebleness of the con- tractions, and also by the decomposition and considerable loss of force occa- sioned by the presence of an ovum, still remaining intact within the cavity of the womb; and such is the unfavorable influence of this latter circumstance, that it is only through the thickness of the second ovum that the contractions of the greater part of the uterine fibres can possibly reach the body of the child that first presented at the upper strait. But when the first child presents by the pelvic extremity, the escape of the head is particularly apt to be attended with difficulties; for, if the perineum be resistant, even in a slight degree, as in primi- parae, for example, the intervention of art will nearly always be indispensable, because the uterus, being wholly occupied by the other ovum, can have no further influence on the head of the first. The following table, which gives the presentation of both children in three hundred and twenty-nine cases of twin pregnancy, will serve, as a matter of curiosity, to show the relative frequency of the positions. IN 329 TWIN PREGNANCIES, THE TWO CHILDREN PRESENTED AS FOLLOWS: Both by the head. 134 times. The lst by the head; the 2d by the breech. 55 times. Both by the breech. 12 times. The lst by the breech ; the 2d by the head. 31 times. The lstby the breech; the 2d by one foot. 11 times. Both by the feet. 8 times. The lst by the feet; the 2d by the head. 29 times. The lstbythebreech; the 2d by the elbow. 1 time. The lst by the head ; the 2d by the shoulder. 7 times. The lst by the face; the 2d by the head. 1 time. The lst by the feet; the 2d by one hand. 1 time. The lst by the feet; the 2d by the breech. 1 time. Nearly always the twins present one after the other at the superior strait, and the expulsion of the first is promptly followed by the birth of the second; and the same is true of the others when there are more than two. But it occasionally happens that the labor does not progress so regularly, and that the children may be born at a considerable interval from each other, and their expulsion be ren- dered difficult by the attendant delays and dangers. It most generally happens that the womb, being fatigued by the efforts necessary for the expulsion of the first born, retracts a little after this partial depletion, and remains in a state of rest for some minutes, in consequence of having lost a part of its contractile pro- perties ; still retaining, however, a greater volume than usual. By placing the hand on the anterior abdominal region, the accoucheur will be able to verify the abnormal size of the organ, and to detect, through this wall, the inequalities appertaining to the fcetus; besides, another amniotic pouch, or the presenting part of a second child, can readily be detected at the upper part of the uterine neck by the vaginal touch. In general, the repose of the womb is but momen- tary, and in about a quarter of an hour, sometimes at the end of five or ten minutes, though rarely later than twenty or thirty minutes, the patient feels the pains coming on again, at first feeble and slow, but soon becoming stronger and more energetic. Care should be taken to rupture the membranes, if this had OBSTACLES DUE TO THE FCETUS. 631 not already occurred, and then to abandon the rest of the labor to the powers of nature. This second delivery is soon over, as a general rule, when the fcetus presents in a natural position, for the parts have been so enlarged by the passage of the first child, that they offer but little resistance to the escape of the second. But in some cases, the pains, which have been suspended after the birth of one of the twins, do not reappear for some hours, and sometimes even not for several days.1 Now, what is to be done in cases of this kind ? Is the labor to be abandoned wholly to nature, or should we attempt to deliver at once ? In some instances, there can be no hesitation as to the proper course; thus, wheu the birth of the first child has been tedious and difficult, and has required the intervention of art, and the forces of the patient seem to be exhausted by the former effort; when any accident whatever, that threatens the life of the mother, or of the second twin, lias occurred during or after the delivery of the first; and, whenever the second one presents in such an unfavorable position3 at the superior strait as to demand the pelvic version, this ought to be performed immediately. But, in all these cases, the expulsion should by no means be rapid, and the accoucheur will draw very slowly on the pelvic extremity, so as not to empty the uterus too soon, and thus avoid the inertia and attendant hemorrhage which might result in consequence of a rapid depletion. It would even be prudent, when the defec- tive position shall have been converted, by the evolution, into a presentation of the pelvis, to trust the rest of the delivery to the expulsory efforts of the womb. The application of the forceps will rarely be necessary, because, if the head is so far engaged -as to render the pelvic version impossible, the labor will probably terminate without assistance. Nevertheless, should the incapacity of the uterus be complicated with any accident serious enough to compromise the life of the mother or child, it would be proper to have recourse to this instrument if the head had arrived at the inferior strait; but in all other cases the pelvic version ought to be preferred, because the introduction of the hand and the evolution of the foetus will not fail, by the irritation they produce, to determine the retraction of the uterine walls, and thus prevent subsequent inertia. " When the two children present well, and the expulsion of the first is effected naturally and without great fatigue to the woman, I wait," says Merriman, "until the pains of the second childbirth come on; ordinarily, this happens shortly after the escape of the first born. If efficacious pains do not occur in the course of a quarter or half an hour, I provoke the contraction by rubbing the abdominal tumor gently with the hand, and by titillating the os uteri with the finger; if 1 Four women, registered in the Dublin Hospital, were delayed ten hours in the de- livery of their second child. The reader will also find, in the Medical and Physical Journal (April, 1811), the details of a case in which the second child was not born until fourteen days after the first; and the author of that communication states, that another case had come to his knowledge, in which six weeks had elapsed between the birth of the twins. A woman was delivered on the 4th of March, 1814, of two children; she found herself so well on the second day that she rose to attend to her affairs, but, on the sixth, she was again delivered of two more. (Gentleman's Magazine, 1814.) 2 It is not very unusual to find the second child presenting by the shoulder; which is probably owing to the vacuum in the womb after the expulsion of the first one, a void that singularly facilitates the displacement of the second. 632 DYSTOCIA. these irritations, made simultaneously on the body and neck, are ineffectual, and several hours elapse without the womb contracting, I deem it advisable to excite the contractions by rupturing the membranes, after having previously administered the ergot. This course is based on the two following reasons: where we have delayed too long a time, the pains have always appeared to me more severe than they would have been if the action of the uterus had been solicited sooner; and the expulsion of the second child has commonly seemed to me more easy through the parts recently dilated by the first delivery." In all such cases, our rules of conduct should be based on the condition of the womb itself, rather than on the length of time that may have elapsed since the birth of the first child; because it must be evident that relaxation and inertia of this organ would forbid all attempts at extraction, and that we should never endeavor to deliver the second child before having excited the organic contrac- tility of the uterus, by all the available means. If, by chance, these measures prove inadequate, it will be better to wait several hours, or, if necessary, even for several days, rather than expose her to the terrible consequences resulting from inertia. When one of the twins, though dead, has remained in the uterus for several months, whilst the development of the other was constantly progressing, the little abortion is ordinarily expelled simultaneously with, or shortly after, the first child; but, unless the accoucheur is very careful, and the size of the womb after the delivery should not excite his attention, its sojourn there maybe considerably prolonged. No doubt, in these cases, the hand ought to be carried up into the womb, for the purpose of delivering the aborted fcetus, but this will not always prove an easy matter. In a case of the kind, communicated to me by Dr. Casau- bon, the internal uterine orifice became strongly contracted immediately after the extraction of the placenta, and it was not without great difficulty that he even- tually succeeded in overcoming its resistance, and reaching the uterine cavity. The little product was then removed, and proved to be an abortion of four months. The other infant had arrived at the end of the eighth month. In certain cases, the presence of two children may render the delivery difficult, and require some special precautions; thus, it may happen: 1. That both present simultaneously at the strait, and retard each other's expulsion; here the most movable head should be carefully pushed up, so as to permit the other to engage first. The difficulty will be greatly enhanced, if the two heads be en- gaged in the excavation at the same time, and neither of them can be pressed back; under such circumstances, the application of the forceps upon the one that appears the most engaged, and, if this does not succeed, the perforation of one of them, seem to me the only practicable operations. However, even here, very prompt action is unnecessary, for it might happen, if both heads were small, ihat a natural expulsion could be effected; an example of which is reported by Allen, in vol. xii of the Medico- Chirurgical Transactions^ The same plan is to be pursued when, instead of the heads, the breech or the feet of the two infants present together. 2. The first child may present by the shoulder; here, the pelvic version is evidently indicated, but, in performing it, the operator must be very careful to seize the feet of the right child, before commencing the evolution, for if both the OBSTACLES DUE TO THE FCETUS. 633 bags of waters were ruptured, nothing would be more easy than to get hold of two feet belonging to different children. 3. Where the first presents by the feet, whether spontaneously, or as a conse- quence of the pelvic version, the greater part of the trunk is extracted without difficulty, but the head may be arrested in the excavation, or above the superior strait. Thus, in the twentieth observation of the fourth Memoir of Madame Lachapelle, the head of the first born had drawn under it that of its brother, which had a tendency to present by the vertex, so that the latter one blocked up the passage of the former, while the first prevented the second from getting above the superior strait; but, fortunately, the children were small, and the head of the second twin escaped spontaneously, alongside of the neck of the first, and then the head of the first followed the neck of the second. A very similar case, given by Dr. Erwin, is related by Dr. Dewees. Had these two fcetuses been of the ordinary size, it is clearly evident that their expulsion could not have been effected until one, or, possibly, both heads, had been reduced by craniotomy. The mutilation of one child seems to me the only recourse we have in these difficult cases; thus, it has properly been recommended to amputate the neck of the first twin, which would render the spontaneous expulsion of the second one possible, or at least would permit its extraction by the forceps; after which, the head of the mutilated infant should be sought after and brought down. However, before resorting to this cruel operation, an application of the forceps ought to be attempted on the head that descended first, as appears to have been done successfully by a surgeon of Dijon. In fact, from the smallness of the children, it is possible that, in many cases, the second head will afford but a feeble obstacle to the passage of the trunk of the child we are endeavoring to extract by the instrument. 4. M. Jacquemier relates a curious case witnessed by him at the Maternity Hospital. A woman, who had been in labor nine days, was brought to the hos- pital in a dying condition; the waters were discharged three days before, and the forceps had been applied without success. At the autopsy, two children were found in the womb. One head had descended into the excavation in the left occipito-cotyloid position, and had passed the uterine orifice. The other child was in the second position of the left shoulder; its head rested in the right iliac fossa, and the front of its neck, which was situated below the anterior shoulder of the first fcetus, embraced the neck of the latter, in a semicircle, so as to pre- vent a further descent of the trunk; thus explaining the fruitlessness of the tractions made by the forceps. Both children were large. 5. Again, two feet occasionally present at the orifice; when, if the accoucheur deem it advisable to aid the expulsory efforts of the womb by tractions, he might, (by supposing they belonged to one child, draw on both, and thus engage parts of both twins at the same time, which could not pass out together; therefore, if there is the least doubt of the character of the pregnancy, he should ascertain, before making any tractive efforts whatever, that the two limbs really belong to the same individual, which is done by passing the hand up into the womb as far as the hips; though it must be confessed that this diagnosis is frequently attended with great difficulty. Pleissman states that, on one occasion, he found the orifice plugged up by the parts that had become engaged, and which at first sight appeared to him to be 634 DYSTOCIA. a quantify of hands and feet. A more careful examination enabled him to dis- tinguish four inferior extremities, which were delivered as far as the ham, and one arm. "At first/' he says, ''I was in great perplexity, because I could find no way of introducing my hand into the womb, for the purpose of distinguishing and seizing the two feet belonging to each child, and because all my efforts to make even one of these extremities go back again proved abortive; besides which, in drawing on any two of them, I might confound and bring down the feet of two different foetuses at the same time; and, lastly, even if I succeeded in seizing the two feet belonging to the same child, I might, by drawing on them, engage the other parts, and thus augment the difficulties. Being greatly embarrassed as to the proper course, and yet obliged to act, the employment of a measure recommended by Hippocrates, under different circumstances, happily suggested itself; it was, to suspend the patient by her feet, hoping that the heads and the bodies of the children would, by their weight, draw one or more of the extremi- ties towards the fundus of the womb, which was still distended by the waters. The husband and brother-in-law of the woman passed their arms under her hams, and thus held her suspended, so that only the head and shoulders rested on the bolster. I intended, as soon as I mounted on the bed, to press back one or more of the free extremities into the womb, but two had already returned from the mere position of the mother, and the other three soon followed by the aid of my fingers. Immediately afterwards, I was enabled to introduce my hand into the uterus, and to withdraw successively therefrom three children by the feet." In bringing forward this case, I only desire to illustrate what has been said concerning the difficulty of diagnosis. I ought also to call attention to the im- possibility of the reduction, and the singular procedure resorted to with a success that seems to warrant its employment again under similar circumstances. ARTICLE III. PROLAPSUS, OR FALLING OF THE CORD. The descent of the cord is quite a rare accident, since Madame Lachapelle states that she met with it but forty-one times in fifteen thousand six hundred and fifty-two labors ; but it is probable, as she appears to think herself, that there has been an error in the registers, for the statements given by other observers show a much larger proportion. I shall only bring forward the account of Michaelis, who says that he had detected fifty-four cases of falling of the cord in two thousand and four hundred labors; and a summary, by Dr. Churchill, of ninety thousand nine hundred and eighty-three labors, in which there were three hundred and twenty-two cases of prolapsus, or one in two hundred and eighty- two, nearly. (Rigby.) The falling of the cord is most frequently observed in the vertex presentations, which circumstance is readily explained by the comparative rarity of the others. But, in proportion to the relative numbers, it is more frequent in breech presen- tations, and far more so in those of the trunk. In thirty-three cases of labor at term accompanied by this accident, Mauriceau observed seventeen presentations of the vertex, one of the face, one of the feet, nine of the hand or arm, three of OBSTACLES DUE TO THE FCETUS. 635 one hand and one foot, one of the breech and one hand, and one of the head and one hand. In sixteen thousand six hundred and fifty-two deliveries, Dr. Collins has met with ninety-seven cases of prolapsus, namely, twelve times in twin preg- nancies (and in seven of these twelve the prolapsed cord belonged to the second child); nine times in footling presentations; twice in those of the breech; four times with the shoulder; seven times when an escape of the hand complicated a head presentation; seven with a dead and putrefied foetus; and lastly, in three cases the delivery took place before term; that is, twice at seven and once at eight months; and the others were simple vertex presentations. Certain authors have endeavored to draw a line of distinction between the prolapsus or presentation and the falling, properly so" called; designating, under the former title, those cases in which the cord, though found in the uterine orifice, is still retained in the amniotic sac, on whose lower part it lies; and, under the latter, those cases only in which it hangs down in the vagina, or even protrudes beyond the vulva, after the rupture of the membranes; but such a distinction is puerile, as it can only serve to designate two degrees of the same accident. A. The causes that may be considered as predisposing to a prolapsus are: the unusual length of the cord itself, a large amount of water, deformities of the pelvis, an obliquity of the womb, and those malpositions of the child which prevent the ^S- 95- presenting part from engaging readily in the superior strait and? excavation. The attach- ment of the placenta near the os uteri also pre- disposes to a prolapsus, by keeping the cord just at the uterine orifice. With regard to the determining causes, we must place in the first rank a sudden rupture of the membranes, and the rapid escape of a large quantity of water, which generally sweeps along with it a fold of the cord. Consequently, when the neck of the womb is almost effaced, the bag of waters very prominent, and the head not engaged in the „_.,___i.: <> n • i • The right posterior occipito-iliac posi- excavation, we must carefully avoid rupturing tion> compUcated by a fallinPg of the C(frd. the membranes during a pain, for the gush of liquid, which then escapes with considerable force, nearly always carries along a loop of the cord, which thus precedes the presenting part. (Martin, of Lyons, Comptes Rendus, page 13.) To these causes, let us further add the descent of a hand or a foot, which seems to act as a guide, as it were, for the cord, and to open the way for it. B. The signs whereby this accident can be recognized, vary according to whether the membranes are ruptured or are still intact. In the latter case, the diagnosis is quite difficult; nevertheless, we can often detect something like a soft, small cord, through the portion of the membranes covering the os uteri, and slipping away before the least pressure, but the true nature of which can only be determined by the rapid pulsations in it. The rapidity of these, which Madame Lachapelle aptly compares to the ticking of a watch, can alone enable us to dis- 636 DYSTOCIA. tinguish them from some other pulsations produced by certain arteries that occa- sionally ramify in the substance of the neck, and which are synchronous with the mother's pulse. This error would be more difficult to avoid, should the finger, when applied on the membranes, encounter one of the arterial ramifications of the cord, which, as in the cases described by Benckiser (see Umbilical Cord), may spread out on the membranes before entering into the proper tissue of the placenta. The size and the mobility of the prolapsed cord would also aid in making out the diagnosis. On the other hand, the thickness and the spongy condition of the membranes, the inequalities they occasionally present, and the folds of the child's scalp, might perhaps lead us to suspect a falling of the cord, if the clearly ascertained absence of pulsation did not promptly rectify the mis- take. But after the rupture of the membranes all the difficulty disappears, for then the cord hangs down in the vagina, and often escapes beyond the vulva, and therefore may always be readily explored. The two portions of the prolapsed fold are not uniform in their relations with each other; most generally, they touch or are simply approximated together; and sometimes they are separated by the whole thickness of the presenting part. Nor is the fold more regular in its length ; at times it only embraces the head, holding it like a sling, while at others it appears externally between the woman's thighs, though most usually it is lodged in the vagina, or at least only reaches the exterior in the latter stages of the labor. It has, in some very rare instances, been known to go up again, and thus become reduced spontaneously. (Guille- mot.) As a general rule, it is situated just in front of one of the sacro-iliac symphyses, or behind the ilio-pectineal eminence. A prolapsus, therefore, can always be detected ; but it is much more difficult though at the same time it is highly important to determine, after the explora- tion, whether the child is living or not. A momentary disappearance of the pul- sations is not a sufficient sign; for it not unfrequently happens that the throbbing ceases in it during the pain, because the cord is then strongly compressed, but it reappears again as soon as the pain is over. This want of circulation in the ves- sels of the cord may continue for five or ten minutes, and it has even been known to last for a quarter of an hour, without necessarily terminating in death. It is therefore during the interval alone that any researches of this nature should be made, and the child's death can only be determined with certainty when this exploration, repeated several times under like conditions, shall have always fur- nished a negative result. A cold, soft, withered, and greenish cord, doubtless belongs, in most cases, to a dead child, but this is not always true; and, on the other hand, as death may result very promptly from a compression of the cord, the latter may still be warm and fresh, though the fcetus be dead. c. Prognosis.—The falling of the cord is only serious as regards the foetus; but to it the danger is imminent, since death itself may result in consequence in the course of a few minutes. Thus, in three hundred and fifty-five cases col- lected by Churchill, two hundred and twenty children, or nearly two-thirds, died; though it is worthy of remark that, in many of these cases, the mothers were not transported to the hospital until some time after the descent of the cord, and when its pulsations had entirely ceased. The compression of the cord, and the consequent interruption of the foeto- OBSTACLES DUE TO THE FCETUS. 637 placental circulation, is the principal if not the only cause of death; though cer- tain authors, among whom I can enumerate Velpeau and Guillemot, suppose that, when the cord protrudes beyond the vulva, the blood may lose its fluidity in consequence of being chilled by the external temperature, perhaps may even coagulate, and that the delay in the circulation thereby produced, combining its influence with that of a slight pressure, completely interrupts the current which, up to that moment, had only been retarded; Delamotte, Baudelocque, and Madame Lachapelle, do not admit this effect of the cold. " For I have seen " says this illustrious midwife, " the cord hang out of the vulva for several hours together without the fcetus suffering therefrom in any wise, because there was no compression; and this, in some of the cases, notwithstanding the patients had come a greater or less distance, either on foot or in some vehicle, from their residences to our hospital." But whatever view may be adopted, it is still to a compression of the cord that we must attribute the greatest share in the production of the child's death; and under this aspect, its position, when prolapsed, will greatly modify the prognosis. The points where it is least exposed to compression are just in front of the sacro- iliac symphyses; and, as M. Naegele has justly remarked, the frequency of the vertex positions in which the occipito-frontal diameter corresponds to the left oblique one of the pelvis, renders the danger in general much less if the fold of the cord happens to be placed behind and to the left. The influence of this compression has been variously interpreted. According to some, the child will die from apoplexy in consequence of an excess of blood, which continues to arrive by the vein, but can no longer return to the placenta through the umbilical arteries; agreeably to others, the circulation will be free in the arteries, the vein alone being obliterated, and then the fcetus will die from anemia or syncope. But it is only necessary to examine the intertwining exhi- bited by the vessels of the cord, to become convinced that this partial compres- sion cannot exist except as an accidental circumstance, and that, as a general rule, the current must be interrupted in all three vessels at the same time. The most plausible opinion, and we believe the only one admissible, is that asphyxia is the sole cause of death; for, as we have elsewhere stated, the placenta is the only organ of hematosis for the child up to the moment when the pulmonary respiration is established; and, therefore, if the circulation in the cord is inter- rupted by any compression before birth, the blood of the foetus can no longer derive the elements necessary for its renovation by its mediate contact with that of the mother in the placenta; and from that moment the child finds itself placed in the same conditions as an adult deprived of respirable air, and, like him, dies asphyxiated. In most cases, it is not until after the membranes are ruptured that the descent of the cord exposes it to a sufficient degree of compression to compromise the infant's life. Indeed, if we might judge from some observations of Madame Lachapelle, the pressure which it undergoes is never great enough to obliterate the umbilical vessels, so long as the head is not engaged in the superior strait. For our own part, we are inclined to believe that the simple pressure of the head on the cord may be so considerable as to interrupt the fceto-placental circulation, even before the discharge of the amniotic waters. D'Outrepont relates two cases 638 DYSTOCIA. which confirm this view; and the numerous instances in which we find the me- conium mixed in large quantities with the liquor amnii at the time of the rupture of the membranes, can only be explained, in our estimation, by a momentary compression of the umbilical cord. D. Treatment.—As regards the treatment, the delivery might be left to the powers of nature: 1, whenever there is a certainty that the child is dead; 2, when, though the infant be living, the membranes are only ruptured as the head becomes firmly engaged in the excavation, and when, from the fact of. the con- tractions being energetic, there is every reason to hope that they alone will be sufficient to terminate the labor promptly; which, in fact, usually occurs in women who have a non-resistant perineum, from having previously borne chil- dren ; and, 3, where the head is small, the pelvis large, and the cord situated in front of one of the sacro-iliac symphyses; for then it is only necessary to return the cord into the vagina to protect it from the contact of the air. But, notwith- standing these favorable conditions, it will still be necessary to watch the state of the cord attentively, and to apply the forceps as soon as the pulsations are found to grow weaker or to become intermittent. Under all other circumstances, the intervention of art will be indispensable. Thus, where the presentation is such as to render a natural delivery impossible, or, even if possible, where the expulsion of the fcetus would require a long and painful labor, the forceps should be applied or the pelvic version be resorted to without delay. The former operation will be the only one practicable in a ver- tex or face presentation, supposing both to be firmly engaged in the excavation, and that the previous attempts at reduction had proved ineffectual. It is gene- rally thought that turning by the feet should be preferred whenever the part is not too strongly engaged. In a presentation of the breech, the operator ought to search for the feet, if the presenting part be still above the superior strait, or bring down the groins with the blunt hook, if it has descended into the excavation. In a presentation of the vertex or face, where these parts have not as yet engaged in the excavation, we should first endeavor to reduce the cord. Several plans have been recommended for this reduction; but the manual method, the oldest of all, is still entitled to the preference, notwithstanding the great number of instruments that have been proposed for the purpose. The operator can always proceed with greater facility behind, and on the sides of the pelvis, close to the sacro-iliac symphysis; the right hand will be used when the cord is to the left, and the left one if it is at the mother's right. Where the loop is small, it will only be necessary to push it up by the middle; but, in the contrary case, it is to be gathered up and pressed back little by little, just as the taxis is usually per- formed in the reduction of hernia. But merely pushing the cord back into the uterus will not be sufficient to protect it, and it must be carried up above the superior strait, and the hand retained in the vagina during several contractions to prevent it from falling down. Some accoucheurs, fearing that it could not be kept in position, notwithstanding this plan, have directed the introduction of the whole hand into the womb, with a view of placing the cord on one of the child's limbs; though this precaution is useless in most cases, it would certainly be pre- ferable to the pelvic version, says M. Guillemot, where there is a slight contrac- OBSTACLES DUE TO THE FCETUS. 639 tion of the pelvis. But the instrumental method must be attempted, where the smallness of the external parts, or an undilated os uteri, &c, render the intro- duction of the hand very difficult or impracticable. Some of the various instru- ments proposed for this purpose might then be used; perhaps M. Dudan's, recommended by M. Guillemot, is one of the simplest and best: He takes a gum elastic (male) catheter, of the size No. 9, armed with its stilet, and having a piece of narrow ribbon introduced into the last eye of the catheter, which is retained there by the extremity of the stilet; the ribbon is next attached to the umbilical cord, without drawing it too tight. If the loop of the latter is short, it is applied near the middle, but if long, the cord is to be first doubled up; being thus secured, the extremity of the instrument carrying the cord is then directed along the hand that had previously been introduced into the vagina, and placed within the uterine cavity. The hand in the vagina assists the return of the cord by preventing it from slipping in the noose of the ribbon. When the reduction is completed, we must wait until the head becomes en- gaged, before withdrawing the instrument; then the stilet is first removed and afterwards the catheter. Where the reduction proves to be impossible, the pelvic version, if the head is high up, and the forceps, if it is already engaged, are the only resources left us. But whenever version is resorted to, it is neces- sary to carry up the cord into the uterus, whilst searching after the feet (Boer), lest it be compressed either by the arm of the accoucheur, or somewhat later by the hips and the trunk of the child. ARTICLE IV. OF SHORTNESS OF THE CORD. The cord may be very short naturally; and, as elsewhere stated, it has been known not to exceed four or five inches in length, but such cases are very rare; most generally its brevity is accidental, that is, it results from the numerous turns made around the body, limbs, or neck of the child. The formation of these circular loops is favored by an unusual length of the cord. The latter, in a case reported by Baudelocque, measured fifty-nine inches, and made seven folds around the infant's neck; and Schneider saw a cord that mea- sured three and a quarter yards (three metres), and made six turns on the neck. Nothing is more common than to find children whose bodies and necks are en- circled by two or three of these folds. An accidental shortening of the cord may render the labor difficult, either by retarding its progress, or by making it absolutely impossible, or by causing the death of the foetus. This latter circumstance may result from the constriction undergone by the vessels of the neck, when the cord is tightly wound around this part; or it may be owing to an interruption of the circulation in the umbi- lical vessels, produced solely from the stricture of the cord itself, where it closely encircles a limb;1 again, these two causes may act simultaneously, and determine the child's death much more speedily. 1 This constriction is sometimes exceedingly great, and authors have certainly erred in / denying that it could ever be such as to strangle the foetus. Besides, it is not only at the 640 DYSTOCIA. The delay in the labor, caused by a shortness of the cord, is not usually mani- fested until the stage of expulsion, properly so called, begins; and then, as M. Guillemot justly remarks, the attendant phenomena will vary according to the point of attachment of the placenta. When inserted at the .fundus, it, like the wall to which it is attached, seems to descend at each contraction, and approach the os uteri, but after the pain, it retreats with the fundus to its original eleva- tion. In ordinary cases, the hand can detect this fact by being merely placed over the uterine tumor; but when a very short cord is forcibly stretched between the placenta and some part of the child's body, a particular phenomenon can be recognized by the touch; that is, the finger, when applied on the head, finds it advancing during the pain, and retreating as soon as it is over, because at this moment the fundus of the womb, which had been depressed by the contraction, regains its primitive position, and draws after it the placenta, cord, and foetus. But this sign will evidently be wanting where the after-birth is attached to the lateral parts of the uterus. We have met with a case in which the unusual shortness of the cord, which was only nine inches in length, certainly detained the head above the supe- rior strait for fifteen hours after the rupture of the ovum and the entire dila- tation of the os uteri; and we can affirm that, notwithstanding the closest at- tention, we were unable to discover any of the signs given by former authors; though it is true that the rapidity in the delivery of the after-birth, after the child's expulsion, did not permit us to ascertain at what point the placenta was inserted. Before the membranes are ruptured, this phenomenon might be confounded with the successive elevation and descent of the head, that takes place in nearly every case of labor. But to avoid such an error, it will suffice to remark, that the ascent of the head then takes place during the contraction, and it only falls back after the pain is over; being just the contrary of what occurs when the cord is dragged upon. Finally, in ordinary cases, when the head engages at the perineal strait, it is found to project during the contraction, and to retreat imme- diately after it from the reaction of the perineum, which, after having been for- cibly distended during the pain, retracts strongly, and thereby presses it back into the vagina. But, as Delamotte and Guillemot have remarked, whenever these movements of progression and repulsion merely depend on the elasticity of the perineum, "they are only present: 1. When the head engages at the inferior strait, and then they are the less evident as the pains are more rapid and more energetic; while, on the contrary, they commence much sooner when dependent on a brevity of the cord, and become more sensible as the head approaches the time of labor, and as a consequence of the tractions produced by the expulsory efforts of the womb, that an effect of this kind is observed, but these turns may also form during the pregnancy, and their constriction may then be extensive enough to occasion death. Thus, M. Monod met with a fetus upon whose limbs they had left very deep marks, not merely in the soft parts, but even on the bones themselves. The infant's neck often ex- hibits undoubted traces of them, and in one case, examined by M. Taxil, there were three circular folds around the neck, which was so diminished in size that its diameter did not exceed two or three lines (four millimetres). It is to such circular turns that M. Mont- gomery refers those spontaneous amputations, which M. Richerand and some others have supposed were dependent on a gangrene of the part. OBSTACLES DUE TO THE FCETUS. 641 vulva, because the tension on the cord is then increased; besides which, they are persistent, whatever may be the strength of the contractions, and are the more marked as the latter become stronger. " 2. On the other hand, when the placenta is attached to the lateral walls of the womb, these movements are very obscure, and the diagnosis quite difficult. In both cases, the shortness of the cord is accompanied by pain, which is felt at the point of attachment of the placenta, particularly in the latter moments of the parturition; this pain is a sensation of dragging, or tearing, which commonly coincides with the movements of progression and repulsion; and which might be compared to those felt by the patient when an attempt is made to remove the after-birth, before its complete separation." (Guillemot.) According to M. Naegele, Sen., these circular turns maybe discovered by auscul- tation during pregnancy or labor, by the existence of a bellows murmur accom- panying the foetal pulsations. I agree with M. Danyau in the opinion, that further research is required to establish the absolute value of this new means of diagnosis. (See Bellows Murmur.) The reader will now understand that a shortening of the cord may retard the progress of the head, whether it be still at the superior strait, or whether it has cleared the excavation and is on the point of engaging at the inferior strait. We ought to add that even the shoulders may be arrested, and the delivery of the trunk be prevented after the complete disengagement of the head, by the circular turns which are occasionally made around the child's neck by too short a cord. We were witnesses to a case of this kind, that occurred at the Clinique, in 1838, where a division of the cord, which was not made until two hours after the escape of the head, could alone effect a termination of the labor: the foetus was born dead. Delamotte (page 305) furnishes an instance precisely similar to this. The intervention of art is therefore sometimes necessary, although it often hap- pens that the trunk is delivered spontaneously. However, the mechanism is not the same in cases of natural and of accidental shortening; for, in those of nor- mal brevity, the head may remain applied against the vulva after its disengage- ment, without much inconvenience, and the extra-uterine respiration may be established and kept up. In a short time, the womb gradually contracts on the parts of the child that it still contains, and, being itself forced along by the bearing-down efforts of the patient, it sinks into the vagina, and, by thus ap- proaching the vulvar orifice, may easily force the trunk to the exterior. Occa- sionally, this descent of the womb does not occur at all, or else is not sufficient to permit the escape of the child; and then a rupture of the cord, or a detach- ment of the placenta, can alone enable the uterine efforts to complete the deli- very. Thus, in a case of the kind reported by Malgouyre, the discharge of the waters, the delivery of the child, and the expulsion of the after-birth, all occurred simultaneously : and the following instance is related by Dr. Rigby. After two or three hours of severe pains, the fcetus was suddenly expelled, and the cord was broken at about two inches from the umbilicus, so that, when the midwife attempted to deliver the after-birth, she could not find the other end of the cord; but, having introduced her hand into the womb, she felt and extracted the pla- 41 642 DYSTOCIA. centa; and it was then discovered that the cord had been lacerated at its point of insertion. In labors complicated by an accidental shortening of the cord, the child's head passes beyond the vagina, and retains its position there until a renewal of the pain; and when the latter comes on, the head is observed to pass to the sides of the vulva, whilst the shoulders, back, and breech successively disengage. This expulsion is sometimes effected so rapidly that it is difficult to follow it; but, if it be delayed in the least, a prompt intervention is requisite, for, as elsewhere stated, the compression made by the folds around the neck may speedily prove fatal to the child. In breech presentations, the labor usually terminates in the following manner, when abandoned to itself; the nates, after having been forced down to the vulva by the uterine contractions, turn up toward the side where the cord is situated, and then the trunk descends, becoming flexed on itself in the passage; so that, by the time the head reaches the excavation, the body of the child forms a curve, whose concavity corresponds very nearly to the symphysis pubis. Independently of the delay that it may cause in the progress of parturition, and the consequent danger to the foetus, a shortening of the cord* may produce other and serious accidents to the mother. It is to this circumstance, particu- larly, that we must, in most cases, attribute the rupture of the cord, and the pre- mature separation of the placenta, points to which we shall return, when treating of uterine hemorrhage. The danger of these accidents will vary greatly with the period of their occurrence; thus, at the commencement of labor, the bleed- ing thereby occasioned might seriously compromise the lives of both mother and child, if the resources of our art were not promptly interposed. But, if they do not occur until the moment when the head is ready to clear the vulvar orifice, they may rather be considered in a favorable light, for, as we have just seen, this is one of the means that nature employs for terminating the delivery. Again, if the cord and the adhesions of the placenta should obstinately resist, it is possible that an inversion, or at least a depression of the uterus, might be the immediate consequence of the child's expulsion. The inversion occurs towards the end of the labor, when the female is urged to bear down, by the distended condition of the parts; and as she still continues to strain, after the cessation of all uterine contractions, the relaxed womb yields the more readily to the action of the diaphragm, which tends to depress its fundus, because the short umbilical cord drags the uterine wall, where the placenta is attached, in the same direction. Treatment.—The disastrous consequences that may result from a shortening of the cord present different indications for treatment, according to the stage of the labor at which its existence is detected. When the membranes are still un- broken, if the os uteri be freely dilated, the contractions energetic, and there is every reason to suppose, from the signs before given, that a dragging on the cord is the cause of the delay, they should be ruptured at once; for, after the waters have escaped, the uterus will contract, its fundus will approach the cervix, and the cord, being no longer dragged upon, will permit the head to descend into the excavation. If the head be at the inferior strait, at the time when the alternate OBSTACLES DUE TO THE FCETUS. 643 movements of elevation and descent begin to manifest themselves during and after the contraction, the forceps should be applied. But where the head has only the resistance of the soft parts to overcome, we must be content with pre- venting it from remounting in the excavation after each pain, as much as pos- sible ; for that purpose we must apply the band strongly on the perineum, and while supporting it, favor the escape of the head by pressing it up in such a way as to aid its process of extension or disengagement. It would also be advisable to have the hypogastrium compressed at the same time by an assistant, in order to prevent the uterus from ascending during the interval between the pains Lastly, after the head is delivered, the accoucheur should immediately loosen the turns of the cord around the neck, and slip them over it; and where these folds are so tight as to resist the tractions made with that object, they should be divided, but it is not requisite to apply the ligature to the umbilical extremity of the cord at once. In most cases, indeed, it is necessary to allow this to bleed a little after the birth, in order to relieve the apoplectic state of the fcetus; for, by applying the ligature too soon, we would be deprived of this resource. Never- theless, where the expulsion is unusually delayed, the fcetal end of the cord will have to be slightly pinched between the two fingers to prevent hemorrhage.. A dragging of the cord entwined around the trunk or limbs is not at all unfre- quent in the natural labors by the breech, and when pelvic version has been effected. It is to be remedied by making moderate tractions on its placental extremity, and if these are not sufficient, it should be divided, and the labor ter- minated as speedily as possible. The same precepts are applicable in all cases where the brevity of the cord is natural; and if the accoucheur is obliged to carry his hand up into the womb to accertain the nature of the obstacle, he should take advantage of the occasion to effect the pelvic version, and to draw down the child until the base of its chest appears at the vulva; then the cord is to be cut and tied, or else compressed with the fingers, and the extraction of the foetus completed at once. It is advisable to introduce the hand again into the uterus, after the placenta is delivered, to ascertain that the fundus of the organ is neither depressed nor inverted. ARTICLE V. MALPOSITIONS OF THE FCETUS. The ancients applied the term malposition to all those cases in which the top of the head did not correspond to the os-uteri. But, as we have already demon- strated, the labor nearly always terminates favorably, both for the mother and child, in the presentations of the face and breech, though it is a little more diffi- cult than usual; and experience has even proved that it is barely possible in those of the trunk. Nevertheless, the first three presentations offer certain ano- malies and irregularities, that may at times render the labor difficult, and require the intervention of art; for, although the presentations of the vertex, face, and breech, are usually free and regular, yet they may be irregular or inclined. (See page 401, et seq.) But these last so rarely constitute an obstacle to the sponta- 644 DYSTOCIA. Fig. 96. neous termination of the labor, that we have not hesitated to include them in the description, heretofore given, of the mechanism of natural labor. In fact, the only modification they determine in this mechanism is that the head, in clear- ing the superior strait or traversing the excavation, undergoes a movement of correction, whereby the occipito-frontal or the sub-occipito-bregmatic circumfer- ence becomes parallel to the plane of the strait. But this movement is necessary; for, if the head exhibits its normal size, the delivery is only possible under that condition,1 and, when it does not take place, the resources of art are indispen- sable. Certain anomalies, capable of interfering with the expulsion, may also take place in the movements of "the head. We must now ascertain what are the indications for treatment presented in these particular cases. § 1. Inclined Positions of the Vertex. Under this title we include all those positions that have been described by Baudelocque, as the positions of the sides of the head, of the ears, the temples, and the occiput; the former of which is re- cognized by the presence of an ear, the angle of the jaw, or by the parietal protuberance; while a presentation of the occiput is detected by the triangular form of the posterior fonta- nelle, by the lambdoid sutures, and the vici- nity of the neck. In general, when an inclination of this kind is detected at the onset of labor, or shortly after the membranes are ruptured, there is nothing to be done; for it is well known that, in far the greater number of cases, the conversion is effected spontane- ously ; but, if the head still retains its primi- tive position for five, six, seven, or eight hours after the discharge of the waters, and its descent is thereby impeded, we must attempt an artificial correction. It is possible to accomplish this with the hand alone, which is always to be tried before resorting to an introduction of the lever or forceps; and it is unnecessary to add that any obliquity of the uterus, should it exist, must first be remedied. As a general rule, that hand should be used whose palmar face would grasp the vertex the most readily; and, when introduced into the womb (see Version), it grasps the occiput so as to draw upon it, after having first removed it from the iliac fossa; whilst considerable pressure is made with the other hand over the hypo- gastric region, in order to force the head to descend. When the correction can- The left occipito-iliac position, strongly inclined on its posterior parietal region. 1 However, we have known this conversion of an inclined vertex position into a free one to occur at the inferior strait in a woman with her first child ; the head was placed in the left anterior occipito-iliac position, and was, at the same time, inclined on the right parietal region. In descending into the pelvis, it retained this position, so that, when it had reached the floor of the excavation, we detected the ear; but it became rectified, after several strong pains, and cleared the inferior strait immediately after having undergone the movement of correction. The head was small, although the foetus was at full term. OBSTACLES DUE TO THE FCETUS. 645 not be effected by the hand alone, most accoucheurs recommend the employment of the lever; but we should decidedly prefer having recourse to the forceps, the blades of which would act at first as a lever in rectifying the head, and then, by their traction, the labor could be terminated almost immediately. Because, where seven or eight hours have been spent (according to our precept) in the vain hope that the powers of nature would be adequate to rectify the inclination; and, where the operator has unsuccessfully attempted to produce the correction by his hand alone, it must be evident that an early termination of the labor is indicated in the double interest of the mother and child; and that, consequently, the for- ceps should be preferred in such cases to the lever. The attempt to seize the head properly with the forceps and bring it down into the excavation, does not always succeed, in which case the difficulty maybe overcome by turning; at least, I found it to answer in two cases of failure by the forceps. I think, also, that I should be disposed to have recourse to it im- mediately, when the uterus was but slightly contracted, and still contained a con- siderable amount of water. § 2. Anomalies in the Mechanism of Labor. The occipito-posterior positions which are not converted naturally into anterior or pubic ones, may also allow of the spontaneous disengagement of the head, though, as we have already stated, they sometimes present insurmountable ob- stacles to the termination of the labor. We repeat that we have but little confi- dence in efforts made with the fingers to produce this movement of rotation, and that the application of the forceps seems to us the most useful means that can be employed. (See Forceps.) It is important to ^observe that the continuance of the occiput posteriorly some- times prevents the engagement of the head, which remains, long after the mem- branes are ruptured, above the superior strait, and that, notwithstanding the contractions are powerful. In such cases, the posterior fontanelle is hidden by the swelling of the scalp, and in order to diagnose the position, it is necessary to carry the finger upward and in front, when the anterior fontanelle will be disco- vered. At each contraction, the vertex strikes the horizontal branch of the pu- bis, and the presentation then tends to become converted into one of the nucha, so called by the old accoucheurs. I have noticed this anomaly more especially in the left occipito-posterior positions, and have always been obliged to use the forceps; quite powerful efforts are usually required to extract the head. The vertex positions, even when not inclined, sometimes present anomalies in their mechanism. Thus the movement of rotation, which, in the transverse positions, is calculated to bring the occiput under the pubic arch, is occasionally delayed for a long time, and thereby greatly retards the labor. When this delay is dependent on the feebleness of the uterine contractions, an application of the forceps is the best remedy. But, according to many authors, it may also be owing to what Levret called the wedging-in of the shoulders; that is, the latter then present their long bis-acromial diameter to the smallest one of the superior strait, and thus become firmly engaged or wedged there, in such a way that they cannot descend any further, and therefore arrest the progress of the head. This wedging of the shoulders, which can scarcely occur without a slight contraction 646 DYSTOCIA. of the abdominal strait, has been detected by Levret, by Delamotte, by Ruysch, et als., and its occasional occurrence is admitted by Desormeaux and Duges; consequently it should be regarded as being possible. This cause of dystocia would scarcely ever be suspected during the labor, unless attention were drawn to it by the mobility of the head in the excavation (Fried); this is the only sign that would be likely to arouse attention, where a normal conformation of the inferior strait has been ascertained, and where the contractions are strong and sustained. Under such circumstances, Levret advises (and Desormeaux seems to approve the counsel) the patient to be placed on her elbows and knees, with her head declining, with a view of removing the weight of the child's shoulders from the mother's parts; and then the accoucheur should slip his hand along between the head and the pelvic walls, seize the shoulder that is locked at the sacro-vertebral angle, draw it to one side and change its position. Although the performance of this manoeuvre is attended with difficulty, yet it is the only one practicable if the foetus be living; but where it is dead, he ought to diminish the head by craniotomy, so as to open a more ready passage up to the shoulders. Supposing this diagnosis to be well made out, it would seem proper to follow the recommendation of Desormeaux; but the fact is, it is so very difficult that, as M. Jacquemier judiciously remarks, the use of the forceps, though in reality irrational, is perhaps the only remaining resource. After the head is delivered, the expulsion of the body may be impeded by the size of the shoulders, and the danger to which the child is exposed in conse- quence, may demand the intervention of art. The forefingers may then be hooked into the axillae and strong tractions performed with them. Unfortu- nately, however, these are sometimes fruitless, and then, says M. Jacquemier, " the successive disengagement of the arms might be attempted with advantage." The rotation of the head, in virtue of which the occiput gets under the sym- physis pubis, may likewise be rendered difficult, or even wholly impossible, by the size of the sero-sanguinolent tumor of the scalp, that is always formed when the head remains in the excavation for some time; for, by engaging itself in the void of the pubic arch, this tumor may render the movement of rotation abso- lutely impossible. (Harnier.) Of course, the forceps must then be applied. Direct occipito-pubic or occipito-sacral positions are very rare, though certainly it is a mistake to deny their existence. We have already stated that the occi- put may be in relation with any point of the superior strait. In the immense majority of cases these direct positions are converted, after the labor begins, into diagonal ones; for the convexity of the forehead in the occipito-pubic positions, and that of the occiput in the occipito-sacral ones, having to glide over the sacro-vertebral angle, are almost always turned either to the left or to the right. In some cases, however, the primitive positions continue, and the labor termi- nates in nearly the usual manner. It occasionally happens that, if the head is large, and the pelvis but moderately developed, though well formed, the former is arrested at the superior strait, and impacted, as it were, by the two extremities of its occipito-frontal diameter. In such cases, the application of the forceps is the only resource. OBSTACLES DUE TO THE FCETUS. 647 § 3. Inclined Positions of the Pelvis. Sometimes one hip, at others the lumbar region, or the lower part of the ab- domen, according to the direction of the inclination, may engage first at the upper strait; particularly where the uterine obliquity is well marked. We must, therefore, correct this obliquity, which is the original cause of the anomaly; then, if that is not sufficient to replace the breech in a horizontal position, the feet are to be sought after and brought down, or else one of the groins be acted on by hooking a forefinger into it. § 4. Positions of the Face. The face positions may likewise be irregular; that is, it may happen either that only one cheek engages, in consequence of a lateral inclination, or else that the head, being but little extended, the forehead is found at the centre of the superior strait; or, on the other hand, this extension being carried to an ex- treme, that the chin and the front of the neck are alone accessible to the finger; but in all these, as in the preceding cases, nature herself is generally able to accomplish the delivery. The instances in which the forehead is first placed at the centre of the upper strait are quite frequent; but the extension being com- pleted at the moment when it engages the excavation, the face then becomes completely horizontal. (See Mechanism of Labor by the Face.) The same is true of the malar positions, the correction of which, like that of the parietal positions of the vertex, is effected during the period of descent. In those rare cases where the inclination resists the power of the uterine contractions, the cor- rection with the hand at first, then, in case of failure, the application of the forceps, if the head is engaged and immovable, or the pelvic or cephalic version, if it be high up, and can easily be displaced, appear to us the proper measures. The spontaneous reduction, just alluded to, as the most ordinary termination of the frontal or malar positions, is much more difficult in the cases where the chin, in consequence of the excessive extension of the head, has a tendency to engage first, and approach the centre of the excavation. For then, according to the observation of Madame Lachapelle, the head not only presents unfavorable diameters, but the body likewise shows a disposition to descend along with the face; though at the same time it presses the latter back from the passage, and thus creates an obstacle to its escape, while the contraction transmitted by the spine rather tends to augment than to correct the inclination. Under such cir- cumstances, we can trust less to the powers of nature, and therefore must en- deavor to change the position by a resort to pelvic version. These lateral inclinations are usually primitive, and, as we have already stated, are reduced spontaneously into correct positions. But it may also happen that a position which is entirely regular at the beginning of labor, may become con- verted into an inclined one, which nothing can restore. Thus, Dr. Birnhaum, of Bonn, mentions a case of right tranverse mento-iliac position, of the most regular kind, which became converted into a left anterior occipito-iliac one, strongly inclined upon the right parietal bone. The labor had to be terminated by the forceps. It is well known that a spontaneous delivery in face positions requires that they should be converted into mento-pubic ones; but this process of rotation, 648 DYSTOCIA. which is easily effected in the mento-anterior varieties, that is to say, in the cases where the chin was primitively in relation with some part of the anterior half of the pelvis, is much more difficult in the mento-posterior positions, and sometimes even it does not take place at all. And it must be acknowledged that an unre- duced engagement of the face, and its want of tendency to reduction, constitute one of the most serious difficulties met with in the obstetrical art. Now. with a view of more clearly specifying the various indications for treat- ment that may present under such circumstances, we will suppose four different cases of face positions, namely: lst. A woman has been in labor for a considerable time, the membranes are ruptured, and five or six hours, or even more, have elapsed since the waters escaped, during all which period the uterine contractions have been very strong; a good conformation of the pelvis, and a complete dilatation of, and no resistance from, the os uteri are recognized by the touch, and yet the presenting part still remains high up and does not engage in the excavation; but, in searching for the causes that retain this part at the superior strait, under so many favorable circumstances, it is found that the face presents in a mento-posterior position. Here there would be reason to conclude, in my estimation, that the delay in the labor is dependent on the non-reduction of the mento-posterior position into an anterior one; and, therefore, I think that an attempt should be made to convert the face position into one of the vertex. This could be done by introducing that hand' whose palmar face embraces the vertex most readily ; which would be the right one when the chin is directed backwards and to the right side, and the left in the opposite case; then, after having grasped the head with the whole hand, endeavor to push it up above the superior strait, and, if successful, surround the vertex with the palmar face of the four fingers, and flex the head on the chest, when, the position of the face being converted into one of the vertex, the uterine contractions will accomplish the rest. I am now convinced that this manoeuvre will rarely prove successful, therefore it should be attempted very carefully, and pelvic version substituted for it with- out much delay. 2d. If, to the mento-posterior position just described, whether the face be engaged or be still above the abdominal strait, any accident whatever be joined that demands a prompt termination of the labor, it is evident that the pelvic version is the only operation that could be resorted to with a prospect of advan- tage. 3d. If the mento-posterior position is coincident with a moderate contraction of the pelvis, most authors advise the conversion of the facial position into one of the vertex, and then the application of the forceps upon the flexed cephalic ex- tremity. It seems to us, that this previous cephalic version would prove very difficult, if attempted long after the membranes are ruptured, and we should give preference to turning by the feet. We shall have occasion hereafter to justify this precept, which is opposed to that given in the second edition of this work. We will then explain why it appears to us that extraction by the feet may be attempted in cases of contracted pelvis. The application of the forceps on the face in the mento-posterior positions, seems to us an extreme measure, which should only be employed when nothing else can be done, as in the next variety. OBSTACLES DUE TO THE FCETUS. 649 4th. Lastly, there are some unfortunate cases where it is impossible to push up the presenting part, either because the head has cleared the cervix uteri, or because the strong contraction of the womb renders every attempt abortive; and, therefore, both the pelvic and the cephalic versions are altogether out of the question. The accoucheur must then necessarily have recourse to instruments. The lever, the common forceps, the crotchet, and the embryotomy forceps have all been proposed in turn; but, before resorting to the latter, the first should al- ways be tried. In certain cases, the lever has proved very useful, and, where applied on the vertex or occiput, has occasionally depressed this part, and thus converted a face presentation into one of the vertex. It is oftentimes more easily managed than the forceps, when the head is high up, owing to the difficulty of getting the second blade of the latter to the proper height and position; and I may men- tion that it proved very serviceable in a case to which I was called by Dr. Four- nier, where the head had engaged in the excavation, in the right mento-poste- rior position, and could neither be pushed up nor advantageously grasped by the forceps. I believe that, in common with many practitioners, I have erred in proscribing this instrument almost altogether from practice; for the lever, in my opinion, may render very important aid in those posterior positions that approach a trans- verse character; and in which, from being still high up, an application of the forceps is exceedingly difficult. (See Lever.) As to the forceps, though proscribed by Madame Lachapelle, in the cases under consideration, it may be tried as a dernier resort, as that would be far better than embryotomy when the child is living; but, to be successful, it is necessary that the operator should be well versed in the movements that are to be given to the head by the instrument. Thus, supposing the blades are pro- perly applied on the sides of the head (and the difficulty of this is well known), should we attempt to bring the chin round in front (Smellie) ? or would it be better, leaving the chin posteriorly, to endeavor to depress the forehead and occiput, and then to disengage these parts first under the pubis? Relying on the cases published by former authors, I do not hesitate to decide in favor of the last manoeuvre; for every practitioner must acknowledge that the ro- tation of the chin forwards exposes the child to very great dangers from the extent of the movement in the atloido-axoid articulation, and the two favorable cases reported by M. P. Dubois, which he himself considers as exceptions, can- not make us overlook all those in which this excessive rotation has cost the child's life.1 1 I have had occasion to prove very evidently the danger attendant on this extreme ro- tary movement. In July, 1845, I had charge.of a case of right mento-sacro-iliac position in a primipa- rous female, and the continuance of which rendered delivery impossible, and required the intervention of art. After fruitlessly endeavoring to press up the head, we were obliged to use the forceps, the child being still alive. Having applied the blades upon the sides of the head, we endeavored to bring down the vertex, but it was impossible. Neither was one of the branches of the forceps applied as a lever upon the vertex more successful. We thought it right, before having recourse to embryotomy, to endeavor to turn the chin in front; therefore, replacing both blades of the forceps, we turned the head so as to 650 DYSTOCIA. I am willing now to be less exclusive, for M. Blot's facts, besides some others, have convinced me that artificial rotation of the chin in front may sometimes be accomplished, without necessarily compromising the life of the child. We may be content, indeed, to bring the chin up to the ischio-pubic ramus, in which case, if it were a sacro-iliac position, the rotation would hardly exceed a quarter of a circle; and if it were at first a mento-sacral position, we might hope that the uterine contractions would cause the body to follow the rotation given to the head by the forceps, and twisting of the neck be thus avoided. We shall see hereafter how far the modifications of the process to be employed, recommended by MM. Champion, Baumers, and Danyau, are capable of facili- tating this rotary movement. Grounding myself, therefore, on the observations of Smellie (t. xi, p. 579), of Meza (Acta Regice Societatis Med. Hauniensis, t. xi, p. 379), and of Siebold (Siebold's Journal, ann. 1830, p. 209), I would begin, after having applied the blades as accurately as possible on the sides of the head, to draw directly down- wards and backwards, with a view of depressing the vertex. I am well aware of the objections to this mode of procedure, and that it may be said that, during the movement of flexion, which you impress on the head, the long occipito-mental diameter must necessarily pass one of the diame- ters of the excavation, thereby often creating an insurmountable obstacle to the delivery. I do not deny the force of this objection, and am willing to confess that in theory it is not altogether satisfactory; still, of what consequence is the theoretical impossibility, where positive facts bearing on this point can be adduced, and some of which I have just quoted? But the somewhat material authority of facts is not the only one I might invoke; for does not our reason tell us that, when any of those cases (fortunately very rare) are presented in practice, which seem beyond the pale of all theoretical notions, and in which the practitioner is constrained to do what he can, not what he would, the wisest course is to follow as closely as possible the route traced out by nature? Now, has it not often happened that the labor terminated alone, in the mento-posterior positions of the face, and yet the chin has remained behind throughout ? And what has been the mechanism under such circumstances ? By consulting the published cases, we shall find that the uterine contraction was incapable of depressing the chin, and has seemed to transfer its action to the occiput; and then the forehead, the vertex, and the occipital extremity, by slipping behind the symphysis pubis, have successively appeared at the centre of the pubic arch. Is it not, therefore, logi- cal to recommend an attempt to impress the same movement of flexion on the head, in the hope that the tractions by the instrument, coming to the aid of the make the chin correspond with the right extremity of the transverse diameter, and next, after a slight rearrangement of the blades, behind the right acetabulum. The face was then in the lower third of the excavation, and the vulva being partially opened by the in- strument, we saw distinctly motions of the lips and tongue of the fetus. The rotation was then completed, and when once the chin came in front, the head was disengaged by the usual flexion. Though the heart of the fcetus still beat feebly, it could not be restored to life by long-continued and well-directed efforts. I am convinced that the death of the fcetus was in this case simply due to the extreme twisting of the neck. OBSTACLES DUE TO THE FCETUS. 651 expulsory efforts of the womb, would succeed in accomplishing what these latter alone could never effect ? What we have stated respecting the impossibility of spontaneous conversion in direct mento-sacral positions, and of its natural explanation in the diagonal mento- posterior positions, finds here its practical application. The consequence is, that if the chin were turned directly toward the anterior face of the sacrum, we should, before flexing the head with the forceps, impress upon it a slight rotary movement, which would bring the chin to one of the sacro-iliac symphyses, pre- ferably toward the right, in order to avoid compressing the rectum, which is situated to the left. Should these efforts to flex the head prove unsuccessful, we ought to endeavor to bring the chin in front; nor would I hesitate to prefer so doing, if the child were dead. My own experience, as well as that of others, has so much changed my view in regard to this point of practice, that I willingly admit having been hitherto too exclusive. I believe, therefore, that both methods may succeed in some cases, and it being impossible to determine a priori in which one or the other will be more successful, it were prudent to try them successively. Again, there are some unfortunate cases in which, after having vainly at- tempted all the different manoeuvres just referred to, craniotomy becomes our only resource.1 Do not the supposititious cases just given (which could easily be sustained from the facts reported by authors), by rendering us acquainted with the vari- ous difficulties that may be encountered in these cases, lead us to adopt, for the mento-posterior position, the rules heretofore laid down by Baudelocque, Gardien, and others, for all face positions ? And though, in the present state of our science, the mento-anterior positions should be abandoned to nature, yet does the same rule hold good with regard to the mento-posterior ones ? In a word, if this last position be clearly recognized before or shortly after the membranes are ruptured, should we not, prior to the engagement of the face, and while the head is still movable, endeavor to convert it into a vertex position, and thus pre- vent the difficulties that might subsequently arise ? If I had to decide under such circumstances, I would certainly resolve the question in the affirmative. § 5. Positions of the Trunk. A natural delivery in trunk presentations is a very unusual occurrence, and 11 have quite recently witnessed a case of this nature with Dr. Letannelet, who requested my attendance on a yo ung lady in her first labor. I saw her at eight o'clock in the evening, and detected, as my learned associate had previously done, a right mento-posterior position (the frontal variety): the head had been firmly engaged since three o'clock in the afternoon, and from that hour had not advanced a single line. At eleven, a^no change had taken place either in its position or elevation, we attempted unsuccessfully to push it up. Both M. Letannelet and myself tried the lever and the forceps in vain; but before resorting to craniotomy, which was then deemed indispensable, we requested M. Dubois to see the patient. He arrived at one o'clock in the morning, and renewed the attempts that we had before made, without any better success, and craniotomy was then decided upon ; but as the woman had great need of rest, and the necessary instruments were not at hand, the operation was deferred until eight o'clock a. m., when it was accomplished with much difficulty; for, notwithstanding his dexterity, M. Dubois had the greatest trouble in ex- tracting the head with the embryotomy forceps. 652 DYSTOCIA. one upon which the accoucheur should never rely. It is therefore an absolute rule in practice to attempt to bring one extremity of the fcetus to the superior strait as soon as possible, by resorting either to the pelvic or the cephalic ver- sion. (For the divisions, causes^ and diagnosis of this mechanism, see Natural Labor, page 449, et seq.; and for the indications, the chapter devoted to Ver- sion.) § 6. Complicated Positions. Under the title of "fallings" (procidentia}), Madame Lachapelle has described the untimely descent of any part whatever of the child, which cannot of itself constitute a particular position on account of its tenuity or mobility, but which, however, might complicate the presentation of a more extended region. Thus, the umbilical cord, the feet, or the hands, may individually or collectively come down at the same time as the head or breech. This complication will be very readily detected by the touch, and therefore it is unnecessary to enumerate the peculiar signs that distinguish each of these parts. We have already spoken of a falling of the cord, and of the means of remedy- ing it. Again, in those cases where one hand has slipped under the head or breech, the labor may terminate alone if the pelvis is well formed and the con- tractions are strong and continued; and hence we should delay all operations. Even the pressure of both hands on the lateral parts of the head has not always proved an insurmountable obstacle to the spontaneous termination of the labor, for all these parts have occasionally been expelled together; but if the passage be somewhat contracted and the soft parts resistant, it would be advisable to ter- minate the delivery artificially by the application of the forceps or by version, according to whether the head has or has not cleared the superior strait; and to bring down the feet in the breech presentations. This latter plan should also be followed if one foot instead of the hand, or if both a foot and a hand accompany the head. Nevertheless, before resorting to an artificial delivery, the accoucheur should always endeavor to push back the hand or foot into the uterus and get it above the head. Most frequently, it will only be necessary to sustain it there during the pain, which urges on the head, to find the latter descending alone and arriving at the inferior strait, and then the labor may be abandoned to na- ture. We must remark, however, that a foot is far more difficult to return than the hand, and that in consequence of its volume it often constitutes an obstacle which cannot be surmounted by the ordinary resources; wherefore, craniotomy is sometimes indispensable, as several recorded observations fully prove. A descent of the foot has hitherto only been observed, I believe, in the pre- sentations of the flexed cephalic extremity; but I have had an opportunity of meeting with it in a face presentation; and the rarity of the circumstance, together with the difficulties that attended the delivery, induces me to narrate it here in detail: I was suddenly aroused on the 4th of November, 1842, at five o'clock in the morning, by M. X----, a pork butcher in the Rue du Cadran, who came to re- quest my attendance on his wife, who had been in labor for two days previously, under the care of Dr. Lome, her physician and accoucheur. Having arrived at the bedside of the patient, I learned the state of the case from my worthy asso- \ OBSTACLES DUE TO THE FCETUS. 653 ciate, after which I proceeded to an examination per vaginam. But before stating its result, I must transcribe here a short account of the case, sent me by M. Lome himself, who gives the detail, much better than I could (from simple recollection), of what he learned of this woman's previous history, as also an account of what occurred during the labor. He says : " I was summoned to the Rue du Cadran, No. 7, on the 2d of November, 1842, at six o'clock in the evening, to attend Madame X----in her confinement. I ascertained from the patient that she had had seven children, and from her ac- count the former labors had terminated in the following manner, namely: ," 1. First child : a long and painful labor of three days' duration; presenta- tion of the cephalic extremity; the labor was natural, but the infant died a few days after its birth. "2. Second and third child: presentation of the pelvic extremity; delivery spontaneous, or by the aid of simple tractions; both children dead. " 3. Fourth child : the uterine contractions disappeared for twenty-four hours after the rupture of the bag of waters ; expulsion of the child during the accou- cheur's absence. "4. Fifth and sixth child : presentation of the cephalic extremity; labor long and painful; delivery natural. One of these infants lived a few months. " 5. Seventh child: shoulder presentation and a descent of the arm. M. P. Dubois, having been called in consultation, ascertained the child's death, and performed embryotomy. After the parturition there was an inflammation of one or more of the abdominal organs. "Madame X----is thirty-two years of age, is of a medium height and san- guineous temperament, and exhibits all the evidences of good health. Nothing in her external organization would lead us to suspect the existence of any defor- mity of the pelvis, and the normal pregnancy seemed to be at its regular term. The preceding night she experienced some pains, which passed off in the morn- ing, but again reappeared at six o'clock in the evening. I examined her, soon after my arrival, and found the os uteri dilated to the size of a five franc piece; I readily distinguished the bag of waters, which was relaxed in the intervals, but was tense, and protruded through the uterine orifice during the pain; but I could recognize no part whatever of the foetus. At midnight the amniotic sac projected into the vagina like a stuffed pudding, and descended nearly to the vulva, when it soon ruptured spontaneously and permitted the escape of more than two pounds of the waters. But still I could touch no part of the child, even after the discharge of the waters, at any height within the reach of my finger. Now, however, the scene suddenly changed; for the pains, that were hitherto strong, died away; and, as the patient assured me that the uterine con- tractions had been thus suspended for twenty-four hours in a former labor (the fourth), and afterwards regained a sufficient degree of force to effect the delivery, I had her replaced in bed. " I found the woman in the same condition at eight o'clock in the morning of the next day, the 3d of November; some pains were perceptible in the left groin and flank, but the parts of the foetus were still inaccessible......No notable change occurred in the course of the day. Nine P.M.—I recognized the left leg and foot lying across the os uteri at the superior strait; the pains were very strong, though they had not the characters of the expulsive ones. 654 DYSTOCIA. u Nov. 4th, the pains were stronger, but the labor did not advance. As the os uteri was sufficiently dilated, I concluded to search after the secoud foot, but it proved to be rigid, and would scarcely permit the hand to enter. I found a hard and rounded tumor just above the foot first detected, which I suspected to be the head. But after making some vain attempts to push it up, and to find the right foot, I sent for M. Cazeaux." Having received this history of the case, I proceeded to an examination of the state of the parts. I found a foot at the upper portion of the vagina, which proved to be the left one, with its heel directed backwards, and a little to the right; then, by passing my finger behind the symphysis pubis, I detected-a voluminous tumor, which was pressed so forcibly against the anterior arch of the pelvis, that I could not insinuate the finger between it and the pubic symphysis; at first, I thought it was formed by the right buttock, and I diagnosticated a right posterior position of the breech, with the left limb doubled up on the an- terior part of the belly, and the other, on the contrary, stretched out along the abdominal and thoracic plane of the child. The contractions again became strong and energetic, but, notwithstanding the complete dilatation of the cervix, the presenting part did not engage. While searching for the cause of this delay, I carefully examined the pelvis, and detected a considerable prominence of the sacro-vertebral angle, whereby the antero-posterior diameter was reduced to three inches and one-eighth at the most. I then resolved to draw on the foot, but, to my great surprise, these tractive efforts proved wholly ineffectual. By again placing my hand on the tumor, that I had originally taken for the anterior but- tock, I found it to be harder and much more voluminous than I had at first sup- posed, and I recognized it as the head, surmounted by a large and soft tumor, or caput succedaneum. I tried in vain to find the sutures and fontanelles; but, by gently slipping the fingers between this tumor and the leg belonging to the pre- senting foot, I felt a very irregular surface, and soon after recognized distinctly the eyes and eyelids, and then the other signs of a face presentation. It was, in fact, an irregular presentation of the face, in which the chin was directed back- „. wards and to the left, and somewhat engaged at the superior strait (a left mento-iliac posi- tion, and the head not completely extended: or, in other words, Baudelocque's fourth posi- tion of the forehead). To sum up, I was, in attendance on a woman whose sacro-pubic dia- meter was but three inches and one-eighth at the outside, and whose foetus was presenting in an irregular or frontal variety of the left posterior mento-iliac position, and this compli- cated by a descent of the left foot; besides which, the waters had been entirely evacuated for thirty-two hours, and the uterus was The left posterior mento-iliac position com strongly retracted. I was not discouraged, plicated by a descent of the left foot. i i n .i_ j-«- n- „„ however, by all these difficulties; my first thought was to push up the foot that had become engaged under the head, but all such efforts proved abortive; I then applied (though not without some OBSTACLES DUE TO THE FCETUS. 655 trouble) a fillet on the foot, and endeavored to press back the head, while draw- ing at the same time on the fillet; but this was equally unsuccessful, for the head was firmly sustained by the powerful contractions of the womb, and did not move. As the child was still alive, I next decided on an application of the forceps. The introduction of the blades and their articulation were effected both without diffi- culty and without much suffering to the patient, and they were placed on the sides of the pelvis; but, notwithstanding the most powerful tractions, which were kept up for half an hour, I could not make the head advance in the least degree. After resting for a few moments, I withdrew the instrument in order to re-apply it, and this time I was fortunate enough to place the blades directly on the sides of the head; I then communicated to the handles a slight rotary movement, so as to get the face in a transverse position. But all proved ineffectual, for I drew with all my force, and M. Lome succeeded me; both of us exhausted our strength to no purpose, and I then withdrew the forceps, and permitted the woman to rest for an hour. Having decided on a resort to craniotomy, if a third application should be equally unsuccessful, I requested my associate to go, during this inter- val, after Smellie's scissors, and the embryotomy forceps. An hour afterwards the common forceps were again introduced and easily applied, and tractions on the fcetus were once more made by M. Lome and myself for half an hour with- out any better success. Being then fully convinced of the impossibility of a natural delivery, and of the impotence of our efforts; as also that, notwithstanding the existence of the heart's pulsations, the unusual delay in the labor (thirty-two hours after the am- niotic sac was ruptured), and the compressions made by the instrument, must have necessarily compromised or even destroyed the viability of the foetus, and having only to choose between a bloody operation on the mother or a mutilation of the child, I resolved on the performance of embryotomy. Smellie's scissors, covered at their points by a little pellet of wax, were guided along the palmar surface of my left hand, and directed perpendicularly on the head, where they had to penetrate through the soft parts to the depth of nearly an inch before meeting with any resistance from the bony vault; I then rotated them, and they entered into the substance of the brain without difficulty; I next opened the blades in two different directions, so as to make a crucial incision, the radii of which were about half an inch in length; then penetrating still deeper into the cerebral substance, I worked the scissors in various directions so as to break up the brain. The male and then the female blade of the embryotomy forceps were next introduced, and locked without any trouble, as also without pain to the patient. The articular part touched the vulva. By aid of the vice, I next closed the instrument, leaving only a space of about one inch between the ends of the handles, and tractions were then made; but I soon found the blades slip- ping. It was necessary to begin the operation anew, and the same accident occurred again. The third time the slipping commenced, and I only succeeded in arresting it by suspending the tractions, and closing the forceps more firmly, when the head was finally extracted; but the chest was arrested at the superior strait, and considerable efforts were still necessary for the extraction of the rest of the trunk. The delivery of the after-birth, being immediately effected, pre- sented no particular difficulty. 656 DYSTOCIA. In a case of twin labor, the particulars of which were communicated to me by Dr. Leflem, of Pontrieux, the second child presented in a mento-pubic position, complicated with procidentia of the right foot and right hand, the heel of the foot being turned toward the pubis. It is true, that since an attempt to turn had been made by a midwife, it is impossible to know whether these situations of the hand and foot were spontaneous, or the result of awkward manipulations. How- ever this may be, M. Leflem found it impossible either to push up the head or to use the forceps with advantage. Not having the proper instruments for per- forming embryotomy at hand, he was obliged to leave the patient for a few hours, and on his return he found that she had expired. It is possible that, if after having discovered the impossibility of turning occa- sioned by the contraction of the uterus, bleeding to syncope had been practised, or if the state of the patient did not allow of this, large doses of opiates or anaesthetics had been administered, the patient might have been delivered. The unfolding of the lower limbs in the positions of the pelvic extremity, and the stretching out of the arms in that of the shoulder, are merely concomi- tants of the principal presentation, and should not be looked upon as an un- favorable complication. The extension of the arm, or the presentation of the hand or arm of certain authors, has been considered by them as one of the gravest complications of labor; but it has already been shown, in the article on Spontaneous Evolution, that a descent of the arm rather favored this latter process than otherwise; and we shall hereafter see that it is only from circum- stances foreign to the presence of the arm itself, that the version is at times rendered more difficult. (See Pelvic Version.) BOOK III. OF THE DISEASES AND ACCIDENTS THAT MAY COMPLICATE LABOR, AND REQUIRE THE INTERVENTION OF ART. The numerous causes of dystocia that have just been studied, are not the only circumstances which, by disordering the regular course of nature, may re- quire an artificial termination of labor; for, even when surrounded by the most favorable conditions, it may possibly be complicated by the occurrence of some accident serious enough to compromise the life of either the mother or the child in a few minutes. The accoucheur should render himself perfectly familiar with the indications presented by these formidable accidents, because their suddenness and danger will rarely permit him to reflect long on the choice of the most suit- able means to be employed; and we cannot, therefore, too strongly urge practi- tioners to make them a subject of serious and profound study. PUERPERAL HEMORRHAGE. 657 CHAPTER I. OF PUERPERAL HEMORRHAGE. Hemorrhage is certainly one of the most frequent and at the same time most dangerous accidents that can occur to puerperal women, whether before, during, or after parturition; for it is most generally fatal to the child, when it occurs at an early period of the pregnancy, and always subjects the mother to the greatest dangers, at whatever period it may come on. Under the double as- pect, therefore, of the mother's safety, and the child's life, it constitutes a pathological phenomenon, which should interest every one in the highest de- gree ; not only every physician who devotes himself more especially to the prac- tice of midwifery, but likewise all who are engaged in the practice of medicine ; for any one may be summoned in a time of pressing danger, and all may, by ill- directed or proper attentions, compromise or save the lives of two beings equally dear. The importance of the subject, therefore, will justify the detail into which we propose entering. We designate as puerperal hemorrhage (or the hemorrhage that occurs in the puerperal state) every hemorrhagic accident that pregnant women may be affected with, either during gestation or in the course of the labor and lying-in; thus, comprising under this denomination, not only the losses of blood that have their source and seat in the genital organs, or in the foetus and its appendages, but also all the effusions that may take place into the tissue of the principal viscera as a consequence of an exaggeration of the modifications impressed on the general circulation by pregnancy. But we shall devote a more particular attention to the discharges that have their source in the vessels of the uterus, or fcetus, or their appendages. As to the other hemorrhages, whatever be their origin, or the seat of effusion, they present the same indications for treatment in the puerperal state as at any other period of life, and consequently do not claim our attention here. For, during the labor, whether the hemorrhage takes place in the lungs, the stomach, or the brain, the only thing to be. done is to combat it by the usual means, if the dilatation of the os uteri is not sufficiently advanced to admit of an artificial termination of the labor. But in the contrary case, the accoucheur should apply the forceps at once, or resort to version, and thus relieve the patient as promptly as possible from the danger that threatens her. ARTICLE I. OP THE CAUSES OF UTERINE HEMORRHAGE. The causes of uterine hemorrhage have been divided into the predisposing, the determining, and the special causes. § 1. Op the Predisposing Causes. We must place in the first rank of the predisposing causes, all the disorders in the general circulation that are induced and kept up by pregnancy, and which 42 658 DYSTOCIA. are manifested by palpitations of the heart, by obstructed respiration, varicose swellings of the veins of the lower extremities, and by the fulness and greater activity of the pulse; but, above all, it is important, in order to understand the mode of action of the causes described below, to bear in mind the changes that have occurred in the structure of the womb itself; which changes have been studied in detail, when describing the anatomical phenomena of gestation, but which we again bring forward in a summary way, for the better illustration of the subject under consideration. The mere fact of conception produces a state of orgasm in all the genital organs, the uterus particularly, which determines a considerable afflux towards these parts. In some women, of a sanguineous temperament, this state of irri- tation is not confined to the hypertrophy of the mucous membrane, but the deve- lopment of its vascular apparatus is attended or followed by an exhalation of blood, and, in the course of a few days, a uterine hemorrhage takes place that seems to be only a menstrual return, but which, in reality, interrupts a commen- cing pregnancy. In certain cases, this fluxion is not limited to the uterine ves- sels ; for, when very considerable, it causes an aneurismatic or a varicose swelling in the neighboring parts, such as the vessels of the broad ligaments, which run to the tube or ovary. These trunks occasionally give way, and produce a mortal hemorrhage, as Al. Leroy says he found to be the case in two women who died a few days after marriage. During the first month of its intra-uterine life the ovum occupies only a very small portion of the uterine cavity, all the rest being filled with the pouch formed by the epichorial decidua and parietal mucous membrane ; and hence, being free and floating, and having as yet contracted but feeble adhesions with the walls of the organ, the product of conception can only be developed by imbibing the juices secreted on the internal surface of the womb (see Nutrition of the Foetus); which secretion requires a much greater activity in the circulation of the uterus, and may become a cause of flooding, under the influence of the least disorder. Somewhat later, the placenta begins to be developed, and with it those numerous vessels which, coming from the internal surface of the uterus, and the external one of the chorion, appear, so to speak, to run to meet each other; then they interlace without inosculating, and ultimately become united, forming a mass that is held together by a species of flaky lymph, a product of the uterine secretion. Now, who does not see in this process of vascular organization, in this copious secretion that is constantly going on, and requiring so much activity in the cir- culation of the organ, a continual predisposition to hemorrhage? For, if any vivid moral impression, or any violent physical commotion, disturbs the harmony that presides over this new creation for a single instant, by causing a derange- ment in the circulation, the just relations established between the ovum and the womb are at once destroyed; and the blood, being forced too rapidly into these recently formed vessels, overcomes the resistance of their feeble walls, and a flooding results in consequence. At a still more advanced period of the gestation, when the placenta is orga- nized, the production of hemorrhagic accidents is singularly favored by the double circulation of which it is the seat, by the great de\ elopment of the uterine vas- cular apparatus, and by the peculiar structure of the utero-placental vessels. PUERPERAL HEMORRHAGE. 659 Quite recently, M. Jacquemier has carefully studied the influence of each of these circumstances, and the following summary will serve to illustrate the re- sults of his inquiries. When we examine the uterus of a pregnant woman in the latter periods of gestation, after having undergone its usual transformations, we are struck with the development of its vascular system; for the trunks of the four arteries that nourish the organ have increased in size, and their divisions or ramifications in the texture of the womb are wonderfully multiplied. The vessels that existed before the impregnation have more than doubled their calibre, and a great num- ber of others that did not exist, or rather were not visible, have successively formed, become enlarged, and attained a considerable size. We have hitherto mentioned (see art. Pregnancy) the extraordinary development of the uterine veins; and it is only necessary to recall here the feebleness of their walls, which are composed of a single coat, their adhesion to the uterine tissue, and the nume- rous divisions sent by them into the cavity of the organ, which penetrate directly or indirectly into the substance of the placenta itself. It results from this ar- rangement that, in the arterial system of the womb, the blood passes from trunks of a moderate size into cavities very numerous and spacious in proportion to the volume of the trunks; which cavities are formed by the numerous rami- fications given off from the latter in the substance of the uterus; while, in the venous apparatus, a much greater disproportion exists between the trunks of the uterine and ovarian veins and their branches, so that the blood passes from very large cavities into narrower tubes. This arrangement has been considered by M. Jacquemier as a cause of the retardation in the uterine circulation, and as being calculated to produce a venous stasis, followed by an engorgement of this system, and, as a consequence, the rupture of the vessels and hemorrhage; which venous rupture is further favored by the want of resistance on the part of the utero-placental veins. According to his view, all the causes under whose influence floodings are found to result, merely act by producing this engorgement of the uterine venous apparatus; and hence the immediate cause of hemorrhage is the rupture of one of the vessels appertaining thereto. But we cannot fully embrace this theory, so far, at least, as regards the hemorrhages that occur during gestation, for we do not believe that the retarda- tion in the circulation is so extensive as M. Jacquemier has described. Al- though the blood arriving by the uterine arteries passes into the larger cavities constituted originally by the arterial and afterwards by the venous ramifications (the uterine sinuses), yet it seems to us that this cause of delay would be com- pensated by the rapidity with which the blood contained in these venous capil- laries must pass into the trunks where they empty; and even by virtue of that very law of hydraulics quoted by M. Jacquemier in favor of his theory, namely, (; when a liquid flows in full stream through a tube, the quantity of this liquid which, at a given moment, traverses the different sections of the tube must everywhere be the same. Consequently, as the tube becomes larger, the rapidity diminishes; but increases as the tube becomes smaller." If, therefore, the course of the blood is slackened in the arteries by its passage from the main trunks into the ramifications, it must be accelerated in the veins by its passage from 660 DYSTOCIA. the ramifications into the trunks; and hence there must be a compensation in its rapidity. But an infinity of circumstances may destroy this harmony; and which series of vessels will then be the seat of the congestion, and afterwards of the rup- ture? M. Jacquemier supposes that some point of the venous system will al- ways yield the first; for he says, u Every part of the uterine vascular circle is not equally exposed to this species of rupture; and the arteries tvould even be wholly excnqit, unless they were the seat of some morbid lesion. The utero-pla- cental arteries themselves would rarely be a primitive seat of rupture from the mere impetus of the blood, although the surrounding delicate tissue in which they ramify supports them in a much less perfect manner than the elastic tissue of the womb, and besides is easily torn; but the utero-placental veins, from their situation and organization, can afford but a very moderate resistance, which will frequently be overcome." No doubt, the venous parietes are less resistant than the arterial ones; but which of the two has the greater stress to bear? Do not all the causes, under whose influence the uterine congestions and subsequent hemorrhages are produced, act first on the arterial, before being perceptible in the venous system ? And is not the plethoric condition first manifested by a fulness of the pulse ? M. Jacquemier supposes that, as the circulation is im- peded in the vena cava inferior, it must determine a reflux of the blood con- tained in these vessels; which reflux would be primarily felt in the uterine veins, and then in their ramifications; and that this would likewise be favored by the particular structure of the uterine veins themselves, which, during ges- tation at least, arc destitute of valves. This absence of valves must certainly favor the reflux of the venous blood; and it is possible that, under the influence of some of the causes enumerated by this writer, a congestion and then a venous rupture might be the primitive phe- nomena; but we cannot admit that this is generally the case in the hemorrhages that occur during gestation. And whilst acknowledging that our friend has rendered an important service to the profession, by calling attention to a par- ticular variety of mechanism in the production of uterine hemorrhages, we must persist in considering his theory as being only applicable to a small number of cases. (See Archives Generates de Medecine, 1839.) I must yet bring forward another anatomical peculiarity, which, perhaps, will serve to reconcile two conflicting opinions. It has been said by some persons that all uterine hemorrhages proceed from a separation of the placenta; while others contend that many of them result simply from an exhalation of blood from that portion of the internal surface of the womb not occupied by the placental insertion. Doubtless, the floodings that occur during pregnancy are most fre- quently caused by a rupture of one or more of the utero-placental vessels; but it is not to be supposed that this rupture is the only source of hemorrhage, for we have already seen that, in the early months of gestation, the ovum only occupied the uterus in part, all the rest of its cavity being filled with the tumefied and very vascular mucous membrane, and that, in consequence of the greater activity of the circulation, an exhalation of blood might take place from the internal sur- face of the womb. This fact is unquestionable; but even after the placenta is completely formed, and the ovum occupies the whole cavity of the womb, there PUERPERAL HEMORRHAGE. 661 are still, as elsewhere described, some arterial and more particularly some venous radicles found existing externally to the placental mass, that might give rise to a hemorrhage, in which the proper utero-placental relations would be in no wise concerned. From the foregoing, it would appear that a hemorrhage may take place during gestation : lst, by sanguineous exhalation, especially during the early stages; 2d, from a rupture of the veins, and oftener, of the utero-placental arteries, properly so called; 3d, from a rupture of the veins and arterioles that ramify in the sub- stance of the decidua beyond the placenta. Among the anatomical modifications impressed on the uterus by gestation, the development of its muscular structure has recently been pointed out by M. Gen- drin as a predisposing cause of hemorrhage. At the close of pregnancy, the womb is formed of two evident layers, an external and an internal one; and it is the relation of these two muscular laminse with the vascular one that explains, according to his view, the influence that it has over the production of flooding. This double muscular layer may, under the influence of various external or internal irritants, become affected with spasms, which produce irregular contrac tions in some part of the organ. He states that such spasmodic contractions are very frequent after the third month, and that they are often noticed after exter- nal, moral, or physical impressions, or the tumultuous movements of the foetus, or, indeed, when the vitality of the latter has ceased. The patient first becomes conscious of it by some peculiar sensations and movements in the uterine globe; and when the gestation is somewhat more advanced, the hand, applied on the abdomen, enables us to ascertain that the sense of movement felt by the woman is dependent on a real contraction of the uterine walls; which gives rise to cer- tain irregular elevations, that slip about and become displaced under the hand by something like a peristaltic movement, of which the patient has always a very distinct perception. These contractions frequently accompany the hemorrhage, sometimes they precede it, and seem to be the earliest phenomena that succeed the action of the pathological cause. Although they may be considered as resulting in the first place from the discharge of blood, and, possibly, from the formation of coagula, whose presence incommodes and irritates the womb; yet, in the second, they must be regarded as an active cause in the production of the flooding. In fact, it is impossible for any contraction to take place in the external mus- cular layer, without modifying the circulation in the subjacent vascular one; hence, when the vascular plexus of this intra-uterine lamina is irregularly com- pressed by the muscular contractions of the organ, the blood must flow back into some part of the placental disk, thereby determining a partial congestion, which may cause the rupture of one of these feeble venous ramifications, and, as a con- sequence, a sanguineous extravasation. But the influence of the spasmodic action is not limited to this; for, by effecting a retraction that is confined exclu- sively to segments of the uterine globe, they necessarily draw upon the placental adhesions, and may, perhaps, rupture them. Besides these local modifications, whose power to produce hemorrhage it is impossible to deny, there are still numerous other circumstances that we might point out, which have the same effect. But, let it suffice to recall the physiolo- 662 DYSTOCIA. gical and pathological changes that gestation impresses on all the functions, which have already been studied under the titles of the Physiology and Pathology of Pregnancy. Let us remember the almost constant presence of serous plethora, the habitual fulness of the pulse, flushing of the face, and increased activity of nutrition and circulation which are manifested in most plethoric women during the early months; also, that succeptibility which the least emotion excites and irritates; that delicacy of sensation natural to most nervous females, but carried to the highest degree in pregnant ones; and, finally, let us recall the fact that, during the gravid state, the uterus is, as it were, the common centre, upon which all the general disorder caused by any moral or physical excitement is directed. Then we will understand the reason why most authors have considered a ple- thoric constitution, a profuse normal menstruation, and the lymphatic tempera- ment, which so often accompanies great nervous irritability, as predisposing causes of puerperal hemorrhage ; why plethoric females are so often affected with flooding at the return of the monthly periods, since their habit determines at these times a greater activity and a more intense congestion in the womb; why venereal excesses have often been followed by a profuse flooding, by causing a long-continued and over-excitation in all the genital organs; and, lastly, why every circumstance calculated to determine or to keep up an unusual activity in the general circulation, and particularly a more considerable afflux of fluids to- wards the gestatory organ, has been at all times considered as predisposing the woman to hemorrhage; such, for instance, as fatigue, the frequentation of balls, of plays, and crowded assemblies, where the air is impure and at a high tempera- ture; prolonged watching; over-heating diet, and the use of alcoholic drinks; as well as all local irritants, such as the abuse of drastic purgatives, which, by pro- ducing excessive irritation of the intestines, may react on the uterus; hip-baths, the frequent application of leeches to the vulva, the existence of any organic alteration, or an acute inflammation in the neighboring organs, or in the womb itself; because all these circumstances are calculated to maintain an habitual state of congestion toward the womb. § 2. Determining Causes. The prolonged action of the predisposing causes jnst enumerated may even- tually produce a hemorrhage; and thus, after having acted for a long time as the predisposing, finally become determining causes. But, in addition to these, some other circumstances have been enumerated by authors, which might be desig- nated as- accidental determining causes. These are so numerous and varied that, to exhibit them, it would be necessary to bring forward nearly all of the cases that have ever been published. Besides, all these causes may be referred either to acute moral emotions, or to physical disturbances; for example, to a violent passion; the sudden arrival of some unexpected person or intelligence; a fit of anger; sharp bickerings, &c.; to the jolting of a rough carriage; to riding on horseback; a fall on the feet or nates; blows on the abdomen; efforts to carry or lift some burden; to cough, vomiting, &c, &c, &c. (See art. Abortion.) But these causes, the list of which I might have lengthened greatly, do not all have the same mode of action; for some of them, such as most of the moral ones, act primarily on the whole organism, and only react on the womb secon- PUERPERAL HEMORRHAGE. 663 darily; while others, like the generality of the physical causes, are addressed, as it were, directly to the gestatory organ, and, by the shock they communicate, have a tendency to disturb the relations existing between it and the product of conception. It is generally conceded that the former determine a more consider- able afflux of blood towards the uterus, then an engorgement of the utero-placen- tal vessels, and finally the rupture of those vessels; or, if the pregnancy is but little advanced, the afflux of blood is followed by a sanguineous exhalation from the internal surface of the organ. But how, it may be asked, is the hemorrhage produced after a fall, blow, or any physical commotion whatever, especially in the latter stages of the gestation ? And is the separation of the placenta, which is then a very common occurrence, the primitive phenomenon, and has it caused a vascular rupture ? Or, indeed, has this rupture taken the precedence, and has the effusion of blood between the after-birth and the uterus resulting therefrom produced the separation of the placenta? The latter opinion appears to me the more probable; for, although there can be no doubt that the feeble bonds of union which attach the placenta to the uterus may be ruptured at once, as a con- sequence of some very violent shock or fall from an elevated place, since, under like circumstances, the very substance of the solid organs, the liver in particular, has been lacerated, yet this certainly does not happen in a large majority of cases; because the ovum forms a full sac, which is in immediate contact with the walls of the cavity that encloses it, and the placenta is sustained by the waters and the fcetus within and by the uterine wall without. The organ and its con- tents constitute a whole, that cannot be separated by any general concussions unless they are very severe. Wherefore, so long as the membranes remain un- ruptured, it is difficult to conceive that the separation could be effected otherwise than by the effort of the blood to escape into the cavity of the womb. In conclusion, although these physical and moral disturbances are enumerated by authors as being capable of producing a hemorrhage, it must not be supposed that they constantly have this unfortunate result; indeed, their influence is far from being always in proportion to their violence and intensity. In general, they only act and are followed by flooding, because a predisposition exists in the patient which the determining cause excites and brings into play. I might men- tion individuals in whom the least excitement has been followed by a hemorrhage that proved fatal to the foetus, whilst others have borne the most severe moral disturbances without accident; and several cases were cited in the article on Abortion, which prove that the most violent physical shocks oftentimes give rise to no disorder whatever. We must, therefore, admit the intervention of a pre- disposing cause in the majority of cases; a cause which often, indeed, plays the most important part in the production of the accident. § 3. Special Causes. Independently of the general causes just studied, there are some which might be termed special causes, because they depend on certain peculiarities in the posi- tion and structure of the ovum; and the influence of which is particularly apt to be felt at an advanced stage of gestation. We allude to an abnormal insertion of the placenta, to a rupture of the umbilical cord, and to some other pecu- liarities about to be mentioned. 664 dystocia. 1. Insertion of the Placenta upon the Lower Segment of the Uterus.—Nearly all the older authors detail cases in which the placenta was found inserted over the neck of the womb at the time of labor. But some of them altogether mis- understood the cause of this disposition, and supposed that the placenta had been detached in totality from the point where it was originally inserted, and had fallen from mere gravity on the neck of the' womb; while others, who had ob- served it to be still adherent by one margin to some point of the periphery of the cervix, concluded that this adhesion was only accidental and merely occasioned by the clotted blood; which, says Deventer, sometimes glues the placenta so closely to the orifice that it might be taken for an excrescence of the part. There were others, again, who had noted the fact with much care, without attempting to give any explanation of it; Levret was among the first to direct attention to this im- portant point, for he demonstrated its frequency and danger, and studied the causes and proper methods of detecting it. However, this abnormal insertion had been pointed out long before the time of Levret; for Giffart, in narrating a case of hemorrhage, wrote, in 1730 : "I cannot receive as absolutely true the opinion of those authors, who say that the placenta is always attached to the fundus uteri, for in this case, as in many others, I have every reason to believe that it adhered on the internal orifice, or very near to it; and that, in dilating, the latter occasioned the separation of the after-birth, and as a consequence the hemorrhage." (Observ., 115 et 116) Heister (Institutiones Chirurgicales, chap, cliv, part i) likewise says : " Some moderns think that the adhesion of the placenta over the neck is a cause of hemorrhage; and, therefore, that the more the os uteri dilates the more abundant is the flooding." Finally, we find in Portal's work, which appeared in 1685, observations which show conclusively that he is entitled to the honor of having first described this faulty insertion. In six of his cases, the placenta presented, was in entire contact with the orifice of the womb, and was adherent throughout. The author even endeavors to show how the hemorrhage occurs in these cases, giving the explanation which was afterward accepted by Levret and many others. As we detailed the various circumstances, when studying the anatomy of the placenta, which, according to most authors, determine the point of attachment of this vascular mass, it will be unnecessary to revert to them here. We would merely observe that the placenta has various relations with the orifice, giving rise to several grades or varieties of'faulty insertion. Thus, the placenta may be inserted near the orifice or on the orifice, covering it entirely or in part. These various insertions have received different names, as marginal when the placenta extends very near the circumference of the orifice; incomplete orjwr- tial when it covers it only in part; complete or central, when it covers it entirely ; and, finally, we have the term intra-cervical insertion when, as seems to be proved by some cases of Madame Lachapelle's, the ovum has happened to insert itself in the cavity of the neck itself. Further observations are, however, re- quired to establish the latter as a true variety. The insertion of the placenta over the os uteri has been considered, since the days of Levret, as an inevitable cause of hemorrhage during the last three months of gestation, and in the course of the parturition. The flooding then, says Gardien, is an immediate result of the gestation, and particularly of the PUERPERAL hemorrhage. 665 labor. Most modern writers, supposing that the modifications occasioned by pregnancy in the disposition of the neck towards the latter months are the sole cause of the hemorrhages that then occur, have adopted the same opinion; and the following, in their view, is the mechanism whereby the discharge is produced. Up to the fifth month, the body of the womb undergoes numerous changes, but, after that period, the neck is also involved and participates therein. (See Pregnancy.) The diminution in its length is accompanied by a more considera- ble enlargement of its base on a level with the internal orifice. The placenta, being fixed and immovable on the spot where it is implanted, cannot follow this spreading out of the upper part of the neck, and hence the bonds of union which it has contracted with the womb necessarily become ruptured, as do also the utero-placental vessels; and this rupture produces a more or less considerable discharge. But it is only necessary to recall what was stated in the article on Pregnancy, to be convinced that this explanation, which is founded on a false, though hitherto admitted fact, ought to be rejected; since it is at the lower part of the neck, at least in women who have previously borne children, that the eversion of its cavity commences; and, in all, the internal orifice often remains closed until the last few weeks of gestation. The neck, therefore, does not spread out at its superior part, and, consequently, we are not to search there for the cause that produces the hemorrhage, when the placenta is inserted over the cervix. The following explanation appears to me more plausible : During the first six months of gestation the uterus is developed more especially at the expense of the fibres of the superior part of the body or fundus of the organ; while in the last three months, the fibres appertaining to the lower third of the womb are de- veloped in a rapid manner, and the cavity of the organ is enlarged in conse- quence of the distension and growth of this lower part; a proof of which is, that the body of the uterus, which was pyriform in the earlier months, is per- fectly ovoidal in shape towards the close of pregnancy; and I will further re- mark, that the development of the placenta is far more rapid in the first six than in the last three months. Now, this double circumstance seems to me quite sufficient to account for the production of hemorrhage; for when the placenta is attached to the fundus, its growth is simultaneous with the enlargement of that portion of the uterine walls on which it is implanted, aud it is evident that no hemorrhage need occur; but when the after-birth is inserted over the cervix uteri, or on some adjacent point, the contrary must necessarily ensue, because the growth of the placenta is nearly completed, whilst a more considerable ex- tension of the lower third of the womb has yet to take place. Of course, the placenta can no longer participate in this rapid development, by conforming to the increase of the uterus, and by following the extension of the wall on which it is inserted; and hence it spreads out from the centre towards its circum- ference, the fissures between the cotyledons become larger, and its different lobes are thus widely separated; but the growth of the inferior wall of the uterus is so rapid in the latter months, that this mechanical enlargement of the placenta, on which M. Jacquemier has particularly insisted, is no longer sufficient to prevent the tension of the utero-placental vessels, or of the cellular tissue in which they ramify; aud this tension being ultimately carried to an extreme, all 666 dystocia. of these cellulo-vascular adhesions give way and become ruptured, and thus give rise to the production of hemorrhage. If this be the true explanation. there is no necessity for invoking a diminution in the length, and a spreadinc out of the upper part of the neck, which really does not take place. By it we can also comprehend the possibility of a circumstance that is inexplicable under the theory generally received,—I allude to the hemorrhages that occur when the placenta is attached to the lower part of the womb, on some point adjacent to the internal orifice ;* for it is not because the after-birth is implanted over the cervix that a flooding takes place during the latter months of pregnancy, but be- cause it is in relation with the inferior third of the uterus. The explanation usually given, is true only with regard to those sanguineous • discharges that come on in the latter weeks of gestation or during the parturition; for then, the spreading out of the cervix uteri, and its complete effacement, must necessarily have a great influence over the production and profuseness of the flooding, in those cases where some point of the circumference of the pla- centa is in immediate relation with the neck; but still more especially in those where the insertion takes place, as it is said, centre for centre. The hemorrhages of which we are speaking occur, besides, most frequently in the latter weeks or during the labor. Although a hemorrhage is usually considered to be inevitable under such circumstances, yet it may not appear even during the labor; and the dilatation of the os uteri may be effected without the loss of a drop of blood. This absence of discharge is doubtless a rare circumstance; but its authenticity at the pre- sent day is well established by numerous cases; authors only differing as to the explanation given of it. Thus Walter supposes that in cases of this kind there is probably a larger and more easy communication between the venous and arterial radicles of the uterus than usual, whereby the blood may pass from the arteries into the veins without escaping externally; and M. Mercier imagines that the exhalant vessels of the womb are then in a state of constriction, of per- version of their sensibility, which is sufficient to retard the course of the blood; but these two explanations appear to me inadmissible. M. Moreau remarks that, 1 It affords me pleasure to acknowledge that M. Jacquemier, in his excellent Memoire sur le Mecanisme des Hemorrhages, has anticipated me in describing the part which the succes- sive development of the fundus and the lower portion of the uterus performs in the pro- duction of certain hemorrhages; but, unfortunately, he does not avail himself of it to explain the flooding in the cases where the placenta is inserted over the cervix uteri; for he says, " As to the latter, the explanation given by Levret, and since adopted by nearly al! observers, is perfectly correct." I believe, on the contrary, it is wholly erroneous; for whilst, according to M. Jacquemier, the tardy development of the lower portion of the body of the uterus can only explain the accident when the placenta is inserted in such a way that its margin is quite near to the orifice of the womb, I consider it the only cause of hemor- rhage during the gestation, even when the placenta is inserted, centre for centre, directly over the internal orifice. So decided a declaration left no doubt in my mind as to the opinion held by M. Jacque- mier in 1839. It appears, however, that I misunderstood my honorable confrere, since he claims at present the priority of the theory which I believed I was the first to give in 1840. " Though," M. Jacquemier said to me, " the explanation is not clearly expressed in my memoir, it certainly was in my mind." I am willing to believe it, since M. Jacquemier says so ; but it must at least be allowed that I committed the plagiarism unwittingly. PUERPERAL HEMORRHAGE. 667 in the reported cases, the children were dead, and perhaps had been so for seve- ral days; now, says he, as soon as the infant dies in the womb, the cessation of the foetal circulation occasions changes in that of the organ; the blood being arrested in the vessels, coagulates there; the latter retract, or even become ob- literated, and no more blood reaches the womb than what is necessary to its nutrition, since the stimulus that heretofore determined a greater quantity to it, no longer exists; and hence the dilatation of the orifice may be effected without hemorrhage, notwithstanding* the vessels are torn that united its borders to the placenta. It seems to me that, in spite of objections raised against it, this view is correct, at least as regards some cases. In others, it may be as M. Jacque- •mier remarks, that the accomplishment of the delivery without accident is due either to the entire separation of the placenta, or to its detachment on one side only to a point just beyond the uterine orifice, so that the dilatation can pro- gress without increasing the detachment; the vessels previously torn having been stopped by coagulated blood. Thus we may account for cases in which hemorrhage had occurred several times during pregnancy, without reappearing at the time of labor. Lastly, if the rupture of the membranes should occur at the commencement of labor, it is possible that the uterine retraction, which would naturally follow a discharge of the waters, and the compression that would be made by the head on the part left uncovered by the separation of the placenta, might entirely oblite- rate the lacerated vessels, and thus put an end to the hemorrhage; and yet the fcetus be living. 2. Rupture of the Cord, or of one of its Vessels.—It is now an incontrover- tible fact, that a rupture of the umbilical vessels, or of the omphalo-placental trunk itself, may take place; and, inexplicable as it may seem, it can no longer be called in question, since it has been successively observed by such men as Delamotte, Levret, Baudelocque, Naegele, &e. This rupture, and the hemor- rhage to which it inevitably gives rise, may be occasioned either by some disease of the vascular tunics, by a particular arrangement of the vessels of the cord, or by a brevity of the latter, whether this be natural or dependent on numerous turns made around different parts of the foetus. A. ''The umbilical vessels," says M. Velpeau, "are sometimes ruptured : I am in possession of several examples of the kind; but it is because they were pre- viously in a diseased state." In a case reported by M. Deneux, the blood escaped through the umbilical vein, which was varicose at several points. The subjoined curious instance, which I reported in my Inaugural Thesis, might pro- bably be attributed to a state of disease in the ramifications of the vessels of the cord; in this case, the hemorrhage occurred between the chorion and the foetal surface of the placenta, in consequence of a rupture of all the ramifications of the umbilical vessels. This case, which I believe is unique, and hitherto but little known, has generally been misinterpreted by those who have referred to it, and I therefore feel justified in republishing it here.1 I must confess, that it is not with- 1 Rooques-Marie-Joseph Herce, aged twenty-nine years, pregnant for the fifth time, and advanced to the seventh month of gestation, was brought to the Hotel-Dieu on the fifth of May, at midnight. The midwife that accompanied her informed us that she had had sharp pains since five o'clock in the evening. The patient appeared much enfeebled; her 668 DYSTOCIA. out some hesitation that I attribute the flooding, in this instance, to a previous disease and rupture of the umbilical vessels. For, might not such a rupture be consecutive to an effusion of blood proceeding from one of the utero-placental face was pale and slightly jaundiced; and this debility had been caused, the midwife fur- ther told us, by a hemorrhage that had lasted since the fourth month of pregnancy. The flooding had considerably increased from the moment the pains began; and it was owing, added the attendant, to an implantation of the placenta over the os uteri. The patient was placed in the ward of Saint-Benjamin, where we made a vaginal examination, the re- sult of which was as follows: the os uteri was dilated to the size of a five-franc piece, and the cervix was soft, wholly effaced, and did not contract at all. The finger, having been introduced into the uterine orifice, detected a hard, resistant, ovoid body, which we reeognized as the fcetal head in the first position. No soft body whatever was interposed between our finger and the cranial teguments, and we concluded that, if the placenta were inserted over the neck, it was not at least by its centre. By carrying the semi-flexed finger around the internal periphery of the neck, we endeavored to ascertain whether the after- birth was not attached to one of the lips of the orifice: but as we found nothing of the kind, the error of the midwife was manifest, and though unable to determine the cause of the hemorrhage, we did not hesitate to reject her opinion. The finger being still in the orifice, we felt the womb contracting moderately, in consequence, probably, of the irrita- tion produced by the touch. The hemorrhage was arrested, the head engaged at the su- perior strait, and the patient, though feeble, still retained a sufficient degree of strength to second the efforts of nature. We thought there was nothing further to be done than to encourage the woman about her condition, and to persuade her to aid the uterine contrac- tions, that began to be developed quite strongly, as much as possible. In fact, the labor advanced very well, without a return of the hemorrhage, and at four o'clock in the morn- ing she was delivered of a dead child of seven months, which was pale and colorless, but exhibited no signs of putrefaction. Its delivery was followed by the expulsion of three large clots of blood, each of which was as big as the fist; but the flooding was not again renewed; the cord was about the usual length, and there was no circulation in it; but we were not a little surprised, after having cut it, to find that it was no longer attached to the mother; but that it exhibited, on what should have been the placental extremity, a kind of membrane, in the centre of which it seemed to be implanted. The membrane was nearly as large as an ordinary placenta, and was evidently continuous with the debris of the bag of waters; and we at first supposed it to be one of those membranous pla- centas spoken of by authors. This view appeared the more probable, as some vessels, evidently arising from the termination of the cord, ramified in its substance. We then thought the opinion of the midwife might possibly be correct, as the want of thickness in the placenta might have prevented us from recognizing it. When we returned to the pa- tient, at eight o'clock in the morning, we found her doing very well; but what was our astonishment, when the nurse brought forward a placenta, which the woman had expelled after our departure! Thenceforth all our suppositions were, groundless, and it was neces- sary to resort to an examination of the pieces for a better explanation of the phenomena offered by this patient. The following was the result, as all the members of the Anato- mical Society have since been enabled to verify: the uterine face of the placenta was smooth and normal,' but its fcetal surface was entirely deprived of the portion of chorion that ought to cover it, and was irregular, nodulated, and clearly exhibited the anfractu- osities that separate the cotyledons. It was covered over by thick clots, and the debris of the torn and separated vessels that ordinarily ramify on its surface could readily be detected; the loose extremity of some of these vessels was an inch long. By a further careful ex- amination of that portion of the pouch hanging to the cord, which we had taken for a membranous placenta, we were enabled to detect on the surface that covered the after- birth, some vascular debris, which had been continuous with those observed on the foetal surface of the placental mass. The cavity of these vessels was patulous, and some were PUERPERAL HEMORRHAGE. 669 vessels, the ramifications of which, as elsewhere demonstrated, get beneath the membranes that cover the placenta ? This effusion would have produced a sepa- ration of the chorion, and then a rupture of the umbilical vessels. The pro- fuseness, and the return of the hemorrhage, and the continuance of the child's life up to the commencement of the labor, would certainly be more easily explained by this latter hypothesis than by the former. An attempt has been made to misconstrue this case since its first publication; and it has been said that numerous loops of the cord probably existed, or else that some artificial tractions had been made upon it; but I can affirm that nothing of the kind took place, and that the circumstance occurred just as I have described it. B. The abnormal distribution of the umbilical vessels, which was pointed out in the description of the cord, may also produce a hemorrhage fatal to the fcetus, during the parturition. The subjoined case, described by M. Benckiser as oc- curring at the clinique of M. Naegele, can leave no doubt on this point.1 obstructed by fibrinous coagula of recent formation. The principal divisions were intact and permeable to the blood. From that examination, we felt authorized to conclude: 1. That the placenta was not inserted over the neck; 2. That the hemorrhage was not produced by a detachment of the uterine surface of the after-birth; but that it resulted from a separation of that portion of the bag of waters that was attached to the after-birth ; that this separation was effected at first on some point of the foetal surface of the placenta, then over a greater extent, and finally separating this mass altogether from the foetal envelopes; 3. That, becoming more and more considerable, this separation had produced a gradual increase of the hemorrhage; and it was only when the detachment had been completed, and the bleeding had become excessive, and all communication being interrupted between the mother and child, that the pains were manifested, and the abortion took place. This examination likewise en- abled us to account for the cessation of hemorrhage from the time of the patient's arrival at the hospital, as also for the quantity of coagulated blood that escaped after the delivery of the child. In fact, as soon as we touched the woman at the time of her entrance, the head began to engage in the pelvic excavation, thus acting the part of a tampon and preventing an external discharge ; but the blood did not tbe less continue to escape and to accumu- late internally, thus giving rise to the formation of coagula, and their discharge after the delivery. 1 A countrywoman, about twenty-six years of age, was admitted into the hospital in No- vember. 1830. Her labor commenced on the seventh of December at noon ; by three o'clock the os uteri was dilated to the extent of an inch, and the tumor formed by the bag of waters could readily be felt. While exploring with the finger, an abnormal cord, about the size of a writing-quill, was detected in the substance of the membranes, running from behind forwards, and exhibiting no pulsation. After the rupture of the bag, the waters escaped, and were followed by a few drops of blood. The head was found in the excava- tion in the first position, and it then appeared that a fold of the cord had become placed between it and the right sacro-iliac symphysis ; but a very feeble pulsation could be dis- tinguished in it, and attempts to push it up were made to no purpose. As the labor was progressing actively, Professor Naegele terminated the labor by the forceps. When the right blade was applied, a large quantity of water mixed with blood came away; indeed, this latter fluid had not ceased to flow during the four hours that elapsed between the rupture of the sac and the termination of the labor, and the patient must have lost six or eight ounces of it; the delivery of the placenta took place half an hour afterwards. The child, though pale and colorless, still presented some evidences of life, but it died in the course of a few minutes ; it weighed six pounds and a quarter. At the autopsy, the fcetus exhibited signs of anemia, and everything evinced that its death had been caused by hemorrhage. An examination of the after-birth discovered the source of the bleeding; 670 DYSTOCIA. c. The brevity of the cord may prove a cause of its laceration, not only after the rupture of the membranes, but even before the commencement of the labor the placenta had its usual form and texture, but the membranes were somewhat thicker and more dense, and their laceration was just sufficient to permit the child's escape; the umbilical cord was attached to the membranes at about two inches from the placental border; and, starting from this point, the vessels of the cord were no longer held together, but they separated and ramified in different directions on the membranes ; and then, after these divers ramifications of the arteries and vein had run over their internal surfaces for a more or less considerable extent (though variable for each, from two inches up to ten), they entered, the placenta, some at its centre, but the greater number by its margin. The author of the thesis alluded to, carefully describes the course and disposition of these various branches ; but, as the limits of this work do not permit me to give his de- scription in detail, I will only quote the principal points. The first branch, arising from the division of the umbilical vein at the point of its insertion in the membranes, ran to- wards the right, traversed a considerable portion of their internal surface, and was ulti- mately prolonged to the opposite border of the placenta ; the rupture of the membranes took place just in this route at its most distant point from the placenta, and this had necessary produced a rupture of the venous trunk just described ; and to it, without any doubt, must be referred the flooding that occasioned the child's death, as proved by the autopsy. The mere descent of the cord could have no influence on its death; for, in cases dependent on that cause, the opening of the dead body exhibits the symptoms of congestion. Dr. Panis, Professor of Midwifery in the Medical School of Reims, has kindly furnished me with a similar case : " Madame H----, of Reims, thirty-six years of age, has had four children ; her labors were fortunate, and the children were large and living. I was called to her in her fifth labor about six o'clock, on the morning of the 17th of January last. I learned, on my arrival, that the waters were discharged at five o'clock, and that they were accompanied with blood. The motions of the child were felt the day before until evening. Mad. H---- had slept all night, and was only awakened by the rupture of the membranes. On exami- nation I found the vertex in the left posterior occipito-iliac position, and the os uteri dilated to the extent of an inch and a quarter. At first, the labor advanced regularly though rather slowly ; blood continued to flow, though in small quantity, and at ten a.m., Mad. H----was delivered of a dead child, which was disengaged in an anterior position. " Being surprised at the death of the child, whose face was but slightly colored and its development perfect, and whose motions had ceased to be felt only at the time the mother fell asleep, I sought for the cause of the accident, and found it in the umbilical cord as soon as I had extracted the placenta. The cord was, in fact, inserted upon the membranes, at the distance of about three inches from the placenta. The vessels composing it were separated, and, after traversing the membranes, entered the circumference of the placenta. One of these vessels belonging to the umbilical vein, was ruptured at the distance of about an inch and a quarter from its insertion in the placenta, precisely at the spot where the membranes themselves had been torn. I immediately concluded that death had been caused by the hemorrhage following the rupture of the vein. It also explained why the discharge of blood had occurred at the instant the membranes gave way. I have pre- served the specimen, which will be placed in the Museum of the Medical School of Reims." Although cases of this kind are very rare, they may nevertheless occur again, since this disposition of the vessels in the cord has already been reported quite a number of times; but it can only endanger the child when the rupture of the sac takes place in the course of one of the venous or arterial ramifications. Where the vascular trunk exists on the por- tion of the membranes engaged in the os uteri, as in the case under consideration, we might anticipate the consequences ; but what measures should then be employed to pre- vent the flooding ? It would appear to us advisable to retard the rupture of the membranes PUERPERAL HEMORRHAGE. 671 and the discharge of the waters; and thus produce that variety of hemorrhage which has been designated as the intra-amniotic. I repeat again, that I am un- willing to reject any fact, however extraordinary it may be, when it is advanced by experienced and conscientious observers, who declare they have taken every precaution to avoid all sources of error; consequently, I admit that this rupture may take place, Madame Lachapelle and Boivin, and M. Velpeau, to the con- trary notwithstanding. In such cases, the rupture has doubtless been favored by an abnormal weakness in the vascular walls, and by the diminished resistance of the sheath that surrounds the vessels; but it may be more particularly attributed to the tensions on the cord itself, that are probably produced before the mem- branes give way, by the immoderate movements of the foetus; which movements are probably excited by the annoyance that the turns of the cord occasion it. After the discharge of the waters, and during the expulsion of the child, the shortened cord becomes stretched, and its tension augments as the head ap- proaches the vulva; when, as a general rule, its rupture alone can permit the expulsion to be effected.1 According to most accoucheurs, this unusual shortness of the cord may give rise to flooding by determining a premature detachment of the placenta. But it appears to me that such a separation can scarcely occur from a mere dragging on the cord, because, during the uterine contraction, the placenta is strongly pressed by the womb externally, and by the amniotic liquid internally, or, still more, after the escape of the waters, by the body of the child. Now, these parts must evidently react on the fcetal surface of the after-birth with all the force of impul- sion communicated by the contraction; of course, the fcetus can only advance, and, consequently, the tension of the cord can only take place under the in- fluence of this contraction; and I repeat that, while it lasts, the placenta is moulded on and forcibly pressed against the parts contained within the sac, and, of necessity cannot be separated from the womb. I believe, therefore, that a separation of the placenta from a tension of the cord is almost impossible during the continuance of the contraction; but it may take place before or during the labor, and prior to the escape of the waters, if the cord be very short and the movements of the fcetus are very active. As to those cases, in which it is com- monly said the child is born with a caul, that is, where the head pushes the membranes before it, it may happen that the dragging to which these latter are subjected, being communicated to the placenta, may occasion its premature sepa- ration and give rise to uterine hemorrhage; more particularly where this body is not attached directly to the fundus of the organ. as much as possible, if they be still whole, and to terminate the labor immediately after their rupture. In the former case, the os uteri should be permitted to dilate sufficiently ; but, in the latter, an attempt ought to be made to terminate the labor before the discharge has been profuse enough to cause the infant's death. These measures would evidently be more urgent if, instead of a venous trunk without pulsation, it should be an arterial one, recognizable by its throbbing, which, from its position on the membranes, was threatened with laceration. 1 For further details relative to the rupture of the cord, see the observations of Portal, Pratique des AcGouchements, p. 267 ; Lamotte, Tra.iti des Accouchements, p. 362 ; Levret, Ac- couchements Laborieux, p. 199 ; Baudelocque, Recueil Periodique de la Sociili de Midecine de Paris, t. iii, p. 1; Naegele, Annates Cliniques d'Heidelberg, 1826; and of Busch, Siebold's Journal, ann. 1828. 672 DYSTOCIA. § 4. Rapid Contraction of the Uterus. A sudden and rapid contraction of the womb may likewise produce a disas- trous hemorrhage, by destroying the cellulo-vascular attachments of the placenta; for this contraction, which, when restricted to proper limits, is a physiological condition of labor, becomes a cause of premature separation of the placenta, when it takes place too rapidly or at too early a period of the travail. This is apt to occur in cases of dropsy of the amnios, where a large quantity of the waters escapes at once; for the uterus then passes from an enormous bulk to a much more circumscribed volume than what comports with the dimensions of the fcetus on which it is applied. It likewise happens after the expulsion of the first child in twin pregnancies; for the contraction that follows this process may, by sepa- rating the placenta appertaining to the other twin, cause a flooding that might prove fatal to both mother and child, if a long interval should elapse between the two deliveries. The hemorrhages that so often complicate a rupture of the body or neck of the womb, and those which constitute the thrombus of the vulva and vagina, have already been considered in separate articles, and we shall not again revert to them here. ARTICLE II. SYMPTOMS OF UTERINE HEMORRHAGE. The symptoms of uterine hemorrhage may be divided into general and local. 1. General Symptoms.—In some cases, the flooding commences in so sudden and rapid a manner that the discharge of blood is the first symptom manifested; this is more apt to occur in those instances where the hemorrhage follows the violent action of some external cause. Most generally, the woman experiences, during the few days preceding the accident, some uneasiness in her limbs, a general and unusual malaise, a sensation of weight and of numbness in the pelvis and a dull and obscure pain in the loins, in the upper part of the thighs and groins, which is augmented by the erect position, by strainings at stool, and by the act of urinating; and, in many cases, there is a constant desire to pass the urine. These phenomena, which are characteristic of a local uterine congestion, are accompanied by the symptoms of general plethora; that is to say, by pains in the head, vertigo, dimness of vision, flushing of the face, and by frequency and fulness of the pulse. After these general disorders have lasted some days, it is not unusual for the active movements of the foetus to die away, and to be- come very feeble, or, perhaps, not at all perceptible to the patient. After the lapse of some time, varying from a few hours to several days, these precursory phenomena give way to the general symptoms of hemorrhage, which are the same as accompany every loss of blood: namely, pallor of the skin, feebleness of the pulse, and coldness of the extremities; the intensity of which, it is needless to add, varies according to the abundance and rapidity of the flooding, the strength of the woman, &c, &c. 2. Local Symptoms.—With regard to the local symptoms that characterize its existence, uterine hemorrhage has been divided into the external and the in- PUERPERAL HEMORRHAGE. 673 ternal. The flooding is called external, when the blood flows to the exterior, and internal, when it is effused into the cavity of the organ; but we shall here- after see that it may be both external and internal at the same time. A. External Flooding.—A discharge of blood externally is of itself a suffi- cient sign of hemorrhage during pregnancy or parturition; but there are certain peculiarities dependent on the various causes indicated above, that demand attention, and which will be pointed out in detail in the following article. B. Internal Flooding.—An internal discharge may take place, during the earlier months of pregnancy, and yet may escape detection; if, however, the amount of blood should be considerable, the clot formed by its coagulation con- stitutes a foreign body, whose presence excites colicky gripings, and pains in the loins, and a feeling of weight about the fundament; and these symptoms obstinately persist until a miscarriage takes place. Besides which, as M. Bau- delocque remarks, there are some instances where the symptoms of occult hemorrhage are either preceded, accompanied, or followed by an external dis- charge of blood. In the former case, the blood, finding a free issue outwardly. continues to escape until its further passage is prevented by the formation of a coagulum, which forces it to accumulate internally; in the latter, the effusion of blood into the cavity constantly goes on, until it reaches the orifice of the womb by gradually separating the membranes; while, in the third case, an ex- ternal discharge will accompany the occult hemorrhage whenever one part of the blood has a free issue, but the other collects in the cavity of the organ. At an advanced stage of the gestation, when the hemorrhage is more profuse, we must add to the precursory signs before mentioned a considerable and rapid development of the belly, and a greater resistance, tension, and hardness of the uterus than usual; sometimes even it presents a very irregular form, seeming to be divided into two parts, one of which is occupied by the ovum, aud the other by the effused blood; and most generally the active movements of the foetus disappear. Iu some few cases, a well-marked fluctuation has been detected. Finally, when the flooding is first manifested in the course of the labor, the interval of each pain is characterized by the escape of clots of blood in greater or less profusion. This discharge of coagula can be explained by the fact that, during the interval, the child's head does not seal up the neck hermetically, and thus its orifice is left comparatively free, and the blood is permitted to escape. Seat of the Effusion.—The point at which the accumulation of blood takes place in those internal hemorrhages that come on at an advanced period of ges- tation must necessarily vary, according to the part of the utero-fcetal vascular apparatus which has been the source of the flooding. For instance:— 1. The blood may be primarily effused between the uterine face of the pla- centa and the corresponding uterine wall; as the discharge progresses, it ordi- narily dissects off the placenta towards some one point of its circumference, and is then effused all round the ovum, by displacing the membraues. But it may also happen that the whole placental circumference remains adherent to the womb, whilst its central portion is entirely detached, the effusion being limited by the margins of this mass; and the hemorrhage may be copious enough in 43 674 DYSTOCIA. such instances to kill the patient promptly, as the case of Laforterie (whatever may be said of it) fully proves. The reader will likewise find, in the New Medical and Physical Journal (1813, No. 38, p. 535). the following case, which, though less known in France than the one of Laforterie, is not the less extraordinary: "A lady, of a weakly constitution and delicate habit, was attacked in the latter months of pregnancy with a slight discharge of blood from the vagina, not amounting altogether to half an ounce, accompanied with alarming symptoms of exhaustion and debility. The os uteri was scarcely dilated to the size of a sixpence, and was in such a state of rigidity, as precluded the possibility of affording any manual assistance. The lady in consequence died; and, on examination after death, it was found that a separation of the centre of the placenta from the parietes of the uterus had taken place, whilst its edges were completely adherent, forming a kind of cul-de-sac into which blood had been poured, to the amount of a pint aud a half, which had become coagulated within the cavity thus formed." 2. The blood may be effused into the proper tissue of the placenta, and thereby constitute those sanguineous collections which have been designated of latter time as placental apoplexy. The woman's life is never compromised by a discharge of this nature, but the death of the fcetus and, as a consequence, its premature expulsion, most generally results therefrom. 3. The blood may be effused on the fcetal surface of the placenta, as in the case referred to above; but the flooding here evidently must have been internal before it was external. Indeed, several observers have reported that they found coagula lying between the chorion and a portion of this foetal aspect of the placenta. 4. The numerous observations detailed in the memoir of M. C. Baudelocque, prove that blood may be effused between the various membranous laminae that constitute the amniotic sac, at all stages of pregnancy. 5. Lastly, notwithstanding the strictures which the cases narrated by Dela- motte, Levret, Naegele, Baudelocque, and others have been subjected to, they constrain us to believe that both a partial and complete rupture of the umbilical cord may take place; in consequence of which an effusion of blood is made into the cavity of the amnios. ARTICLE III. DIAGNOSIS. A. External Discharge.—The difficulties hitherto described (see Diagnosis of Abortion), as complicating the diagnosis of hemorrhage during the first six months of pregnancy, are scarcely ever met with at a more advanced period. In fact, it is so rare to find women regular as late as the last three months, that every discharge of blood from the vulva at that period may be considered as a symptom requiring immediate attention; for, at the most, we could only confound a very slight hemorrhage with a return of the menstrual discharge, and, in both cases, the precautions to be taken would be the same; or, at least, if indifferent in the one, they might prove very serviceable in the other PUERPERAL HEMORRHAGE. 675 When a hemorrhage does come on in the course of the last three months of gestation, or during labor, the question arises, what is its cause ? But this question, though very important both as regards the prognosis and the treatment, is sometimes exceedingly difficult to answer. It has been shown that often, perhaps even, according to certain authors, the most frequently, it is owing to an insertion of the placenta either over the os uteri, or on some adjacent point; and most of them go further, and endeavor to point out the signs whereby this ab- normal situation of the after-birth may be recognized. The signs that announce the existence of this anomaly may be divided into the rational and the sensible. The first are derived from the mode of development of the accident, and its attendant circumstances; while the second are furnished by the touch. When the flooding comes on at an advanced stage of the gestation, more par- ticularly in a woman who has previously borne children, it is most generally possible to detect the presence of the placenta over the internal orifice by the touch. In this case, says Levret, there is sometimes difficulty in finding the neck, notwithstanding it be in a measure within reach of the finger; for a great quantity of coagula, a part of which is adherent, is ordinarily found in the vagina, and their detachment augments the hemorrhage ; beyond all these, a soft, fleshy, and, as it were, a pulpy tumor is detected.1 When the accoucheur examines this tumor with the extremity of his finger, it feels as if he were touching the head of a small cauliflower, and he recognizes there the anfractuosities peculiar to the external surface of the placenta; then, by searching out the circumference of the tumor, the uterine orifice, which surrounds it towards its superior part, is made out; but all attempts to pass the finger between the tumor and the orifice will prove unsuccessful without a resort to violence, and a detachment of the tumor at the point where the index is passed up; or if one place should hap- pen to be free, the same would not be true for the whole periphery of the cervix. A somewhat voluminous coagulum, situated in the os uteri, might be mistaken for the after-birth; but, by a little attention, it will generally be found that the clot is much less resistant, more friable and movable than the placental mass, which latter can scarcely be changed in position, and whose parts are separated with much more difficulty. Sometimes, quite a thick layer of coagulated blood covers the external surface of the after-birth, and prevents the finger from reach- ing its proper tissue, though the clot can always be detached by a slight effort, and the intervals between the cotyledons be made out. Fungous or cancerous tumors of the cervix, syphilitic vegetations, polypi, and hydatid tumors, might be mistaken for the placenta inserted upon the neck; but a consideration of the •In general, this examination has to be made with the greatest possible care, because the separation of the clots often causes a return of the hemorrhage. Where the os titen is not sufficiently dilated to permit the introduction of the finger without difficulty, it would be proper to wait until the discharge had continued long enough to produce its relaxation. Indeed unTels the flooding be profuse enough to render a premature labor inevitable, and unless there be an actual commencement of the labor, or the patient be very near her full term, all explorations of this kind should be suspended, and the gene-al measures calcula- ted to subdue the symptoms be employed instead. 676 DYSTOCIA. antecedents of the patient, the general symptoms she has presented, and, espe- cially, a minute and attentive examination, will, I think, enable us readily to avoid mistakes of this character. As stated above, the flooding may be dependent on an improper insertion of the placenta, and the latter be so far removed from the internal orifice that the finger, introduced into the os uteri, can only detect the naked membranes; if the patient be examined during labor, the extremity of the index should be passed over all the parts adjacent to the orifice, when the margin of the after-birth will most generally be felt, or, at least, the membranes will be found thicker than common; or, still more likely, an epichorion that is softer, and of a triple or quadruple thickness, will be detected towards that side of the os uteri where the placenta is inserted. Iu certain cases, the diagnosis may be further facilitated by an examination of the lower part of the uterine tumor, even where the cervix does not permit the introduction of a finger. Thus, for instance, in a woman, used in my course for the practice of the '-touch," who had advanced to the fifth month of her gesta- tion, I observed the following condition of things: All the superior part of the excavation was occupied by a thick, fleshy, and comparatively soft tumor, which was vtry nearly of the consistence of the uterine walls at the second or third month of gestation. Towards whatever part of the superior strait I carried the finger, it still encountered the same resistance, and I found it impossible to de- tect any portion of the foetus, or to perform the ballottement. From this single fact, I suspected an insertion of the placenta over the os uteri, but was unable to verify my diagnosis; though I have since ascertained that she was delivered, six weeks subsequently, after a moderate flooding. M. Gendrin has made a similar observation; for he says that, in cases of im- plantation of the after-birth over the os uteri, the only unusual phenomenon that can be recognized is the absence of the ballottement. When the hemorrhage takes place either in a woman with her first child, or at an early stage of the gestation, when, in a word, the cervix uteri is not sufficiently dilated to permit the introduction of a finger, we might still be enabled to deter- mine the cause of the flooding by the following signs, namely: 1. A hemorrhage caused by insertion of the placenta over the internal orifice never occurs before the end of the sixth month; and, most frequently, not until the last four or six weeks of gestation. Besides, it is highly probable that the period at which the flooding comes on, is usually subordinate to the greater or less extent of the placenta corresponding to the neck; that, in cases of insertion, centre for centre, it is manifested much sooner than where only one of its mar- gins is in apposition with the orifice. Nevertheless, there are numerous excep- tions to this (as M. Naegele considers it) nearly general rule; for, in a large number of the cases of central insertion, the hemorrhage is not developed prior to the c6\nnienceinent of labor. 2. It commences spontaneously, without an appreciable cause, and without any precursory phenomena; the woman being often suddenly aroused in the middle of the night by the escape of blood from the genital parts. 3. When manifested for the first time, it is generally inconsiderable in amount, and soon over; but, after having disappeared altogether, it returns, PUERPERAL HEMORRHAGE. 677 sometimes in the course of a few hours, at others, not for several days; but, at each reappearance, the discharge is a little more abundant, and lasts somewhat longer. 4. The cervix uteri (considering the period of gestation) is usually thicker, softer, and more spongy, because the placenta, by becoming fixed over this point, determines there a more considerable afflux of blood. 5. If the labor has commenced, and the membranes are still intact, the flood- ing constantly augments during the uterine contractions, and diminishes in the intervals. But the contrary is observed when the discharge is occasioned by a separation of the placenta attached to any other point; for then the womb, by contracting, obliterates the vessels, either by a retraction of its own proper tissue, or by the compression they are subjected to from the parts enclosed within its cavity; but,in the case under consideration, the contractions that effect the dila- tation of the cervix, destroy the vascular adhesions which unite it to the placenta, more and more, and thus multiply the sources of hemorrhage. This sign is one of great value before the membranes are ruptured; but, after the waters are dis- charged, the child's head presses on the orifice during the contraction, and pre- vents the blood from escaping. 6. AVhen the insertion is complete or central, the bag of waters does not form as in an ordinary labor; for the insertion of the placenta over the neck closes its orifice, and prevents the lower segment of the ovum from engaging therein, and from being accessible to the finger. But when the placenta covers but a part of the orifice, the finger discovers a greater or less extent of membranes, one point only of the orifice being occupied by the edge of the placenta. 7. Lastly, according to Dewees, the blood has a brighter color at the onset of the hemorrhage than when it comes from the fundus, and coagula never come away, excepting when the discharge has lasted for some time, or is on the point of disappearing. In the case I have reported, where the flooding was produced by a rupture of the umbilical vessels, itself caused by a separation of the chorion from the foetal surface of the placenta, the symptoms were very similar to those which accom- pany a hemorrhage induced by insertion of the placenta over the os uteri. Thus, the discharge commenced towards the middle of pregnancy, was several times renewed at irregular intervals, and always in increasing abundance; and it wa.i manifested anew at the onset of labor. The vaginal examination could alone determine the diagnosis, by enabling us to ascertain the absence of the placenta from the internal orifice. Finally, in the case detailed by Benckiser, there was something like a cord that crossed the opening in the neck at an acute angle, aud this was detected before the ruptuie of the membranes. This cord was devoid of pulsations, but it certainly would have exhibited them if, instead of a venous branch, it had been one of the ramifications of the umbilical, arteries. Should another case of the kind be met with, the presence of such a vascular trunk on the membranes ought to receive attention, and arouse a suspicion of the possibility of a hemorrhage from its rupture. B. Internal Discharge.—The diagnosis of the internal hemorrhages becomes more easy as the gestation advances. The general phenomena that accompany 678 DYSTOCIA. all profuse discharges would first attract attention; while the unusual and rapid development of the abdomen, and occasionally its irregular form, would confirm the surmise. The hemorrhage can always be recognized whenever it is abundant enough to endanger the mother; though it must be acknowledged that a quan- tity of blood may be effused between the womb and the placenta, which may effect nearly an entire separation of the latter, or destroy the child, without giving rise to any other phenomena than a manifestation of labor. A considerable enlargement of the belly is a sign of the first importance; but it must not be forgotten that this may be occasioned by an entirely different cause. Thus, for instance, a tympanitis of the abdomen or a dropsy of the amnios may give rise to it; however, the sonoreity in the former case, and the slowness of the development of the abdomen in the latter, conjoined with the absence of any general phenomena, will always prove sufficient to avoid an error. Again, the patient may be affected with a syncope during the labor that is wholly foreign to any discharge of blood ; but then the size of the abdomen will not increase. On the whole, therefore, the general phenomena that accompany all losses of blood, and a rapid enlargement of the belly, are the two characteristic signs of internal hemorrhage, whether it occurs in the latter stages of pregnancy or during the parturition. Finally, internal hemorrhage during labor is frequently followed by weakening or even suspension of the pains. The abdomen sometimes becomes painful (Levret), and, in some cases, an obscure fluctuation can be detected. (Leroux.) Nevertheless, 31. Henning has observed that, under certain circumstances, the abdominal swelling may be altogether wanting, and yet the syncope be dependent on an internal discharge. Thus, he says, the patient is taken at first with violent uterine pains, that reappear at certain intervals, and each one of which is followed by a slight issue of blood from the vulva; then, at a moment when least ex- pected, the symptoms of a most alarming syncope come on, though but little blood can be fouud upon the cloths, and the uterus is scarcely distended. But, by making a careful examination, the accoucheur will find, that although this organ may enclose but an inconsiderable coagulum, and although the blood does not escape freely to the exterior, yet it is because the vagina is distended by an enormous clot as large as a child's head. I deem it necessary, he adds, to insist on the presence of uterine pains, in these cases of intra-vaginal hemorrhage; for they are generally regarded as an evidence that nothing is to be feared from the discharge, whilst, in reality, they are often a distinctive character of the hemorrhage in question. ARTICLE IV. PROGNOSIS. As a general rule, the prognosis of uterine hemorrhage is unfavorable; though, perhaps, in a single instance, the discharge occurring in a pregnant female may prove advantageous—it is where the patient is harassed by all the symptoms of a general or local plethora, and a moderate discharge takes place that relieves her of the surplus that gave rise to all these symptoms. But as we cannot PUERPERAL HEMORRHAGE. 679 always moderate a flooding at will that has already commenced, it would be better both to relieve the patient and to prevent the menorrhagia by resorting to vene- section. The gravity of the prognosis depends very much on the amount of the dis- charge, and the period at which the hemorrhage takes place, being always so much the more dangerous both for the mother aud child as the blood escapes in larger quantities. Other things being equal, the infant's existence will be more seriously compromised when the flooding comes on at an early stage of gestation; as regards the mother, it is generally much more serious at an advanced period; yet it is well to observe that the danger is greater in the seventh and eighth months than toward the end of the ninth. Thus, of lo7 cases of hemorrhage occurring in the seventh and eighth month, 38 were fatal; whilst, of 78 oc- curring in the course of the ninth month, 16 only were fatal. This difference is certainly due to the slowness with which the neck dilates in the earlier months. During childbirth, this accident will be more serious both for the mother and child when it is manifested at an early stage of the process; and it will be still more dangerous in a primiparous woman than in one who has previously borne children. For it must be evident that, if the flooding should occur at the com- mencement of labor, that is, long before the dilatation of the os uteri is effected, and before the external parts of generation are suitably prepared for the free and easy passage of the foetus, the means adequate to, and calculated for, the termi- nation of the labor will be of much more difficult application, and more delayed; and, consequently, a larger quantity of blood might escape. As regards the cause producing the hemorrhage, that variety which is depen- dent on an implantation of the placenta over the inferior segment is the gravest of all: to the mother, because it is renewed several times during the, latter months of her gestation in a constantly increasing amount, and because, being always present during the labor, it usually requires the intervention of art; to the child, because such an intervention is not without danger to it, and the in- terruption of the utero-placental circulation, resulting from the detachment of the placenta, produces an asphyxia that oftentimes proves speedily fatal.1 The 1 The foetus then dies by asphyxia, and not by hemorrhage, as has been asserted, and again repeated, in the recent work of M. Gendrin. For the foetus can only lose its blood when the source of the hemorrhage is in a lesion of the umbilical vessels; while, in a case of simple detachment of the uterine surface of the placenta, the child dies only because the circulation is interrupted in the utero-placental vessels, and its respiration can no longer take place. (See Functions of the Foetus.) The blood, being shut up in the um- bilical vessels, cannot come any more into the usual mediate contact with the maternal blood, and the infant is then in the same condition as an adult deprived of respirable air, and like him must die asphyxiated. Besides, the autopsical examination in such cases exhibits the anatomo-pathological characters of asphyxia. There are some rare cases reported, in which the child's head, being forcibly urged on by the powerful contractions of the womb, has perforated the placenta near the middle, and thus opened for itself a passage through this central opening. This occurred in Portal's twenty-ninth observation; and W. White reports that, in a case where the pla- centa appeared to be inserted over the os uteri, centre for centre, the patient suffered two or three very intense pains, during which the head perforated the after-birth and was de- livered. The child was stillborn, but the woman recovered. 4 680 DYSTOCIA. following statistics, by Dr. Simpson, prove the danger of this complication, namely, of 399 women in whom this misplaced insertion of the placenta was observed, 134 perished. When the placenta is inserted over the neck, centre for centre, the hemorrhage would evidently be much more profuse than in the cases in which it is in con- tact with the orifice by one part of its circumference only. We would add the remark of M. Duval, that as the ovum can then yield only with great difficulty, because of the strength of that part of the chorion which bears the umbilical vessels, the labor is greatly prolonged, the fruitless contractions weaken at last, and the hemorrhage is increased by inertia of the womb. A singular circumstance sometimes takes place in cases of central insertion. The gradual dilatation of the cervix may effect the complete detachment of the placenta, which, may, perhaps, be entirely expelled through the vulva several hours before the expulsion of the child. This accident, which, at first view, would seem likely to have the most disastrous consequences, is nevertheless proved by experience rarely to compromise the mother's life, though it is gene- rally fatal to the child.1 1 Chapman relates an instance in which the after-birth was thus expelled four hours in advance of the child; and Perfect furnishes a very similar case. (Cases, vol. ii, page 288.) " I was once consulted," says Merriman, "by a very careful and judicious practitioner, respecting a woman, who, when I first saw her, was rapidly sinking under puerperal fever. In this case, the placenta was expelled many hours before the child was born, and no extraordinary means were used to expedite the delivery of the child; a physician-ac- coucheur, who was consulted on the occasion, having deemed it more prudent to leave the case to nature. The fatal event, however, would lead one to doubt whether it was wise, under such circumstances, to decline the interference of art." (Synopsis, page 126.) Smellie has reported three cases of the same kind; Lamotte, three (Obs., 321, 322, 323); Lee, three (Med. Gaz., 1839); Ramsbotham. Sr., five (Practical Obs., Case 153); Baude- locque and Barlow, each one;, and Dr. Collins (Practical Treatise, page 91) narrates an in- stance in which the placenta was expelled about eighteen hours before the foetus; the membranes were ruptured, and the waters escaped two weeks before the entrance of the patient into the hospital; from that time until the eve of her admission, the flooding had continued with more or less abundance. We satisfied ourselves, says he, that the pla- centa had been extracted the evening before by the midwife who attended her. This woman recovered perfectly, and left the hospital on the thirteenth day. Cases of this kind are much more common than might be supposed; thus, Dr. Simpson has collected 141 authentic observations, and, in order the better to appreciate the effect of this premature separation, he has divided them into four categories. In the first, 47 in number, there were 41 stillborn children, and 10 of whose condition nothing could be learned, but all the women except three recovered. In all, the hemorrhage di- minished greatly, or ceased altogether, immediately after the expulsion of the placenta, although an interval often hours at the most, and often minutes at the least, had elapsed between the expulsion of the after-birth and the birth of the child. In the second are placed 24 cases. In all of these rather less than ten minutes intervened between the ex- pulsion of the placenta and that of the fcetus; 9 of the children were stillborn, 2 were putrefied, and 11 were alive; no information respecting the two others; all the mothers but three recovered. The third contains 29 observations, in which the expulsion of the child followed that of the after-birth immediately; 14 stillborn, and 11 living children; no information respecting the others; all the mothers recovered, except one. Finally, in > PUERPERAL HEMORRHAGE. 681 In some rare cases, it has happened that the head, under the influence of powerful contractions, perforated the centre of the placenta, and was expelled through the passage thus formed. Portal's twenty-ninth observation relates to a case of this kind; and W. White informs us that in an instance of apparently central insertion upon the neck, the woman had two or three very strong pains, during which the head perforated the placenta, and was expelled. The child was stillborn, but the mother recovered. When the placenta is situated only in the vicinity of the neck, the hemor- rhage may not appear during the labor, although it may have occurred several times in the latter stages of pregnancy; for, should the membranes rupture pre- maturely, and the head be presenting, it is possible that its engagement might compress the torn vessels sufficiently to prevent the discharge of blood.1 The internal hemorrhage is generally more dangerous than the external, be- cause it often takes place imperceptibly in the commencement of gestation, and thus destroys the fcetus; while, at a more advanced period, it compromises the mother's life, before having given rise to any symptom whereby its existence could be positively recognized, so that the accident is often detected too late to be remedied. Where the blood collects in the uterine cavity, the accumulation cannot take place without detaching a new portion of the placenta, and this secondary sepa- ration becomes a fresh cause of vascular rupture, and, as a consequence, aug- ments the chances of flooding. For even suppose the hemorrhage were arrested, whether spontaneously or under the influence of the measures employed, there does not the less remain a voluminous coagulum in the uterus, a veritable foreign body, whose presence will irritate its walls, will determine there a more con- siderable sanguineous fluxion, and will excite premature contractions, and thus become perhaps the cause of another discharge. Lastly, during the parturition, the internal hemorrhage is less to be feared before than after the membranes are ruptured; because, in the former case, the womb, being already occupied by the amniotic liquid, will yield less readily to a new distension, and, consequently, will prevent a great effusion of blood'. Besides this, the integrity of the membranes will admit of their artificial rupture, which, by the salutary retraction that follows it, is one of the most valuable re- sources of our art in these unfortunate cases ; and of which, it is unnecessary to add, we are deprived, when the waters escape prematurely. 10 cases, the time between the birth of the child and the delivery of the placenta was not noted. Only 3 mothers died, and 9 children survived. Thus, according to these facts, the premature separation of the placenta, which does not appear to have had a very serious effect upon the mothers, is extremely dangerous to the child, since all the children of the first series died ; half only of the second, and eleven of the third category, survived. We shall refer to these figures hereafter, in order to appreciate the practical conse- quences which Dr. Simpson thinks himself able to deduce from them. 1 When, says Plenck, the orifice is half covered by the adherent placenta, the case should be left to nature; for the head of the child pushes the presenting part of the placenta aside, compresses the bloodvessels, and thus prevents hemorrhage. This pre- cept, though too absolute, at least proves that Pleuck had made the same observation that we have just mentioned. 682 DYSTOCIA. But the dangers that threaten the woman whilst the hemorrhage lasts, are not the only ones to be dreaded; for her constitution and health may be broken down for a long time by these grave accidents. For even when the patients have the good fortune to escape with their lives, they ordinarily suffer for a con- siderable period; they are tormented with constant pains in the head; their digestion is painful, their vision and hearing are defective;1 and there are often wandering pains in the limbs, trembling, &c, &c. Most frequently the labor is lingering, the pains are short and distant, and inertia of the uterus results from this general weakness. Those females who have been afflicted with profuse hemorrhages are far more disposed than others, during the lying-in, to acute in- flammations, and to peritonitis especially; which inflammations then advance more rapidly to a fatal termination, because the general condition of the patient does not permit an active resort to the antiphlogistic treatment. The cephalalgia noticed by all observers, and which I have frequently had opportunities of verifying myself, only disappears after a very long time, and not until the reparation of the blood, and the re-establishment of the strength, have taken place. M. Baudelocque supposes that the pain is particularly apt to be seated in the hinder part of the head. Leroux attributes this affection to a diminution in the quantity of blood contained in the vessels of the brain, which occurs as an immediate consequence. I would rather explain it like Baudelocque, by the direct influence which the loss of blood must exercise over the nervous system. The child's death does not necessarily result from the hemorrhage ; for, when the latter is inconsiderable, the gestation continues its regular course. The loss of blood has even been carried to an extent calculated to inspire just fears for the mother's life, and yet without being followed by abortion. But although the foetus may have resisted the violence of the first accidents, it must not be supposed that it experiences no injurious effects therefrom. Though but a small portion of the placenta may have been separated, the foetus is nevertheless deprived thereby of a portion of its means of respiration and of nutrition, and this deprivation, though partial, may eventually prevent its com- plete development, and even destroy it before the termination of pregnancy. Therefore, when born alive, it is often emaciated, and weaker than under ordi- nary circumstances, and this congenital debility, which is generally regarded by authors as a consequence of the anaemic condition of the mother, should, in my opinion, be attributed to the partial separation of the placenta. When the mother has had the good fortune to escape the danger that menaced her, and the pregnancy continues, how then is the hemorrhage arrested ? The mode of termination varies somewhat, according to the cause that has determined the accident. Thus, when the flooding has been preceded by general plethora, or by uterine congestion, it may happen that the escape of blood removes this condition, and thus remedies the symptoms itself; and this must nearly always be the case, where the discharge resulted from a sanguineous exhalation. But where there is a rupture of one of the utero-placental vessels, it is possible that 1 In a case reported by Ingleby, the patient became suddenly blind; for five days she could not distinguish anything at all, and her sight was not perfectly restored till six months afterwards. PUERPERAL HEMORRHAGE. 683 the flow of .blood, by relieving their distension, will permit these vessels to be- come flattened down and depressed, from the double pressure of the ovum and womb, and then the hemorrhage is arrested. Again, where the placenta has been detached from the womb to a moderate extent, the bleeding can only be checked by the formation of a coagulum, which creates an obstacle to the ulterior issue of the blood, by being placed between the uterus and the placenta; for, '• while the blood is endeavoring to glide towards the os uteri," says M. Velpeau, " a more or less extensive portion of the placental mass becomes fully saturated with it: first one clot forms, then a second, then a third, and these several layers, of various thickness, soon become sufficiently numerous, provided the energy of the hemorrhagic affluxion becomes diminished, to exert such a degree of pressure as to retain the blood within its own vessels." All the vascular tubes corresponding to the point where this coagulum is formed, are thenceforth rendered useless to the utero-placental circulation, which can only be kept up through those that have not been lacerated. The authors of the Dictionnaire de Medecine (art. Hemorragie Uterine) seem to admit, from a case reported by Noortwyk, that the detached portion of pla- centa may contract new adhesions with the uterine wall; but from what has just been said respecting the formation of the coagulum, which, by its presence, puts an end to the symptoms, it is impossible to admit that this re-attachment can take place without the intervention of a fibrinous clot, which evidently precludes the re-establishment of the circulatory relations. Besides, this matter is satis- factorily proved at the time of labor; for, by examining the uterine surface of the placenta, we can then detect one or more fibrinous laminae, of a variable size, and differing from each other iu the degree of degeneration, according to the period at which the separation was effected ; in addition to which, the portion of placenta that had been detached is often atrophied and deprived of juices; in a word, the corresponding placental cotyledons have withered away completely. ARTICLE V. TREATMENT. The management of uterine hemorrhage may be subdivided into the preventive and curative treatment. The prophylactic measures are as numerous as the predisposing causes, and they consist in preventing the action of those causes ; hence, to furnish a detailed account of them, it would be necessary to enter into a series of repetitions. Besides, they are included in the hygienic and general therapeutic management of pregnancy, and, therefore, we need not dwell further upon them here. But if, notwithstanding all the preventive means employed, or if, from the influence of any unforeseen causes, a hemorrhage is developed, what course shall we adopt to subdue it ? The frequency of this accident, and its great danger in many cases, have at all times claimed the attention of practi- tioners ; and, with a view of facilitating the study of the numerous measures that have been recommended, we shall divide them into the general and the special ones. The first, being applicable in all cases, are nearly always the same; but the second vary according to whether the flooding takes place in the course 684 DYSTOCIA. of the gestation or during parturition, and according to the abundance or the trifling character of the discharge. § 1. General Therapeutic Measures. Whenever an accoucheur is summoned to a pregnant woman who is affected with flooding, he should immediately attend to certain precautions that we are about to point out, namely :— The woman ought to be kept in a horizontal position, care being taken to have the pelvis elevated somewhat higher than the rest of the body. All feather beds must be proscribed, and, whenever possible, she should lie on a hair mattress that is rather hard. The bed is to be placed in a large, well-ventilated chamber, so as to be easily accessible on all sides; in the summer season, the room might even be sprinkled ; and the woman is to be lightly covered. It is desirable to have the chamber somewhat darkened, and the attendants should be advised to discharge their respective duties without making any unnecessary noise. He should endeavor to satisfy the patient as to her conditiou, and to remove all sources of vexation and opposition ; for calmness of mind is not less essential than rest of the body; especially, when the discharge has been occasioned by violent passions or acute moral affections. Cold drinks, slightly acidulated with vinegar, gooseberry, or lemon syrup or even with lime or orange juice, are the most suitable. We should endeavor to obviate the strainings the patient might make on the close stool, because they niight possibly increase the flooding; for this purpose, the bowels are to be kept free by injections, or, if these are not sufficient to remedy the constipation, by mild laxatives; and, lastly, if the woman has the least difficulty in urinating, it would likewise be necessary to empty the bladder by the catheter. § 2. Special Therapeutic Measures. These vary, as stated, according to the abundance or trifling character of the discharge, and according to whether the latter is manifested in the course of the gestation, or during the labor. We shall first examine them during preg- nancy. A. Moderate Hemorrhage, occurring in the last three months.—If the flooding has been preceded by the general phenomena of plethora, and if at the time wheu the woman is examined the pulse be fouud full, strong, and developed, the face flushed, &.c, in a word, if the hemorrhage appears to be owing to, or kept up by, the plenitude or morbid action of the vessels, it is necessary to have recourse to general venesection, which will act both as a revulsive and as .an autiphlogistic; but this measure is recommended in those cases only in which labor has not yet commenced, and where the discharge is inconsiderable, and has lasted but a short time. Bloodletting must be proscribed under the opposite circumstances, as also in those instances where the flooding is not associated with plethora. When the hemorrhage is not very abundant, and, as a consequence, when there is some reason to hope that the pregnancy will continue on its regular course, opiates may be administered; they niight be given by the mouth, but it is much better, in general, to exhibit them by injection, iu the dose of twenty drops of Sydenham's laudanum, diffused in a small quantity of some mucilaginous vehicle; PUERPERAL HEMORRHAGE. 685 and this may be repeated three or four times, at intervals of ah hour or more, where the first have not been sufficient to arrest the symptoms. A long expe- rience, says Burns, enables me to recommend this measure in all cases where bloodletting is not practicable. For the first twenty-four hours, the patient must be subjected to a strict regimen. Such are the measures to be employed in cases of moderate hemorrhage occur- ring in the last three months of gestation; and they should be continued until it has entirely disappeared. After the symptoms are wholly subdued, the woman ought to take the greatest precautions to avoid a relapse, by keeping in bed for a week at least, eating but little, and that of non-succulent articles, especially if the discharge had been attributed to plethora, &c, &c. B. Profuse Hemorrhage occurring in the last three months.—Where the flooding is more abundant, the remedies to be employed are also.more active and, to the measures already enumerated, except venesection, which, as before stated, must be rejected when the discharge is very profuse, we may now add : 1. The application of compresses, steeped in some very cold liquid, to the upper part of the thighs, hypogastrium, or loins (in one instance, M. Gendrin successfully administered an opiate injection at the temperature of melting ice); and, where the heat is very great, cold sponging over the legs, arms, and even the body. But the action of cold is not to be resorted to without discrimination; nor, as a general rule, should it be kept up for a very long time; because, although its application may be useful at the commencement of the attack, when the phenomena of local congestion are manifest, it would certainly prove inju- rious if a very copious and persistent flooding had already enfeebled the patient, and if there was reason to fear the powers of life were giving way, and that the woman was likely to sink into a state of complete prostration. When the skin is cold, and the pulse small and feeble, the refrigerants are not indicated, and they should be suspended at once, if already in use. 2. In this latter case, if the flooding continued and the prostration augmented, it would be necessary to have recourse to revulsives applied to the superior parts. I have seen, says M. Baudelocque, a profuse hemorrhage suspended almost in- stantaneously by placing the hands in very hot water. Under the title of revulsives it has been recommended, since the days of Hip- pocrates, to apply cups either above or just under the breasts, and between the shoulders. M. Velpeau advises the employment of a sinapism at the upper part of the back; for he has found this remedy beneficial in a great number of instances, and at all stages of gestation; " nevertheless," he says himself, "there would be little wisdom in relying upon it to completely suppress a hemorrhage that had already become serious and alarming." It is, however, an auxiliary measure that should never be neglected, for it can have no disastrous tendency; but, in my opinion, the same cannot be said of revulsives applied to the breasts, since it is by no means certain that they may not prove injurious. Indeed, many authors, relying on the sympathy existing between the uterus and the mammae, have supposed that every stimulant applied to the latter must excite the action of the former, and, consequently, tend to renew, or to keep up, the hemorrhage. 686 DYSTOCIA. 3. If the measures hitherto enumerated be not sufficient to arrest the flooding, the ergot niight be exhibited in the dose of half a drachm divided into three parts, one of which is to be taken every ten minutes. This medicine, which is recommended by M. P. Dubois under such circumstances, appears to him to have nothing more than a hemostatic action; " for, if it be objected," says he, " that this remedy might excite uterine contractions, and thus provoke a prema- ture labor, we answer that, up to the present time, not a single well-founded observation proves that the spurred rye has the property of provoking the ute- rine contractions; though, where these exist already, it increases them, or restores them when suspended; but it does not cause them to appear if the uterus is in a state of perfect rest. On the other hand, even supposing that it had this virtue, that would not be a just ground oi exclusion, for it must not be forgotten that the question is before us of arresting a serious accident, one which cannot continue without prejudice to both mother and child; and that the only other resource is the use of the tampon, which, even more than the ergot, would expose her to the hazard of a delivery before term. (Journ. de Med. et de Chir. Pratique, 1836.) 4. But it sometimes happens that, notwithstanding the employment of refri- gerants and ergot, the flooding continues, the woman becomes pale and colorless, the pulse small and thread-like, and she has vertigos, &c.; and the violence of the symptoms endangers the lives of both mother and child. Under these grave conditions, the accoucheur has only to choose between an application of the tampon and a provocation of the labor by rupturing the membranes. A. Use of the Tampon.—When speaking of the natural termination of those hemorrhages tlyit come on during pregnancy, we stated that the discharge was arrested in consequence of the formation of coagula, which, by becoming applied over the orifices of the vessels, perhaps even by being continued into these ori- fices, prevented a Subsequent discharge of blood; and that it is on the formation of these salutary coagula that we must found our hope, so long as there is a chance of preserving the infant. It was with this view that the older physicians resorted to the use of astringent injections, and more especially to pessaries made of some old linen saturated with such liquids. But they did not depend upon the coagulating and astringent properties of these substances alone; but also relied on their mechanical effect in retaining the blood. For this purpose, there- fore, Leroux, of Dijon, proposed his tampon in 1776. This remedy, says he, is exceedingly simple ; it consists in the creation of an obstacle to the escape of the blood, by filling up the vagina with balls of linen or tow, saturated with pure vinegar. Desormeaux thought it was better to first double a large piece of fine linen, and then carry up the fold to the fundus of the vagina; and afterwards to fill the pocket, thus formed by the linen, with bits of charpie, or tow, or any other soft substance that may be at hand. M. Moreau condemns this procedure, because, he remarks, it is difficult and painful, and it would be almost impossible not to leave some space. between the tampon and the cervix uteri. He recom- mends the mode of application to be altered to suit the particular case : for in- stance, if the os uteri is a little dilated, he advises the use of a roller, wound tightly in the form of a cone, and well fastened; then the conical extremity of this plug is introduced into the uterine orifice itself, and is retained there by the PUERPERAL HEMORRHAGE. 687 finger. When the dilatation is somewhat more advanced, he makes use of a lemon, having the rind pared off at one extremity, and he introduces this into the neck of the womb, where its bulk obliterates the orifice, and its juice irritates the organ; and lastly, when the os uteri is freely dilated, he recommends the vagina to be crammed with lint steeped in vinegar, and the whole to be secured with a T bandage. Leroux was also in the habit of saturating the tampon with vinegar. The astringents were considered useless by Desormeaux ; for, he says, it is only on the mechanical action of the tampon that we can rely, and not upon the irritation which its contact, and that of the acids with which some persons saturate it, may have on the uterine wall. It would be very fortunate, indeed, if the only effect of the tampon was to prevent the issue of the blood, and to de- termine its coagulation; for then, by arresting the hemorrhage, we might preserve the life of the foetus much oftener than is now done. But, unhappily, it has yet another effect, that is, it frequently irritates the organ by mere presence, and by forcing the blood to coagulate in the uterine cavity, whereby a more or less volu- minous coagulum is formed there, which further adds to the irritation produced by the tampon itself; contractions are excited, and, in most cases, the womb soon drives out the tampon, coagulated blood, and foetus altogether. This, we may observe in passing, is the most serious objection that can be urged against the use of the tampon, a reproach that it often merits, especially when it is satu- rated with vinegar. But, after all, notwithstanding these disadvantages, the tampon is a remedy that cannot be dispensed with in practice; and we do not know how to better describe the cases in which it may be resorted to with advantage, than by fur- nishing the following extract from the memoir published by Gardien, in the ninth volume of Leroux, Boyer, and Corvisart's Journal. The tampon may be applied : 1. To arrest any hemorrhage that might arise from the ruptura of a varix on the uterine neck, or in the vagina; 2. In a case of laceration, occurring at the orifice of the womb during labor, .and when there is any inertia, by a direct application to the tdrn surface; 3. In cases where the placenta is inserted over the os uteri centre for centre; the blood being retained by the tampon, forms a coagulum which is compressed between it and the after- birth, whereby the serous part is expressed, and a concretion takes place which contracts adhesions with the adjacent parts, and suspends the discharge uutilthe rupture of some other vessel renews the hemorrhage. Nothing is to be feared in these cases from an internal bleeding; for, although we have quoted some examples of the kind, these are so rare that they cannot counterbalance all the advantages of the tampon; besides, the mere fact of its employment does not dispense with the necessity of carefully watching the patient; 4- It is likewise serviceable in the floodings attending the abortions which take place in the course of the first three months, whether before or after the delivery of the after-birth: before, because Puzos' method might render this delivery impossi- ble, or at least, very difficult; and after, because there would be no cause to fear an internal hemorrhage, for the reasons before given; 5. It might answer in those instances where there is no dilatation of the os uteri, or when this is impossible, and consequently where it would be impracticable to pierce the membranes; 6. And lastly, where the flooding continues after the membranes have been punc- 688 DYSTOCIA. tured, and it is impossible to effect a forced delivery; as in the cases reported by Lamotte and Smellie. Nevertheless, its employment then should always be watched over with the greatest possible attention ; for the uterus, in which a void is created after the discharge of the waters, is susceptible of becoming distended, and an internal hemorrhage might take place. Under such circumstances, an artificial delivery must be resorted to. But the tampon should be rejected : 1, whenever we might reasonably hope to prevent an abortion ; for even Leroux himself made use of the ordinary means before resorting to this measure ; because, by retaining within the womb the blood that would otherwise escape, it distends this organ by forming a coagulum, which may increase the detachment of the membranes and placenta, and may likewise irritate the womb by its presence, and thus bring on the contractions; and, 2, whenever (as hitherto stated) the placenta is inserted over the os uteri, and the labor is far advanced. B. Rupture of the Membranes.—When the hemorrhage is profuse, and has made its appearance during the latter months of gestation, more especially if the labor has already begun, a rupture of the membranes should generally be pre- ferred to the use of the tampon. The child's life is then almost as precious as the mother's, and we must endeavor to remove it from the threatened danger. It was with this view that our predecessors resorted to an artificial labor under such circumstances. But Puzos has proposed a measure which conjoins the advan- tages of the natural with those of a forced delivery. It is necessary for this purpose, he says, to introduce one or more fingers into the uterine orifice, by which an attempt is made to dilate it with a degree of force proportioned to its resistance; this gradual dilatation, which is interrupted by intervals of rest from time to time, excites the pains; the womb contracts, and during its contraction the membranes become tense, and engage a little at the upper part of the cervix, and these latter are ruptured as soon as possible, in order to effect a discharge of the waters. The presenting part, particularly if this happens to be the head, should be carefully pressed up by'the finger for some moments, so as to permit the liquid to escape. The objects to be accomplished are obviously to encourage a discharge of the waters, to arouse the contractility of the uterine tissue by their evacuation, and to solicit its retraction ; whereby the vessels situated in the thick- ness of its walls would undergo certain modifications favorable to an arrest of the hemorrhage. Further, when the womb is well contracted on the body of the child, and some portions of the latter are forcibly applied against the patulous vessels that furnish the blood, the compression thereby produced must evidently arrest the flooding. This method, which has been adopted by Dr. Rigby, of England, has been severely criticised by his countryman, Duncan Steward, who endeavors to sup- port his own opinion by the following observations: by rupturing the membranes before the uterus is dilated, we retard rather than accelerate the expulsion of the child; and, besides, it is by no means certain, as experience has demonstrated, that this measure will arrest the hemorrhage; while it often diminishes the chance of saving the life of the mother and child, by rendering the version much more difficult, if this operation should subsequently become necessary. Notwithstanding these objections, which, after all, have no great force, the PUERPERAL HEMORRHAGE. 689 rupture of the membranes is advocated by most of the teachers of the present day, in cases of profuse flooding, occurring at an advanced stage of gestation. Nearly all teach, however, that a regular commencement of labor, manifested by evident uterine contractions, should precede its performance; but, as M. P. Dubois remarks, it is important to bear in mind that, when a considerable hemor- rhage takes place, the contractions of the womb are often feeble, and that the labor may actually be progressing though the pains have not clearly marked its onset; while, on the other hand, the discharge of a large quantity of blood and the escape of voluminous coagula, both relax and dilate the uterine orifice; and these circumstances, which are doubtless joined to some non-painful contractions, may dilate the os uteri, without the knowledge of the patient or the suspicion of the accoucheur. This phenomenon is not at all unusual, especially in women who have previously borne children; and, therefore, whatever be the condition of the body of the uterus, and whether there be any apparent contractions or not, he should carefully ascertain the state of the os uteri. In cases of profuse flooding, this will most frequently be found sufficiently dilated to permit the in- troduction of a finger, at least; and the membranes will then be felt tense and protruding at intervals; which protrusion is a certain proof that the womb begins to contract, and the rupture of the membranes will then be effected to the greatest advantage. Besides, this operation does not exclude the employment of the various stimulants calculated to excite the contractions; thus abdominal frictions might be resorted to, and the finger, when introduced into the neck, should first titillate and irritate this part before making the rupture; and it would even be prudent to administer two or three doses of ergot to the patient, provided the neck is softened, and it seems to offer no marked resistance to the dilatation. Most accoucheurs advise the application of the tampon, when the discharge is produced by an insertion of the placenta over the cervix; but M. P. Dubois teaches that the course to be pursued in such cases will vary according to the degree of this insertion. For instance, where it takes place centre for centre, or in other words, when the placenta covers all the superior part of the internal orifice, and the membranes are inaccessible, or can only be reached by detaching some portion of the circumference of the still adherent placenta, we should have recourse to the tampon; but where the placenta corresponds to the orifice by only one of its borders, and particularly where it is inserted at some point adjacent to this orifice, he likewise recommends an artificial rupture of the membranes; being satisfied that, after the waters have escaped, the child's head, by becoming ap- plied on the detached portion of the placenta, will, by compressing it, put an end to the flow of blood. Quite recently, M. Gendrin has entertained the idea of adopting Puzos' method, even in those cases in which the after-birth corresponds to the os uteri centre for centre. Under almost identical circumstances, Rigby had deemed it advisable to push his finger through the centre of the placenta, and thus pass directly into the amniotic cavity. The following are the observations of M. Gendrin on this subject: Authors, he says, have advised that labor should be induced by direct manipulations, which consist in forcing the dilatation of the os uteri and passing into the womb through the placenta, or by detaching this organ from one portion of the neck; but these manoeuvres occupy much 44 690 DYSTOCIA. time, and besides are very difficult, and, if the blood continues to flow, the enfeebled patient may become prostrated. We propose instead the following process, which has the great advantage of keeping up the relation between the after-birth and the uterus, as long as possible. It consists in evacuating the waters, by making a puncture with a female catheter, which is directed along the finger previously introduced into the os uteri, and is passed into the mem- branes through that portion of the placenta lying over the neck. In the two eases in which he adopted this plan, the hemorrhage disappeared immediately; and this measure may, therefore, be employed, when the amount of the discharge indicates a resort to the method of Puzos, and when the presence of the placenta is the only obstacle. We think, however, tljat if the woman is pregnant for the first time, and the dilatation but slight, the tampon had better be applied, and the puncture of the ovum be deferred somewhat later. Internal Hemorrhage.—We can only expect to overcome those internal dis- charges that are serious enough to compromise the mother's life, by emptying the womb and terminating the labor. Two different conditions may then be met with, viz., one, in which the labor has not yet commenced, the neck is still un- dilated, and its margins hard and thick; in the other, on the contrary, there are some labor pains, the cervix is softened, and is more or less dilated. In the latter case, the indications for treatment are obvious; that is, to rupture the membranes and employ all the various measures which are calculated to hasten the contractions (such as abdominal frictions, titillations of the orifice, and ergot), and to watch the state of the womb after this rupture attentively. Such is the course to be pursued when the dilatation is inconsiderable; but, on the other hand, when the os uteri is either dilated or dilatable, the delivery should be effected at once by turning, or by an application of the forceps, according to circumstances (see Version, and art. Forceps). But where the symptoms occur a short time before the full term of gestation, particularly in a woman with her first child, the complete obliteration of the cervix may constitute an insurmount- able obstacle to the introduction of the smallest instrument. In these grave cases, after having employed the usual means to moderate the effusion of blood without benefit, such as irritations made on the neck and over the fundus of the womb, with a view of bringing on its contractions, it will be absolutely neces- sary to perforate the membranes, and if the hemorrhage continues, and the woman becomes weaker and weaker, and is threatened with death, to have re- course to a forced introduction of the hand. Generally speaking, the slightest efforts will be sufficient to overcome the resistance; since it is scarcely possible for a considerable effusion of blood to take place in the cavity of the uterus, without causing a development of some pains, or at least, a marked diminution in the resistance of the cervix. But if it should unfortunately happen that this resistance cannot be surmounted, I think that multiple incisions ought to be made on the neck itself. If the symptoms were not very urgent, it would be better perhaps to have recourse to compression of the abdomen, which would prevent the womb from becoming inordinately distended. This procedure has so often ap- peared successful, that its employment under like circumstances would be justifiable. PUERPERAL HEMORRHAGE. 691 C. Moderate Hemorrhage during Labor.—When the flooding occurs during labor, the indications it presents likewise vary according to the intensity of the symptoms and the degree of dilatation of the os uteri. When the blood escapes in small quantities, and the accoucheur is satisfied that it does not accumulate within the organ, he will employ here the same means as were recommended for the slight hemorrhages occurring in the latter stages of gestation; except the bloodletting, which should only be practised when evident phenomena of plethora exist, and also excepting the opium, which would here be attended with the serious inconvenience of suspending the uterine contractions. These general measures will usually prove sufficient when the neck is but little dilated and the discharge is inconsiderable. But should the cervix be freely opened, or be so softened as to offer no re- sistance, we should rupture the membranes, if they are yet intact; and if the flooding still continued after this rupture, the labor lingered, and the pains, though at first energetic, became gradually feeble, and the intervals between them longer, they should be aroused by the administration of ergot. D. Profuse Hemorrhage during Labor.—Whether the hemorrhage be internal or external at the time of labor, it always offers the same indications for treat- ment; and these latter are also based on the variable degree of dilatation of the neck of the uterus. For, if this is but little advanced, that is, if the cervix be neither dilated nor dilatable, the remedies we have advised for the profuse hemor- rhages occurring in the latter months of pregnancy should again be brought into service; that is, the refrigerants, the ergot, and a rupture of the membranes if still intact. Should the flooding continue after the rupture, and the retraction of the os uteri render an introduction of the hand absolutely impossible, the tampon should be applied at once; and the precaution be taken to make com- pression over the anterior surface of the abdomen, particularly if there is any inertia of the womb, so as to prevent an accumulation of blood within the organ. And, where the flooding persists, notwithstanding these measures, so as to en- danger seriously the mother's life, and if at the same time the non-dilated and undilatable neck should make it impossible to introduce the hand, ought we, according to the example of certain authors, effect delivery at all hazards, and introduce the hand by force? Upon contemplating the published cases of this kind, we are forcibly struck with the results of this style of proceeding. Almost all the patients died (21 out of 25 according to statistics by Simpson), and authors universally regard the operation as of the gravest character. We there- fore think it prudent not to risk the injuries of the neck, which result so often from a forcible introduction of the hand, but if, after a few moderate efforts, the rigidity is not overcome, we would much prefer, if the case were urgent, to resort to Simpson's method, and first detach and then extract the placenta. Whilst the author of this process has certainly advised it too generally, it seems to us that it could be usefully employed in these circumstances. Professor Simpson has, in consequence of these facts, proposed to separate completely, and bring away the placenta, whenever its insertion upon the neck has given rise to a hemorrhage which threatens the life of the mother. Although rather too absolute at the outset, Mr. Simpson has finally yielded to the nume- rous and valid objections made to his precept, so far as to confine its application 692 DYSTOCIA. to the following conditions: 1. When the flooding has resisted the principal measures, and especially the evacuation of the waters; 2. When the slight dilata- tion or development of the cervix, or contraction of the pelvis, render turning or any mode of artificial delivery dangerous or impossible; 3. When the death or immaturity of the fcetus restricts the duty of the accoucheur to caring for the safety of the mother. It is, therefore, especially with primiparous females, in cases of premature labor, or rigidity of the cervix and of its spasmodic contrac- tion, of organic narrowing of the pelvis or of the genital passages, of the death or non-viability of the fcetus, and, finally, of extreme exhaustion of the mother, that the artificial separation may be practised. It is to be understood, he adds, that in cases of separation or of extraction of the placenta, the fcetus should be withdrawn immediately, unless the hemorrhage should cease, which it does in the great majority of cases. Even with this reservation, we cannot approve of the advice of Mr. Simpson; for we think that when the flooding continues after the evacuation of the waters, and when the neck does not allow the hand to be introduced, there is some chance left of saving both mother and child by applying the tampon. We also think, that when an obstacle dependent on the neck, the soft parts, or the pelvis, prevents the termination of the labor, the tampon may be applied with advantage until the dilatation of the neck allows of the intervention of art; for I cannot see in.what way, under these circumstances, the extraction of the placenta could facilitate that of the fcetus, which Mr. Simpson recommends to be practised immediately afterward. The obstacles which prevented earlier action exist none the less afterward. It is, therefore, only when caring very little for the life of the child, in case of the death or non-viability of the latter, that one could undertake to separate and extract the placenta, if-the hemorrhage were dangerous, in order to spare the mother the pain of applying the tampon. Finally, it is hardly necessary to add, that if the neck is sufficiently dilated, the delivery should be effected as soon as possible, either by turning or by the forceps. When describing these two operations, we shall point out carefully the cases in which one or the other should be preferred. A host of other remedies have been successively extolled, but I have not spoken of them, because I have, never had an opportunity of employing nor of seeing them employed; besides, their mode of action appears, on theoretical grounds, to be of little value ; and hence, in my opinion, their enumeration would uselessly burden the memory of students. I do not know better how to conclude my remarks concerning the hemorrhages that may affect females, in the course of the latter months of pregnancy, and during labor, than by placing before the reader a short summary of their treat- ment which M. P. Dubois caused to be distributed among the students that attended his clinique; for, as the Professor states, this table may be considered as a kind of vade mecum. Besides, the reader will see by it how far I have conformed to his ideas, in the treatment of hemorrhages just given. A SYNOPTICAL TABLE Showing the Treatment of External Hemorrhages before and during Labor. BEFORE LABOR. Moderate Hemorrhage. B. Profuse Hemorrhage. f Horizontal position. Absolute rest. Fresh air. Cool acidulated drinks. Restricted diet. Venesection, if there are any symptoms of plethora. Empty the bladder and rectum. Same measures as in A, excepting venesection. At first cold applications—then, Ergot 5ss divided into three doses, at intervals of ten minutes. And, if these are insufficient, to apply the tampon, or perforate the membranes. f Moderate Hemorrhage. . DURING LABOR. Orifice not dilated J Membranes entire. < and undilatable. 1 ,, , j , (_ Membranes ruptured, f f Membranes entire. \ [ Profuse Hemorrhage. Orifice dilated. ( Membranes ruptured. f Membranes entire. Orifice not dilated and undilatable. [ Membranes ruptured. Orifice dilated dilatable. or ("Membranes entire. [ Membranes ruptured .{ Same measures as in A, excepting venesection, which is impro- per, unless the plethoric condition be well marked. Idem. Id. Id. Id. Same measures as in A, then wait, or rupture the membranes. Id. Id., then wait; if the pains are slow and feeble, administer ergot. Id. Id., except venesection, then refrigerants ; and in case of inefficiency, and the pains are weak, ergot, then rupture the membranes; lastly, if the orifice should not per- mit the version, apply the tampon. Same measures as in A, then refrigerants; then ergot, if the pains are slow and feeble; in case of inefficiency, compression of the uterus, tampon, forced delivery. Rupture the membranes; if this is not sufficient, make version, or apply the forceps. Version, if the head is above the orifice ; forceps, if if is in the excavation; simple extraction, if the pelvic extremity present. 694 DYSTOCIA. CHAPTER II. OF PUERPERAL CONVULSIONS. Among the various convulsive diseases that may appear during pregnancy, parturition, or the lying-in, there is one which has such well-marked charac- teristics, and whose physiognomy is so peculiar, that I can scarcely comprehend the want of accuracy that still exists in most of our classic works on this sub- ject. This confusion evidently arises from the fact that the authors who have written on puerperal convulsions have included under this title all the affections whose striking character is a convulsion; forgetting that the epithet puerperal should be applied, not to every disease which is developed before, during, or after labor, for then we might admit a puerperal pneumonia or pleurisy, but simply to one that is intimately associated with that state, and which is only produced during its continuance. This confusion is further caused, in my opinion, by designating as convulsions some affections that do not merit the name. These two propositions will be easily sustained by an expose of the distinctions admitted by some authors. According to them, the convulsions that occur during gestation may be either partial or general. Under the name of partial convul- sions, they have described those affections whose principal character is a rapid, abnormal, and involuntary contraction of one or more muscular organs, and which, consequently, are convulsive; but which are otherwise so different from what has usually been comprised under the denomination of the convulsions of pregnant women, that it is with some hesitation, and only to avoid the reproach of having omitted any important facts, that I allude to them here. Thus, to give an ex- ample, those violent contractions of the stomach, observed in certain women who are affected with severe and obstinate vomitings during gestation, as also the palpitations of the heart experienced by some others, have been classed among the puerperal convulsions. M. P. Dubois relates having seen the walls of the belly contract with such force, in a woman in the fifth or sixth month of her pregnancy, that the uterus was completely pressed back into the excavation; and the organ was afterward observed to return briskly to its place, and to rebound like an elastic ball when thrown on the ground. Some other tumefactions appeared in the flanks, in the epigastrium, and umbilical region, which seemed to depend as much on the spas- modic contraction of the viscera as on that of the walls of the abdomen. Never- theless, this woman recovered without aborting. M. Velpeau states, in his excellent thesis, from which I extract the foregoing case, that a countrywoman, aged twenty-two years, was much alarmed on the tenth day after her delivery by movements that took place in her belly; some- thing like a globe was observed through the integuments and muscles, which would travel sometimes towards the excavation, at others towards the flanks, and again in the direction of the umbilicus. This species of ball would transform itself at times into several lumps, which traversed the abdomen with a rumbling noise ; but the walls of this cavity always seemed to preserve their normal sup- PUERPERAL CONVULSIONS. 695 pleness. This woman died insane"two years afterwards, without these singular movements ever having altogether disappeared. Can such a case be referred, with truth, to puerperal convulsions ? According to certain accoucheurs, the vaginal parietes are occasionally so vio- lently contracted, as to prevent the escape of the child, and even to benumb the hand of the attendant by their spasmodic action. But of all the partial convul- sions, those of the uterus are the least questionable. We have already treated of the spasmodic contraction of the external and internal orifices of the neck, which are capable of-retarding the labor greatly in ordinary cases, and, in breech pre- sentations, may cause extension of the head, and thus render its extraction diffi- cult ; and we shall see, hereafter (art. Delivery of the Placenta), what influence this retraction of the orifices, which is evidently due to a convulsive contraction at the superior or inferior part of the cervix, as well as the partial one of some of the fibres in the body of the womb, may have over the delivery of the after- birth. We shall only mention here, that other cases, similar to those detailed by M. Dubois, have been reported, in which the uterus has been observed to pass rapidly upwards, downwards, and towards the sides of the abdomen; and even to descend with such violence towards the vulva, that it was necessary to sustain the latter witn the fingers to prevent it from escaping; but, for further particu- lars, we refer the reader to the essays of Baudelocque and Miquel. The instances just referred to, doubtless resemble some of the features of the disease we are about to describe under the name of eclampsia, in being charac- terized by a rapid, abnormal, and involuntary contraction; but they differ from 'it so much, in the triple aspect of symptoms, prognosis, and treatment, that they cannot, in my opinion, be classed under the same denomination, without confounding things that are essentially dissimilar. v The question now recurs, what is the state of the case as regards the general convulsions of pregnant women ? Hysteria, tetanus, catalepsia, and even apo- plexy, have been observed during pregnancy and parturition, and have, on that account alone, been forthwith denominated as puerperal diseases; and although these affections offered the same symptoms as when they occur in the non-gravid state, though they were essentially different from eclampsia, properly so called, yet they were considered as mere varieties, or particular forms, of this latter complaint. True, there can be no doubt that hysteria, tetanus, &c, are modified by the peculiar condition of the pregnant female; and, as in all other diseases that occur during the puerperal period, the danger to which they expose the patient is increased by that to which they subject the foetus; but the hysteria does not thereby become less an hysteria, and the tetanic convulsion has not the less its characteristic persistence. These are evidently, therefore, distinct affections. . , I ought, however, to add, that the form of the convulsion may vary, and that an attack which at the outset presented all the characters of eclampsia, might finally assume the tetanic or even the cataleptic form. Supposing that no error of diagnosis has been committed, the latter are exceptional cases, in regard to which it is difficult to say whether the same disease has assumed two different physiognomies successively, or whether one disease, catalepsy, has 696 DYSTOCIA. succeeded to another, eclampsia. Dr. Schmidt, of Paderborn, and M. Danyau, have each published a case of this kind of transformation. (Journ. de Chirurgie, 1844.) Apoplexy may occur in the puerperal state, either as the principal disease or as a termination or complication, of eclampsia. Often, indeed, as stated below, the puerperal convulsions determine a cerebral effusion ; but then it is an effect, and not a cause, of the accident. There are likewise some cases in which the general circulation, as an effect of the remarkable modifications it undergoes during pregnancy, is strongly determined towards the brain, and may even result in an effusion; and if so, the latter is sometimes preceded by slight con- vulsions, or a tetanic stiffness in one or more limbs; but these soon pass away and do not reappear. Here, then, the apoplexy is the disease ; but it is nothing more. In my opinion, therefore, it must be admitted that, during the gestation, the parturition, or the lying-in, women may have attacks of hysteria, of tetanus, or catalepsy, or may be struck with apoplexy ; but these are so many distinct affec- tions, having but one common symptom with eclampsia,—the convulsion. We hope that the details, into which we are about to enter, will illustrate the nume- rous differences between them. For myself, I understand by the term eclampsia an affection characterized by a series of fits, in which nearly all the muscles of relation, and often, also, those of the organic life, are contracted convulsively, and which fits are usually accom- panied with or followed by a more or less complete suspension of the sensorial and intellectual faculties for a variable period. General convulsions (eclampsia, properly so called) constitute a quite rare disease. M. Velpeau did not observe a single case in a thousand labors super- intended by him at the Clinique. It is probable, however, that this proportion is too small; for, by consulting the statements furnished by Madame Lachapelle, Merriman, Ryan, Pacoud de Bourg, &c, it appears that there was one case of convulsion in about two hundred deliveries. On the other hand, the practice of the prinoipal accoucheurs of Great Britain would furnish one case of eclampsia in four hundred and eighty-five labors, nearly.1 It is, however, almost impossible to ascertain an exact proportion by consult- ing the practice of any single man, since great variations are observed in different years; in my own experience, for example, I met with but three cases in two 1,89? women, met with 2 cases. Bland in Joseph Clarke • Merriman, 1! Granville, II Cusack, 11 Maunsell, It Collins, It Beatty, !( Ashwell, 11 Mantell, it Churchill, II 10,387 !< It II 19 " 2,947 It 11 II 5 " 640 1< It 11 1 case. 398 (( 11 II 6 cases. 848 11 (1 II 4 " 16,414 11 11 II 30 " 399 I< II II 1 case. 1,266 II II I( 3 cases. 2,510 [( II II 6 " 600 It II II 2 " 38,306 79 Thus we have 79 cases of convulsions in 38,306 labors, or 1 in 485, nearly. PUERPERAL CONVULSIONS. 697 thousand deliveries occurring under my care at Hotel Dieu and the hospital of La Faculte, whilst house physician at those institutions, whilst, on the other hand, I me.t with seven cases within the months of July, August, September, and October, 1846, whilst in service at La Clinique. Eclampsia appears indifferently at all seasons of the year; although some au- thors have seemed to consider, improperly, I think, that certain atmospherical conditions are not altogether foreign to its production, and that it occurs more frequently in some seasons than in others. Madame Lachapelle, who appears quite disposed to adopt this opinion, notwithstanding the summary she furnishes sustains her views but very imperfectly, relies upon the fact' that at the hospital of La Maternite, several individuals are nearly always affected at the same time. But I am strongly disposed to believe this circumstance is rather owing to imi- tation than to the influences of the atmosphere. This affection is very unusual in the early months of gestation: M. Danyau, Sr., however, met with it in a young girl, who had only reached the sixth week, and in whom nothing but the extraction of the ovum could remove the symp- toms. The eclampsia came on again in her next pregnancy, about the same period, and was followed by an abortion; but, in this instance, the fits continued for some time after the abortion. A lady of Ferrara, about twenty-eight years of age, of a bilious temperament, and the mother of three children, was periodically attacked by convulsions as soon as she had conceived, and these attacks were renewed every two weeks throughout gestation; so that their appearance constituted in her a sign of preg- nancy. As a general rule, they are quite rare prior to the sixth month; they are particularly frequent during parturition; and they appear somewhat oftener after the delivery than during the gravid state. The period at which they are liable to occur after delivery varies greatly; though the eclampsia most commonly appears a few hours, or sometimes even a few days after delivery, examples are not wanting of its being postponed for eight, ten, or even twelve days. § 1. Causes. The causes of eclampsia have been divided into predisposing and determining causes. Upon a careful investigation of the individual conditions under which eclamp- sia is generally found to occur, we are forcibly struck with a singular circum- stance, which entirely escaped the notice of the older observers: this circum- stance is the almost constant presence of albumen in the urine of eclamptic wo- men. I say almost constant, forf with the exception of six or seven cases mentioned by M. Depaul and Mascarel, in reference to which we shall have more to say hereafter, I am aware of nothing to limit the assertion. This very remarkable coincidence, which is at present well determined by the observations of many physicians, and which I have invariably remarked in all the cases which have come under my own notice within the last eight years, evidently seems to be the dominant fact in the etiology of puerperal convulsions. Since the presence of albumen is discovered almost constantly in cases of eclampsia, the severest mind can hardly avoid establishing a more or less intimate relation of causality between the two facts. 698 DYSTOCIA. But, it has been observed, the presence of albumen in the urine does not con- stitute a disease; it is but the symptomatic expression of a local lesion, or of a general affection of the economy. The latter are doubtless capable of producing eclampsia as they had already caused albuminuria; but most frequently, their influence is limited to the modification of the urinary secretion without pro- ducing any nervous disorder. This is true, and M. Blot was right so far as he considered these two morbid conditions as merely concomitant, and not that one was a consequence of the other. M. Blot's remark has not, however, in a clinical point of view, all the importance that has been attributed to it. Though the cause of eclampsia be attributed to an organic lesion of the kidneys or to an alteration of the fluids of which albuminuria is the symptom, it is nevertheless true, that as both these general or local lesions are to be detected with great difficulty during gestation, whilst the presence of albumen may always be dis- covered with ease, it was judicious to insist upon the importance of the albumi- nuria, which is alone capable, in most instances, of exciting a suspicion of the organic condition to which the eclampsia is apparently due. Since albuminuria is present in the immense majority of eclamptic women, it, or rather the disease of which it is the symptom, may be rightfully regarded as the predisposing cause of eclamptic convulsions. I say the only known predis- posing cause; for, since attention has been fixed upon this point, of all preg- nant women, those only who are affected with albuminuria (a few cases excepted) have been known to be attacked with convulsions. Though all eclamptic patients have albuminuria, it does not follow that albu- minuria, however severe, necessarily gives rise to convulsions. Happily, it is by no means uncommon for pregnant women to have the urine highly charged with albumen without presenting a single convulsive symptom. Of 41 women with albuminous urine, observed by M. Blot, but 7 had convulsions; and of 20 men- tioned by MM. Devilliers and Regnault, 11 only were affected with them. The latter gentlemen, it is true, examined the urine of such women only as were dropsical, and it is very certain that many cases of albuminuria are not attended with infiltration. Still, by taking the mean between these different results, and having regard to my own observations, I think that I come near the truth in saying, that one out of every four or five patients with albuminuria will be | affected with convulsions. The amount of albumen in the urine increases greatly during the convulsive attack, and generally diminishes after it. This peculiarity has led some persons to inquire whether the eclampsia, instead of being due to the alteration of the urine, might not be the cause of it. I can understand why there might be hesi- tation in regard to this point, if a single cas^could be cited in which it had been proved that the urine was entirely free from albumen for several weeks before the appearance of the accidents: this, I believe, has never been done, but often, on the other hand, albuminuria has been known to be present for some time before the convulsions occurred. Besides, when we come to reflect upon the obstruc- tion to the venous circulation produced by eclampsia, we can very readily account for the active congestion with which the internal organs, and the kidneys in par- ticular, may be affected during the attack. Now, it is well known that renal congestion increases the secretion of albumen. PUERPERAL CONVULSIONS. 699 The organic conditions which produce albuminuria are certainly the most, I would even say the only ones, favorable to the production of eclampsia. This proposition, which is at present incontestable, explains the influence of certain circumstances which most authors have mentioned as predisposing causes: thus, among the latter has been classed as one of the most active, oedema of the lower extremities, when considerable, but, above all, general infiltration, invading suc- cessively the body, upper extremities, and face. It is now a well-ascertained fact, that this general oedema is almost always connected with an alteration of the urinary secretion, and that only when accompanied with albuminuria does it appear to give rise to eclampsia. It it be true, as M. Rayer thinks, that the compression exerted by the deve- loped uterus upon the renal vein may eventually produce hyperaemia, and then an inflammation of the kidneys, we are able to understand the mode of action of all the circumstances capable of increasing this compression. Thus, we can ex- plain the possible effect of, 1, the extreme distension of the uterus, whether due to dropsy of the amnios or to the presence of several children; 2, of a first preg- nancy, in which the uterus is strongly applied to the posterior walls of the abdo- men, in consequence of the resistance of the abdominal parietes;1 3, why, according to the observations of M. P. Dubois, rachitis is often connected with eclampsia, since, in women affected with this disease, the small stature and limited space within the abdominal enclosure, obstruct the development of the uterus, which, by reacting in its turn upon the surrounding parts, forms a greater mechanical obstacle to the regular fulfilment of all the functions, and to the venous circulation in particular. Whatever the cause may be, long-continued albuminuria necessarily occasions a notable diminution of the amount of albumen which enters into the normal composition of the blood. Hence, it is extremely probable that this fluid, when thus altered, gives rise to a peculiar excitement of the cerebro-spinal centre, which becomes itself the direct cause of the convulsions, or, at least, which is more frequently the case, renders it more susceptible of the excitements which reach it either from without, or from previously irritated internal organs. These excitements, which, under any other circumstances, would have no effect, become here so many determining causes of an attack of eclampsia. An alteration in the quantity or quality of the blood often gives rise to con- vulsions under other cirumstances than the puerperal condition. M. Rayer, and several other observers, have called attention to symptoms resembling epilepsy, as one of the- modes of termination of albuminuria caused by albuminous ne- phritis, and it is well known that convulsions often occur in the last moments of the unfortunate victims of profuse hemorrhage. It is, therefore, no cause for astonishment, that the alteration of the blood produced by albuminuria may have the same consequences during pregnancy. The reason why these nervous dis- orders are more frequent in pregnant women with albuminous urine than in the other diseases attended with albuminuria is, that to the only producing cause of 1 Seven-eighths of the cases of eclampsia have occurred in primiparous women (Lacha- pelle) ; in thirty-eight of those reported by Merriman, twenty-eight were of this class ; and more than two-thirds of the instances given by Ramsbotham, and twenty-nine in thirty of those by Collins, refer to women who were delivered for the first time. 700 DYSTOCIA. epilepsy, in ordinary cases of albuminuria, are added the congestions to which the nervous centres are so liable during pregnancy and labor. Although the convulsions are generally spontaneous, and may be attributed simply to the condition just mentioned, there are some whose appearance seems to be connected with,a more readily appreciable cause, and which, therefore, may be justly regarded as a determining cause. In the list of occasional causes, certain writers have included the most com- mon and indifferent circumstances, the mere recital of which we shall spare the reader; but will simply mention strong moral emotions, whose influence, though incontestable, is, in some cases, hard to be explained. There are some, however, which, in reference to treatment, deserve a careful mention, for it is especially by removing the cause that the attack may be arrested, or at least rendered less dangerous. The influence of the circumstances to which we allude is at first limited to organs at a greater or less distance from the nervous centres, and it is only secondarily that the irritation transmitted to the latter excites them, and gives rise to the convulsion. Thus it is, that an irritation of the nerves of the uterus, vagina, bladder, rectum, or stomach, may become the determining cause of general convulsions. A. Uterus.—All the causes of essential dystocia, which require longer con- tinued and more powerful efforts on the part of the womb, may occasion an excitement of the sensitive nerves of this organ, which, when transmitted to the spinal marrow, is calculated to awaken the reflex action of the motor nerves. Under this head, we would indicate a malformation or obstruction of the pelvis, a partial or complete obliteration of the vagina or vulva, organic alterations, and spasm of the body or neck of the womb, fcetal deformities, or monstrosity, &c. Unfavorable positions of the child have not, certainly, so great an influence as might at first be supposed. Churchill says that " the effect of unfavorable posi- tions has been greatly exaggerated, for Drs. Clark, Sabat, and myself, have witnessed but a single case of convulsions coinciding with a bad position in 48,397 labors." Eclampsia almost always occurs in head presentations; but, as Tyler Smith remarks, the first attack does not come on at the moment the head presses upon the neck or clears its orifice, but rather when it distends the peri- neum, and partially dilates the vulva. It is then, especially, that a prompt termination of the labor puts an end to the convulsive attack by removing the pressure from the soft parts. All the unfortunate circumstances that may complicate the labor and require the introduction of the hand, whether before or after delivery, should be men- tioned as capable of producing the same excitation; such are encysted placenta, its abnormal adhesions, its partial or complete retention, the presence of large clots, retroversion of the uterus, &c. B. Intestinal Canal—The irritation produced by distension of the intestinal canal, and especially by the accumulation of large quantities of fecal matters, and the presence of worms or foreign bodies in the large intestine, is sometimes also the determining cause of eclampsia. Both Merriman and Chaussier have insisted upon the influence of a saburral condition of the priraae viae, which influence is, they say, sufficiently shown by PUERPERAL CONVULSIONS. 701 the state of the tongue, and epigastric pain which the patient nearly always complained of at the onset of an attack. The presence of indigestible food in the stomach appears, in some cases, to have been the cause of convulsions. John Clarke relates the history of several women who were so affected after delivery, in consequence of having eaten largely of oysters. C. Bladder.—Lastly, the same may be said of irritation of the walls of the bladder produced by its extreme distension with urine. The curious observation of Mauriceau is well known, and Dr. Vines mentions an exactly similar case. In the latter, the convulsions which had for two days resisted the delivery and all the generally recommended means, ceased immediately upon withdrawing from the bladder, by means of the catheter, five pints and a half of a turbid and highly ammoniacal urine. Numerous other predisposing causes have likewise been described, the influence of which, however, it must be acknowledged, is far more difficult to appreciate; thus, for instance, M. Baudelocque enumerates in his thesis, a residence in large cities, the use of small or tight garments, an over-succulent diet, the abuse of spirituous liquors, constipation, retention of the urine (pointed out by Delamotte), sexual intercourse, the suppression of an habitual discharge, too much sleep, want of exercise, the frequentation of balls or plays, anger, jealousy, bickerings, dis- appointments, &c. There can be no doubt that all these causes, by modifying or disordering the circulation, may render it more active, and thus facilitate a sanguineous determination towards the brain; but they should evidently be con- sidered in the light of a secondary predisposition, which may be added to some one of those mentioned above. Epilepsy has also been considered, though improperly, as constituting a pre- disposition to eclampsia; for, though the two diseases have a close analogy, yet those pregnant women who were epileptic before their gestation commenced, are less subject to attacks then than at any other time. Indeed, some authors have supposed that pregnancy suspends the epileptic fits altogether; but this is not absolutely the case, for they only occur then more seldom than usual. Dr. Tyler Smith relates a curious case of an epileptic woman who had an attack immediately after what she regarded as the fecundating intercourse, and who experienced an entire suspension of the disease during the remainder of her pregnancy. We would repeat, in terminating this etiological study of eclampsia, that the various determining causes exist very frequently without giving rise to convul- sions. The reason of this is, that they are of themselves incapable of producing them, and have no real influence except in cases presenting in a greater or less degree the general or local lesion which occasions albuminuria. A review of all the causes will enable us to explain their mode of action. It is evident that all of them have a tendency to produce an irritation of the ner- vous centres. This irritation is direct, when due to the immediate contact of vitiated blood, and indirect, or by reflex action, when it follows the excitement of a distant organ, as the bladder, uterus, &c. I am happy to find in the work of Scanzoni a confirmation of these views, long since proposed by me. Setting out with these ideas, Scanzoni divides eclampsia into, 1. Reflex convulsion, proceed- 702 DYSTOCIA. ing from the peripheral extremities of the irritated sensitive nerves; 2. S/inal convulsion, produced by direct irritation of the spinal marrow, whieh irritation is transmitted to the peripheral extremities of the nerves; 3. Cerebral convulsion, when the irritation resides in the brain, aud is transmitted to the spinal marrow. The existence of this latter form is doubtful, and, for our own part, we are much disposed to believe that eclampsia always has its origin in spinal irritation. It is a fact, proved experimentally by physiologists, that irritation of the spinal mar- row, of the medulla oblongata, or of the tuberculae quadrigeniinae, gives rise to convulsions only, whilst irritation of any other part of the brain produces nothing of the kind. It is true that cerebral lesions may destroy voluntary motion, but involuntary contractions, the excess and disorder of which constitute eclampsia, are not affected by them in the least. The latter may be produced by irritation of the spinal marrow or of its nerves, even when the cerebrum and cerebellum have been completely destroyed. § 2. Symptoms. Like Madame Lachapelle, we shall describe three orders of phenomena in the attack of eclampsia, which, under the triple aspect of diagnosis, prognosis, and treatment, are of great importance, namely, the precursory symptoms, those which are manifested during the fits, and those which are sometimes developed in their intervals. A. Precursory Phenomena.—An attack of eclampsia scarcely ever appears unexpectedly, as it is almost always preceded by certain phenomena, which enable us to foretell its speedy invasion. Chaussier even supposed these to be so con- stantly present, that, in the few exceptional cases where the observers have not mentioned them, it was because they were of short duration, and, therefore, either passed away unperceived, or else were misunderstood. This opinion is, however, rather too unqualified. The precursory symptoms are sometimes absent, and, as M. Wieger remarks, the comparative frequency of the prodromes differs according to the periods at which the convulsions make their appearance. Those which come on before labor are, he says, preceded by premonitory symp- toms in forty per cent, of the cases; those appearing during labor or the delivery of the placenta, have the symptoms in thirty per cent.; and such as are delayed until after delivery, in twenty per cent, of the cases. These precursory phenomena are variable in duration; thus, for some days, though occasionally only for a few hours, before the invasion of the puerperal epilepsy, the patients complain of agitation or malaise; they are easily excited, are impatient and irritable; they experience a marked difficulty in respiration; and they suffer from an exceedingly poignant and acute pain in the head, which, like the megrim, occupies but one-half of the cranium, and sometimes is even still more concentrated, and appears fixed upon one coronal boss, or some other equally circumscribed point. This pain in the head, which is one of the most important diagnostic signs, nearly always resists all the curative measures usually employed; it is accompanied with nausea, or even vomiting, by vertigo, dimnei-s of vision, tinnitus aurium, and sometimes by an acute pain in the epigastrium. (Chaussier, Denman.) When these primary symptoms have lasted for some time, they acquire a PUERPERAL CONVULSIONS. 703 greater degree of intensity, and are often complicated with a more or less marked disorder in the sensorial and intellectual faculties. The vision becomes affected, the sight seeming to be obscured by a thick mist, and the patient distinguishes objects less clearly; sometimes even, as in a case observed by Dr. Meigs, of Philadelphia, she sees only one-half of an object held before her.1 The hearing is likewise less distinct; the touch not so fine and less delicate; the woman's countenance exhibits an unusual hebetude; the expression is fixed, the linea- ments immovable, and she appears sunk in a deep abstraction, from which she can only be aroused with some difficulty; she scarcely comprehends the ques- tions addressed to her, and very frequently replies incoherently. In a plethoric female, the pulse is full, slow, and hard, and the face is occasionally flushed and animated; on the contrary, where the patient is affected with anasarca, particu- larly if she happens to be of an irritable, nervous constitution, the pulse is small, hard, and contracted, the face is pale and the skin cold, especially on the extre- mities; and sometimes there is a slight chill, or an imperfect horripilation. In addition to these, some women experience pricking sensations and formications in the limbs. When the eclampsia appears during labor, it is often preceded by extreme in- docility and agitation; the uterine contractions also present for a time that pecu- liar character of continuity and irregularity which has gained for them the name of uterine tetanus. The patient laughs and weeps alternately, and speaks with volubility. A state of hebetude and stupor sometimes succeeds to this extreme agitation. B. Phenomena of the Attack.—After a variable duration and intensity of the symptoms just indicated, the first fit comes on; a most accurate outline of which is furnished by M. Prestat, in his inaugural dissertation, as follows : The ex- pression becomes at once completely fixed, and there is a moment of general immobility. Then, if the patient be attentively examined, the muscles of her face will be found agitated by slight, limited, and very rapid movements, which, however, are perceptible through the skin; these movements become more and more marked, the features are wholly altered, the muscles of the face contract in a thousand ways, and she grimaces horribly; the eyelids are agitated by an in- cessant winking, though they are wide enough apart to bring the ball of the eye into view; the latter rolls in the orbit in every direction, and then becomes fixed on one side, where it remains stationary; the pupil is dilated and immov- able; the muscles of the alae of the nose, being forcibly contracted, draw the base of the nostrils outwards, and thus render its extremity sharper; the lips are in continual motion, and one of the angles of the mouth is drawn towards the same side as the eyelids, that is, to the one towards which the head is inclined; the mouth, being at first partly open, permits the tongue to hang out, which latter is excited by irregular movements, and is thrust forward between the dental arches; and, unless the precaution be taken to return it, or to prevent the closing of the teeth, the masseters force the jaws together, and the tongue is se- 1 It seems to me that these disorders of vision are not due, as hitherto supposed, to ce- rebral congestion, preceding the eclampsia, but, that in at least the majority of cases, they are consequent upon the lesion producing the albuminuria. It is well-known, indeed, that disordered vision and even blindness, are not uncommon occurrences in Bright's disease. 704 DYSTOCIA. verely bitten or bruised. The small muscles of the chin, by contracting, like- wise render its extremity more pointed ; so that, according to the comparison of M. Dubois, the woman's countenance then looks like a satyr's. The convulsions never appear to this extent in the muscles of the face, with- out soon invading those of the extremities and trunk ; affecting the extensor muscles particularly, the contractions of which overcome those of the flexors. The arms, being forcibly extended along the sides, and sometimes held a little in front of the trunk, though often turned in a forced pronation, are excited by small convulsive jerks; the fists are usually clenched, and the thumb is either flexed into the palm, or else extended between the index and the medius; the lower extremities exhibit a similar extension, and the same spasmodic jerks, as the arms ; the body, also, is in a state of almost permanent extension. Whence it follows that the continual tendency to throw herself about, and to change her position every instant is not met with iu this affection, as it is in many other convulsive diseases; for when the woman is placed on ber back, she retains that position throughout the whole duration of the fit; and there is no necessity for taking any precautions to prevent her from falling out of bed, or from striking herself violently on the face or other part of the body. The muscles of the hollow organs do not remain altogether indifferent to the disorder in the external muscular apparatus; for the fecal matters, the urine, and the contents of the stomach, are often expelled by the convulsive contraction of the reservoirs in which they had accumulated. The respiration is interrupted, noisy, and affected by continual jerkings with- out any regular order; sometimes, indeed, as Madame Lachapelle has observed, it is wholly arrested by the spasmodic contraction of the diaphragm and other muscles of the thorax. According to Dr. Tyler Smith, the muscles of the larynx are contracted con- vulsively, so as to obliterate the glottis almost completely ; hence the respiration is either suspended or noisy, and the inspiration short and quick ; consequently, hematosis is either suspended or diminished. This momentary asphyxia ex- plains satisfactorily the bluish, or even blackish color of the face and extremities, the swelling of the head and neck, which are gorged with black blood, as also the frightful turgescence of the skin, eyes, and tongue. The carotids beat violently, and the jugulars stand out prominently. The secretion of the salivary glands is increased by their congestion. The jaws are closed forcibly, and in consequence of the approximation of the teeth, and the quantity of saliva in the mouth, the air escapes with a hissing noise, and by agitating the saliva, forms a thick foam, which is expelled continually from the mouth. This foam is not unfrequently stained with blood from wounds produced in the tongue by the teeth. The spasm of the pharynx renders swallowing impossible, so that substances placed upon the base of the tongue, remain there to the risk of producing as- phyxia. In a case of this kind, Dr. Simpson (of Stamford) excited deglutition by placing the substance to be swallowed in the upper part of the pharynx, and sprinkling the face with cold water. According to Dr. Smith, the muscular fibres of the heart may also participate in the general convulsion. The extreme lividity and turgescence of the entire PUERPERAL CONVULSIONS. 705 surface of the body are sometimes greater in eclampsia than in ordinary asphyxia, the entire body being in the condition in which the head is found in persons who have been hung. Dr. Smith thinks that this state is attributable to the venous circulation ; may it not be asked, he says, whether there is not a spas- modic contraction of the right auricle, giving rise to a congestion of the entire venous system from the vena cava to the capillaries ? And is not this suppo- sition confirmed by the autopsy, exhibiting, as it does, the ventricles and auricles completely emptied of blood ? A very remarkable circumstance, and one which seems to me to prove the ursemic nature of eclampsia, is the suspension for a longer or shorter time of the urinary secretion. I have had occasion, several times, to introduce the catheter durinof the attack, and have found the bladder quite strongly contracted, and entirely empty. In the majority of cases, I have not been able to obtain more than half a spoonful of urine, whilst, in others, it was impossible to extract a drop. It is well known that ischuria is one of the symptoms of poisoning by ursemia. At the commencement of the fit, the pulse is full and hard, subsequently be- coming smaller and almost imperceptible; the skin is hot and dry, and is soon covered by a profuse perspiration. This transpiration usually coincides with a diminution in the frequency and intensity of the spasm, and announces its speedy termination. While it lasts, the sensorial and intellectual functions are wholly abolished ; the patient is conscious of neither sound nor light; the sensi- bility is entirely lost, and we may pinch, incise, or burn the skin with impunity, and without her knowledge, and even without her recollecting it after the fit. The effect of the convulsions upon the contractility of the uterus is extremely variable. During the attack, the uterus sometimes remains passive, astonished, as it were, at the universal disorder; whilst, on the other hand, there are cases in which, whether the eclampsia comes on during labor or precedes it, the con- tractions continue with their normal regularity. Occasionally, also, it seems to participate in the general irritation, and expels the foetus very rapidly, even when the slight dilatation of the neck would appear to indicate that delivery was yet distant. This rapid expulsion, of which the patient is entirely unconscious, may escape the attention of the accoucheur, and in some instances the child has died asphyxiated between the mother's thighs, for want of the proper attentions. I think, however, that these rapid deliveries are far less frequent than some accoucheurs imagine. The idea of an earlier delivery than usual may have had its origin in a neglect to ascertain the condition of the cervix, which may have become dilated without the consciousness of the female. Whenever I have been able to follow up the labor, the cervix has always appeared to me to dilate very slowly, and has often seemed to be contracted spasmodically, as though it participated in the general convulsions. The expulsive stage, is, I think, shorter than usual, a fact readily accounted for by the energy of the uterine con- tractions and the slight resistance of the perineum, the muscles of which are in a state of resolution during the coma. Although the fits do not accompany each pain, they nearly always come on just at the commencement of one. " This appears to me to be so manifest and decided," says Dewees, " that I think I could tell what is going on at the mouth 45 706 DYSTOCIA. of the uterus, without an examination per vaginam." This, however, is not always the case; for, under some unusual circumstances, the contraction appears only when the convulsion has reached the lower extremities. Therefore, al- though in the first case the uterine action appears to determine the convulsive attack, in the second it seems to be the consequence of it. It is possible that this difference may furnish an explanation of the variable effect of eclampsia upon the termination of labor. The cessation of the convulsive attack is never abrupt; the movements and spasms gradually become less violent; the respiration is less hurried and more full; the face loses part of its lividity ; the muscles are only agitated at intervals, and their action resembles that which is excited by passing a brisk electric shock through them. In general, the first fit is of short duration, and not very violent; but, in most case, the fits are repeated frequently, and the symptoms become more and more frightful in proportion as they are renewed ; the succeeding one, say Merriman and Velpeau, being often heralded by an uncommon slowness in the pulse. In the latter paroxysms, Madame Lachapelle has remarked that the convulsive shocks are less considerable, and sooner over than the earlier ones, but that the comatose symptoms are more grave and persistent. I do not regard this as cor- rect, but it is true that the comatose symptoms are more serious and persistent. The duration of an attack is very variable. The first fits are commonly the shortest, becoming more prolonged as they are renewed. At first, they last from one to two minutes, and afterwards from three to four; but they rarely exceed six to eight minutes. It is said that they have lasted for a quarter or half an hour, and even for a whole hour; but those authors who pretend to have known them to continue for several hours, have evidently regarded both the convulsive and the comatose periods as parts of the paroxysm. The number and rapidity of the convulsions are equally variable; in nearly all cases, there are two or more, and sometimes they have reached as high as sixty. In some instances, there is an interval of several hours, or half a day, between them ; while in others, on the contrary, only a few minutes elapse before the return of the next. C. Interval.—The patient remains in a state of complete prostration during the intervals of the first three or four paroxysms; but she.soon comes to herself, opens her eyes, and looks at everything around with astonishment; she scarcely recognizes the persons and objects about her, and cannot be made to comprehend the distress and anxiety of her friends and family, for she has no knowledge of what took place while the fit lasted ; but in a short time her ideas become clearer, and at length she entirely recovers the use of her faculties. These lucid inter- vals are quite prolonged after the early attacks; but, as they are renewed, the moments of intelligence become shorter and shorter during their intervals, and the woman ultimately sinks into a state of profound coma or apparent death; from which she is only aroused by the return of fresh convulsive movements. This comatose state presents all the characteristics of an intense cerebral con- gestion, of which indeed it certainly is a consequence. Even if it be supposed that during the convulsion the muscular fibres of the auricles present no obstruc- tion to the return of the venous blood, the violent contraction of the muscles of the neck certainly compresses the veins there situated, and, by preventing the PUERPERAL CONVULSIONS. 707 return of the blood, gives rise to a cerebral congestion, which produces the insen- sibility during the attack, and the sleep which follows it. The stupor is pro- found, the face injected, the respiration stertorous, and the limbs are in a state of perfect flexibility; but the sensibility, though greatly blunted, is rarely lost altogether, for when we pinch the patient, or rub her roughly, she shows signs of uneasiness, and groans very much like individuals who are laboring under a severe concussion of the brain. However, the torpor may be such that the sensi- bility is entirely lost; but even then the female appears to be conscious of the pain caused by the uterine contraction, for, when the latter comes on, she evinces by her countenance and groans, the sufferings she experiences. The intellectual faculties seem to be wholly abolished, the pupils are dilated and insensible. In general the pulse is strong and developed. When this comatose state is about passing off, it changes into a somnolency, from which the woman may be aroused by speaking to her; and the sensorial faculties gradually return. When the torpor is dissipated, she complains of great fatigue, and of a feeling of painful weariness; then, at the end of a vari- able period, this prostration gives way to great anxiety, the prelude of a fresh attack. § 3. Termination of Eclampsia. An attack of eclampsia may terminate either by recovery, by death, or by giving rise to some other disease. When the patient is likely to get well, the paroxysms are usually few in number, of short duration, and occurring after long intervals. During this latter period, the female recovers more or less completely the use of her limbs, as also of her sensorial and intellectual faculties. When there is to be no return of the fit, the intellectual faculties are the longer in regaining their normal condition as they have been the more disor- dered, or as they have been suspended for a greater period. The memory parti- cularly is much weakened, sometimes even is altogether destroyed, for the patient not only cannot recall what took place during the fit, but she has likewise for- gotten the common occurrences of the few days preceding the invasion of the symptoms; and it is only restored by degrees, each hour adding some facts to those of which she had previously recovered the recollection. It is singular that this defect of memory is often limited to isolated words; thus some have been known to forget entirely the names of their nearest relatives; others could no longer recall the name of the street, or the number of the house they occupied; and certain others again had entirely lost the memory of dates. Alphonse Leroy reports one instance in which a very singular aberration of vision followed some convulsive phenomena, that held the patient's life in jeo- pardy for several days; all the objects that were brought before her, and all the surrounding persons, looked black. The sight and hearing likewise require a certain time for the recovery of their perfect integrity; the woman's general condition is thus gradually ameliorated, and ultimately she regains her usual health. On the contrary, when the disease is about to terminate by death, the convul- sive attacks are observed to last for four, five, or six minutes with great inten- sity; they occur in rapid succession, and, during the interval that separates them, 708 DYSTOCIA. the female is sunk in a torpor, from which she cannot be aroused by any exter- nal irritants. The period at which death takes place under such circumstances is very variable, though in general it is between twelve and forty hours"after the invasion of the first symptoms. Sometimes, however, the patient dies at the out- set of the disease. The head, says M. Depaul, began to distend the perineum and appear at the vulva, and there was nothing to excite alarm, when I sud- denly observed a change in the patient's countenance, characterized by convul- sive movements, and grimaces, heralding eclampsia, and death followed imme- diately. The child was extracted alive by the forceps, but it died a few moments after with eclamptic convulsions. Death may occur in the convulsive stage, or in that of the coma. In the former case it is evidently due to asphyxia, which is itself produced by the paralysis, or rather by the permanent contraction of the muscles of the chest and of the glottis j1 in the latter, it is a result of the cerebral congestion, and sometimes even of a true apoplexy. Finally, there is no reason why we should not admit with M. Aran, that death may, in some cases of eclampsia, result from a sudden arrest of the movements of the heart.2 Again, an attack may not be grave enough to end in death, and yet may give rise to several very serious disorders. For instance, when the eclampsia occurs in the commencement of the labor, the violent contractions of the womb may cause a rupture of the organ, if the os uteri is not sufficiently dilated. Again, it is possible that the disorders in the circulation may occasion a cerebral conges- tion ; and the consequent engorgement of the vessels of the brain may be such as to produce their rupture, which is followed by an apoplectic effusion, and, as a consequence, by hemiplegia. In plethoric women, this anatomical lesion might even be produced by the early paroxysms; and it is probably in this way that the cases observed and described by M. Meniere, under the name of puer- peral apoplexy, might be interpreted. A sanguineous determination may also take place towards the lung, and thus produce congestion of that organ. As a possible consequence of the congested condition of the brain and its membranes, we should also mention a state of irritation, which occasions and 1 This asphyxia might also result, according to Boer, as a consequence of the obstruction of the bronchial ramifications, in which a considerable quantity of frothy mucus some- times accumulates. 2 The heart, says M. Aran, is a muscular organ, and as such is certainly liable to have its innervation affected, as also the properties with which it is endowed as a contractile agent, that is to say, its irritability, motor power, and tenacity. To whom, for example, is it not evident, that if the heart, which is sometimes known to be lacerated by its own contractions, should be paralyzed by an interruption of nervous action or by the loss of some of its muscular properties, death would be instantaneous? Would it not be equally so, if, instead of ceasing to contract, it should be affected with spasm, as happens to some of the external muscles? May it not be supposed that several convulsive neuroses, in which death sometimes takes place suddenly, as epilepsy, eclamp- sia, spasm of the glottis, &c, prove fatal less from deficient hsematosis than from a com- plete and instantaneous cessation of the pulsations of the heart? PUERPERAL CONVULSIONS. 709 maintains for a longer or shorter time, a complete or partial delirium, and some- times, even, the symptoms of a true meningitis or meningoencephalitis. Of the seven eclamptic women treated at the Obstetrical Clinic, whilst I was on duty, four presented evident symptoms of meningitis after the coma had en- tirely passed off; two of them died, and exhibited the anatomical characters of meningitis at the autopsy. But independently of these unfavorable complications, which constitute so many new diseases for the physician to combat, there is another one which is less immediate, but not less rare, says Madame Lachapelle; that is, puerperal peritonitis. In conclusion, certain cutaneous or intestinal inflammations may result in consequence of the energetic measures employed against the eclampsia. Thus, the life of the patieut has sometimes been endangered by an attack of entero- colitis. The sinapisms, also, which are then crowded on the lower extremities, are not felt by the patient, and may be forgotten in the general agitation ; con- sequently, they remain applied too long, and thus produce erysipelas and severe vesications. A lady, reported by M. Velpeau, was attacked, on the second day of her convalescence, by a violent erysipelas over the whole leg, because the sinapisms applied there produced no effect at first, and therefore were allowed to remain on too long. § 4. Diagnosis. The minute detail into which we have entered in describing the symptoms of eclampsia might possibly dispense with a return to its principal characters; but as there are some affections that have a strong analogy to puerperal convulsions, we shall again bring forward the signs by which they can be distinguished. When considered as a whole, eclampsia is so easy to diagnosticate, and its symptoms are so well marked, that it really seems useless to recapitulate them; but it is composed of two widely different stages, the paroxysmal and the coma- tose, during either of which the physician may be called upon to decide what is the nature of the affection. Thus, during the paroxysm, it may be con- founded with hysteria, epilepsy, catalepsy, or tetanus; while apoplexy, concus- sion of the brain, and the coma of drunkenness may be mistaken for it in the comatose stage. However, in hysteria there is sometimes an alteration, but never a total abolition, of the intellectual powers; indeed, the sensorial faculties have an unusual degree of delicacy and perfection ; there is no coma after the fit, and the convulsive movements are altogether different from eclampsia; thus, the limbs become forcibly flexed (instead of being extended), and subsequently writhe with violence; there is a continual tendency to change the position, and the patient would certainly throw herself out of the bed if she were not held down by vigorous arms. Again, an hysterical paroxysm is nearly always pre- ceded or accompanied by the sensation of a ball rising from the hypogastrium towards the throat, which gives rise to a feeling of suffocation similar to that produced by strangulation. Deglutition is very difficult or impossible, but the muscles are much less strongly contracted, and instead of that whistling respiration which indicates 710 DYSTOCIA. constriction of the throat, there are loud cries, proving a free opening of the larjnx. There is almost never frothing at the mouth as in eclampsia. The thumb, instead of being flexed in the palm of the hand, is extended dhtside of the other fingers, which are flexed. Finally, hysteria generally appears in the early months, whilst eclampsia appertains more particularly to the termination of pregnancy. But of all the convulsive affections, epilepsy is the most likely to be confounded with eclampsia; however, after the epileptic fit is over, there is but little or no coma, whereas more or less of it always exists after the puerperal convulsion. Still, as epilepsy is sometimes followed by a profound coma, it will be necessary to examine the urine, which will not usually be found to contain albumen as it would in a case of eclampsia. Moreover, in the latter disease, microscopic examination of deposits in the urine within twenty-four hours after its evacuation, may detect the presence of the cylinders of fibrin described by German authors, as well as blood and mucus corpuscles and epithelial cells from the ureters. It is well, however, to bear in mind that the same observation applies to the presence of these cylindrical bodies in the urine as to the albumen and blood, namely, that sometimes few or even none are detected by the most careful ex- amination ; and the same thing has been observed in all varieties of Bright's disease. It has been shown by Weld, that the occurrence of these exudations is intermittent, and that, consequently, there are times when none are present in the kidneys. This explains why some observers, M. Blot, for example, have never met with them. (See page 288.) The persistence of the convulsive rigidity of the limbs distinguishes tetanus from every other disease. Finally, catalepsy presents as an essential character the singular peculiarity,—that the extremities often preserve throughout the whole fit the position which they happened to have at its commencement, or any one we can succeed in making them assume during this convulsive state. The comatose stage of eclampsia will be distinguished from apoplexy by the following signs: it has been preceded by convulsive phenomena, which is not the case in the latter disease; all the extremities are in a state of complete resolu- tion, and they have entirely lost their sensibility and motility; and, most gene- rally, only hemiplegia results as a consequence of the cerebral effusion. It must, however, be observed that, when the eclamptic paroxysms are frequently re- newed, and the patient's intelligence has been lost for some time, the cerebral congestion, which keeps up the coma, may determine an effusion into the sub- stance of the brain. Hemiplegic phenomena then appear at once, and it will be possible to detect, on the side opposite to the one where the effusion took place, a more complete loss of sensibility and motility, though the limbs on the other side may be in a state of resolution. The reader will understand that, if the previous history were unknown, the diagnosis would then be very obscure. The loss of intelligence is always constant and total in eclampsia, whilst this pheno- menon may be wanting in apoplexy, or be limited to a simple obtuseness. In cases of concussion of the brain, the absence of all previous convulsions, together with the presence of the marks of a fall, or of a violent blow on the head, will serve to make out the diagnosis. PUERPERAL CONVULSIONS. 711 Lastly, the previous history of the patient, the ejection of the contents of the stomach mixed with a large quantity of alcoholic liquors, and the vinous odor of the breath of intoxicated individuals, will enable us to distinguish the coma of drunkenness from that of eclampsia. § 5. Prognosis. Eclampsia is a very dangerous affection, but we cannot agree with Madame Lachapelle, who states that one-half of the women affected with it are lost. In order to appreciate this conclusion from the practice of the illustrious midwife, it is necessary to bear in mind the peculiar conditions in which the patients at La Maternite are placed. After consulting the numerous cases which I have had occasion to observe, I think I might safely say, that when the patients receive proper care in due time, the mortality is hardly greater than one out of three and perhaps four. The prognosis varies, however, according to the cause that gave rise to the convulsions, to the stage of the puerperal condition at which they are manifested, and to the particular progress of the symptoms. Of all the various predisposing causes, a serous plethora, or a partial or general infiltration, says Madame Lachapelle, must give rise to the most unfavorable prognosis. This proposition now appears to us a great deal too absolute. Gene- ral infiltration should doubtless be considered as predisposing to eclampsia much more than partial oedema; but when the disease has once appeared, the general or partial infiltration adds nothing to the gravity of the prognosis. This results evidently from the observations of MM. Blot, Regnault, and Devilliers. Thus, of four patients with eclampsia, observed by M. Blot, three died, whilst all of three others affected in the same way, but free from oedema, recovered. So, also, MM. Regnault and Devilliers, who had two deaths for two non-infiltrated cases of eclampsia, observed but five deaths for nine oedematous cases, and three others fell victims to later complications succeeding the eclampsia. In short, the pa- tients with eclampsia and albuminuria, without oedema, give a mortality of 7 out of 15; and those with oedema, a mortality of 11 out of 51. As albuminuria is almost always pre-existent to eclampsia, it can have no other effect than is referable to its longer or shorter duration and its quantity. Albuminuria of very recent date, or of the kind styled transitory, and which gives only a slight cloud by the use of reagents, will lead to a much less unfavor- able prognosis than if it had existed for several months and had afforded a copious deposit of albumen. An old case of albuminuria always supposes an advanced disease of the kidney, or else an altered state of the fluid. The cases observed by MM. Devilliers and Regnault, prove that death then occurs most frequently either during the coma, or as a consequence of ulterior complications. The following table of 36 cases, by Braun, leads to the same conclusion. 712 DYST OCIA. Albuminuria. No. of cases. Mothers cured Died. In the convulsions. Of complica-. tions. Very considerable, . . Slight,....... 3 7 14 8 4 1 3 9 7 4 2 3 4 0 0 0 1 1 1 0 The convulsions that are developed in hysterical and epileptic patients, or in women of great nervous susceptibility, and those which succeed any acute moral emotion, are less formidable than those which have no relation with the former nervous state of the female. Finally, the eclampsia that can only be explained by the general alteration of the blood produced by albuminuria, is much more dangerous than that whose appearance seems connected with the irritation of some organ, as the uterus, bladder, intestine, &c; for in the latter case, sublala causa, tollitur effectus. As the depletion of the uterus is one of the most favorable conditions for the cure of the paroxysms, it is evident that, other things being equal, eclampsia is far more serious when it comes on at the commencement of the labor, than where it is not manifested until the dilatation of the parts is so advanced as to render a spontaneous or an artificial delivery both possible and easy. The convul- sions are likewise more dangerous when manifested at an early period of the gestation; not only because the patient, in case of recovery, is exposed to fresh attacks during the remainder of this state, but also because the complete oblite- ration of the orifice, and the hardness and length of the cervix, will render the depletion of the womb impossible. It is unnecessary to add that, in this respect, primiparae will be much more exposed than women who have previously borne children. The truth of this assertion has been questioned of latter time, but I am happy to find a resume in the memoir of M. Wieger, which confirms it fully. Of sixty-five women at different stages of pregnancy, who were attacked with eclampsia, twenty-five died, either during the attack, or in consequence of sub- sequent complications. That which takes place after the delivery is the least unfavorable of all; or rather such is the opinion of Duges; but I believe with Ramsbotham, that the prognosis would then be much more serious. I have remarked, says the latter, and here again I agree with him, that when the convul- sions come on in the last stages of labor, and continue after the delivery, the woman generally dies; but if they are arrested by the delivery, they seldom return, and the gentle slumber which then succeeds is the signal of a prompt convalescence. The course and intensity of the symptoms of a convulsive attack greatly influence its termination: thus, when the paroxysms are numerous and violent, and follow each other in quick succession, more particularly if the comatose state is prolonged during the whole interval that separates them, and when the patient does not recover the use of her sensorial and intellectual faculties in this interval, the prognosis is exceedingly unfavorable, for death most usually results. PUERPERAL CONVULSIONS. 713 Again, it must not be supposed that all danger is over when the labor is termi- nated and the convulsions have altogether disappeared; for, according to Denman, Collins, and others, the patients are then much exposed to consecutive abdominal inflammations, which, as is well known, often compromise their existence. After the complete cessation of the accidents, the albuminuria is generally found to disappear rapidly, so that sometimes no traces of it remain at the expi- ration of four or five days subsequent to delivery. This circumstance is a happy one, since it justifies the expectation of a happy convalescence. But if the urine remains charged with albumen for ten or fifteen days after the termination of the eclampsia, a return of the accidents is to be feared, as I once observed on the fifteenth day; or else it may be dreaded lest the alteration of the secretion niight be due to a more advanced degeneration of the kidney, which of itself would be likely to endanger the woman's life. If the prognosis is grave as regards the mother, it is at least equally so for the child, since it very frequently dies during the convulsions that take place in the course of the gestation or at the commencement of parturition; for the disorder created in the maternal circulation must necessarily affect that of the foetus. The latter may be affected with fatal eclampsia in the womb. I have sometimes seen it present a contracted state of all the muscles of the limbs, immediately after its expulsion; nor is it necessary to the production of the latter condition, that the mother's convulsions should have lasted for a long time. I saw (October, 1846) a highly infiltrated primiparous female, in whose case the complete dila- tation of the cervix and powerful expulsive pains gave promise of a speedy delivery notwithstanding a slight contraction of the pelvis, suddenly seized with an attack of convulsions. I applied the forceps immediately, and the child, whose heart was beating a few moments before, was extracted without difficulty. It was dead, and the upper and lower extremities, those of the right side espe- cially, were strongly contracted. The biceps muscles were extremely hard. M. Prestat mentions a nearly similar case. Although the foetus may escape the danger to which the convulsions expose it whilst still within the womb, it is not yet entirely safe, for it is subject to a sort of hereditary influence, during the early part of its existence, which renders it liable to convulsions similar to those with which the mother was affected. Schmitt (of Paderborn) relates, that a woman in whose case an attack of eclampsia assumed for more than three hours the appearance of decided cata- lepsy, was delivered by the forceps of a living child. At five o'clock of the next day, the latter presented symptoms of catalepsy resembling precisely those of the mother, and died in spite of all that could be done. But these are not the only dangers to which eclampsia exposes the child, for it is evident that version or the application of the forceps, which is then so often necessary, always endangers its existence more or less. Thus, of fifty-one children reported by Merriman, thirty-four were stillborn, and seventeen were born alive; which statement, unfavorable as it is, proves at least that, contrary to the opinion of many accoucheurs, the child is not always lost; and that we should not regard its life as worthless in those cases in which the intervention of art becomes requisite. Notwithstanding the gravity of the general symptoms of eclampsia, its effect 714 DYSTOCIA. upon the progress of gestation is not always so disastrous, for it has been known to continue in spite of long and frequent attacks. Generally, however, abortion or premature labor are the result, and that, whether the child be living, or whether it has perished in consequence of the violent shocks experienced by the mother. However severe the attack may be, it is very unusual for the woman to die undelivered, unless the expulsion of the fcetus be prevented by a mechanical obstruction. Still, sudden death has several times been known to take place, four cases of the kind being mentioned by M. Wieger as having occurred in the practice of German accoucheurs. The Caesarean operation was performed upon the bodies. § 6. Pathological Anatomy. Thus far post-mortem examinations have thrown no light on the nature of eclampsia, for most usually this disease leaves no appreciable anatomical lesion behind. Often, indeed, there is a little serosity found in the ventricles or arach- noid cavity, and possibly a more or less evident congestion of the encephalic vessels; and when the affection has terminated in apoplexy, the dissection has exhibited either an apoplectic extravasation into the cerebral substance, or else a free effusion on its surface. But these are evidently nothing more than secon- dary lesions, the effects, and not the cause, of the convulsions. In a woman who died from puerperal epilepsy, M. Prestat found a little body, of a stony consistence, and about as large as an ordinary pea, in the corpus striatum of the right side; and, in another case, M. Baudelocque detected an ossification of the dura mater. But M. Prestat was certainly correct in regard- ing such anatomical lesions as mere coincidences, for nothing would warrant the conclusion that a relation of cause and effect exists between them and the con- vulsions. What we have stated in regard to the almost uniform coincidence of albumi- nuria with eclampsia, and to its common connection with lesions of the kidneys, sufficiently indicate that the anatomical lesions are hereafter to be sought for in those organs. For our own part, we have never failed to do so for the past ten years, nor do we hesitate at the present time to consider albuminous nephritis as one of the most common lesions after puerperal convulsions. As already stated, the kidneys have almost universally presented the anatomical characters of nephritis, the more or less advanced degrees of which appeared to coincide with the chronicity and abundance of the albuminuria. Other observers, amongst whom I might mention MM. Blot and Depaul, state that usually they have met with no disease of the kidney, and regarding the above-mentioned facts as altogether exceptional, insist that in the majority of cases Bright's disease has no connection with eclampsia. In the first place, I would call attention to the fact, that I do not regard Bright's disease as residing in the lesion of the kidney exclusively (page 285); and that although the kidneys should present nothing abnormal, the alteration of the urine is sufficient to prove its existence. I might, therefore, strictly pay no regard to the facts mentioned by my opponents; but let us examine whether, independently of the opinion which I support, the observations of MM. Blot aud PUERPERAL CONVULSIONS. 715 Depaul are of much value. They have found nothing, say they; but perhaps their not having done so is their own fault in not having examined sufficiently, and I have to acknowledge that hitherto I had committed the same error. Works recently published in Germany show, in fact, that the naked eye is en- tirely incompetent to detect anatomically the commencement of albuminous nephritis, and that the first degrees of renal alteration can be discovered only by the microscope. The nature of this book does not permit me to enter into the anatomical and microscopic details found in Frerichs' work; but the researches of which I speak evidently show the small value of observations in which the microscope has not been employed. All negative facts should, therefore, be regarded for the moment as having no existence, and more accurate observations are necessary to determine whether or not there are cases in which the lesions of the kidneys are altogether wanting. Henceforth, therefore, attention should be especially directed to the kidneys. § 7. Nature of Eclampsia. As a consequence of the labors of those modern pathologists who have fol- lowed the impulse given by M. Rayer, eclampsia, which had been so long classed with the neuroses, that is to say, with diseases whose nature is entirely unknown, begins to be better understood. Whoever shall have read attentively what we have said of puerperal albuminuria (page 281), and of its relations with eclampsia (page 697), will perceive that we can no longer withhold our opinion as re- spects the nature of puerperal convulsions. In the first place, let us return to what we regard as the fundamental fact, which must decide the whole question, namely, that eclamptic females are almost always affected with albuminuria. Now, although it is true that albumi- nuria may be present in a great number of general or local diseases of easy diagnosis (Rayer), and although it may be produced artificially by wounding cer- tain parts of the nervous system of living animals (Claude Bernard), it is very certain that, aside from these conditions, which are rare and exceptional in preg- nant women, the presence of albumen in the urine during the puerperal state, always denotes a general alteration of the urinary secretion. This alteration, as stated (page 281), first consists in a modification of the elements of the blood, which is soon complicated with a lesion of the kidneys, constituting its anato- mical expression, as albuminuria and still later eclampsia are its symptomatic expression. Eclampsia is, therefore, the ultimate phenomenon of Bright's dis- ease, whether it be merely a general affection or more especially localized in the kidneys. This alteration of the blood, or species of poisoning, has received the appella- tion of urazmia from the German authors. It is characterized anatomically by the loss of albumen from the blood, and by its admixture with a greater or less amount of urea. It is impossible for me to exhibit and discuss the value of the theories of Frerichs, Schotin, and others, in regard to uraemia. I must content myself with observing that, although differing as regards the explanation, all of these authors agree in considering the alteration of the blood as the cause of most of the symp- toms of Bright's disease. 716 DYSTOCIA. We have already said that this alteration of the blood had been detected during pregnancy ; let us now examine whether the symptoms to which it gives rise are also met with in the pregnant female with albuminuria. In the excellent memoir of M. Imbert-Goubeyre, which was crowned by the Academy, the author, who defends with much brilliancy and talent the opinion which I hold, has proved that the history of the symptoms of Bright's disease is also the history of puerperal albuminuria. In both cases, he has observed amau- rosis, cephalalgia, lumbar pains, partial paralysis or hemiplegia, various neural- gias, blindness, contractions, hemorrhages, gastric disorders, convulsions, and lastly, what it is almost unnecessary to mention, the analysis and microscopic examination of the urine furnish in both cases the same results. But, it may be said, these symptoms are rarely observed in puerperal albu- minuria. We might reply, that they are also rare in albuminous nephritis. Still, they are probably much more common during gestation than is generally supposed. They have, in fact, always been noted in connection with pregnancy, but the examination of the urine was neglected. However, since attention has been turned to the subject, several authors have pointed out their coincidence with albuminuria. Besides, in Bright's disease, these symptoms are rarely met with, except at an advanced stage, whereas during pregnancy it is unusual for the renal affection or the alteration of the fluids to be carried so far. Therefore, they are witnessed more rarely. Considering the slight progress made by the so-called puerperal Bright's disease, it would seem as though the symptoms ought to be met with still less frequently, and in most cases their appearance might be regarded as premature; but this early appearance is readily explained by the reflex irritations resulting from the pregnancy and labor. The similarity of the symptoms and anatomical alterations induce me, there- fore, to attribute the eclampsia and the albuminuria which always accompanies it, to Bright's disease. MM. Blot, Depaul, and some others, having raised several objections to this opinion, we shall next endeavor to appreciate their value. " 1. As albumen is not discovered in the urine of all pregnant women, there- fore eclampsia is not necessarily connected with albuminuria and Bright's dis- ease." Supposing the observations upon which this first objection is based to have been well made, and some of them, at least, seem to me deserving of all confi- dence, they still do not prove incontestably what is desired. Albumen, indeed, is not found invariably in all individuals who, not being in the puerperal state, are certainly affected with albuminous nephritis; although very abundant at cer- tain periods it diminishes greatly at others, and sometimes even disappears en- tirely for a longer or shorter time, but only to return again rather later. These same intermissions may also be met with during pregnancy, and we may readily imagine that unless the urine of the same woman, who afterward was attacked with eclampsia, had been examined frequently and through a long period, it could not be concluded that she was not albuminuric, especially if the albumen should appear during the convulsive attack. Furthermore, facts have been observed by Mazoun, a Russian physician, and referred to by M. Imbert-Goubeyre. which appear to me to answer the objection PUERPERAL CONVULSIONS. 717 still more completely. Mazoun mentions three cases in which the autopsy dis- closed,—once, the anatomical type of the second degree of Bright's disease; once, a lard-like condition of the kidney; and once, the characters of the first degree of Bright's disease: yet, although the patients were observed daily for several weeks, albumen was never detected in theirurine. Unless we admit that the fatty kidneys did not mark a case of Bright's disease, it must be allowed that this disease may exist exceptionally without albuminuria. Now if this is so, what can be concluded from those rare cases in which the eclampsia was neither preceded nor accompanied by albuminuria ? "2. When the kidneys present no alteration at the autopsy, can it still be said that the eclampsia was the consequence of Bright's disease ?" I have already replied to this objection affirmatively, if we regard, as always should be done, the general alteration of the fluids, and also if the microscope has not been employed, for it alone can now enable us to say that no real altera- tion exists. " 3. The difficulty and rarity of the cures of Bright's disease are well known; how, then, if puerperal albuminuria is due to the same cause, explain the prompt disappearance of the albumen after delivery, and the rapid recovery of the pa- tients ?" It is true that the albuminuria disappears quickly in a certain proportion of cases; but generally in those cases no eclampsia had taken place, or, at least, the patients recovered. Here, as was stated (page 288), it is probable that the blood was but slightly altered, and that the active or passive congestion of the kidneys produced by the obstruction to the venous circulation, contributed to a certain extent to the production of the albuminuria. We can then readily imagine that, one of the causes being removed by the delivery, the other might be incapable of maintaining the functional disorder; but it is not true to say that in other than these favorable conditions, the albuminuria ceases in a few hours. I have already quoted the statistics of 31. Imbert-Goubeyre (page 286), from which it evidently follows that when the disease proves fatal, the albumen continues to the end; and that in a certain number of cases, which will probably be found to in- crease when the patients shall be followed more carefully, it passes into the chronic condition. I might add with M. Wieger, that the medium duration of the al- buminuria in the non-fatal cases is from eight to ten days after delivery. We see, therefore, that these objections have no great force, and are not of a character to invalidate the many good reasons which go to support our opinion. We do not wish to deny absolutely the possible occurrence.of apparently eclamptic convulsions, in the case of a woman in labor, who presents neither albu- minuria nor any of the symptoms of Bright's disease. On the contrary, we be- lieve that in some very rare cases, the reflex irritation produced by an extremely painful labor, or the violent congestion of the veins of the spinal column, occa- sioned by the extreme efforts of the woman, may over-excite the spinal marrow and give rise to partial, or even general convulsions. But we regard such cases as altogether exceptional, and would even be disposed to debar them from the title of eclampsia, and consider them as simple convulsions, hysterical or other- wise, in their nature. Such, at least, is the impression left upon us by the two cases of the kind which have come under our own observation; and the reading 718 DYSTOCIA. of the published cases inclines me to believe that most of them were not instances of real eclampsia. § 8. Treatment. The management of eclampsia must necessarily be divided into the preventive and the curative treatment. We have dwelt sufficiently upon the etiology of eclampsia to show the impor- tance which we attach to albuminuria, or, rather, to the disease of which it is the symptom. The presence of albumen in the blood of a pregnant woman, is the indication of a marked predisposition on her part to puerperal convulsions, and the best preventive treatment would be that which would result in the most favorable alteration in the condition of the blood, or in the amelioration of the renal affection which is the apparent cause of the albuminuria. Unfortunately, all the therapeutic measures employed hitherto in other conditions than the puer- peral, have been very unsatisfactory. The tonic treatment, however, has seemed in some cases to be sufficiently useful to encourage new trials, especially during pregnancy, in which, as we have seen, the diminution of the albumen is attended by a lessening in the amount of all the solid principles of the blood. I would, therefore, have no hesitation iu recommending the animal diet and the adminis- tration of iron, in cases of albuminuria complicating pregnancy. The recent investigations of M. Mialhe, which prove that an excess of water in the blood is one of the most active causes of albuminuria, are evidently calcu- lated to confirm us in the therapeutic course which we have recommended for a long time. But, as we have already observed, convulsions almost never appear in a preg- nant woman with albuminuria, unless some accidental circumstance, so to speak, should happen to excite them. They are usually connected with cerebro-spinal congestions, themselves occasioned by fortuitous circumstances, with serous ple- thora, or the mechanical obstruction to which the venous circulation is subjected during gestation and labor; therefore, the first object should be to prevent this congestion. On this account it is, that bleeding should have the precedence of all others as a preventive measure. It should be practised several times during the latter months of pregnancy in such women as may present some of the symp- toms of cerebral congestion ;x it might also be practised with the happiest suc- cess in oedematous females, mere particularly when the precursory phenomena of eclampsia shall be manifested. In the latter, we should also resort to the mea- sures calculated to diminish the volume of the parts distended by infiltration; such as derivatives to the intestinal canal and urinary passages, the application of compresses steeped in cold water, or some aromatic decoction, and to punctures with the lancet. Nervous and irritable women, of a dry habit, will also be bene- 1 By way of showing the importance of venesection, as a preventive measure, Dr. Dewees relates the following case : Mrs.----,.pregnant with her first child, was seized with fre- quent headaches towards the end of her gestation; she neglected to be bled, and was at- tacked with severe epileptic convulsions at the onset of labor, from which, however, she recovered. During her second pregnancy she was bled freely, and delivered without acci- dent. In the third and fifth, venesection was not resorted to, and they were attended with convulsions; whilst, in the other gestations, she had recourse to this remedy, and was safely confined. PUERPERAL CONVULSIONS. 719 fited by a moderate bleeding from the arm, and by lukewarm baths, repeated frequently during the latter months of pregnancy; and they should avoid all acute moral emotions, &c, with the greatest possible care. Reserve is called for in the use of diuretics, for, although they are useful in certain cases, they may, in others, affect the progress of the disease unfavorably. Generally speaking, when there is no diminution in the amount of urine ex- creted, they should not be employed, for the increased urination would augment the waste of albumen, and consequently the impoverishment of the blood. When, however, the patient passes but little urine, it is important to increase the secretion, in order to prevent an admixture of the principles of the urine with the blood, and thus lessen the chances of ursemic intoxication. The prepara- tions of squill, digitalis, juniper, &c, may then be used with advantage. After the venesection and purgatives have been tried, Drs. Collins and John- son highly extol the use of tartar emetic, administered in such a way as to nau- seate without producing vomiting. For this purpose, a tablespoonful of the following mixture is given by the mouth every half hour : R>—Tartar emetic, . . . . . gr. vj. Laudanum, ..... gtt. xxx. Simple syrup, ...... f'5ijss. Infusion of pennyroyal, .... f §iij. F. M. The quantity of tartar emetic is increased or diminished according to the in- tensity of the symptoms, and the imminence of the disease. The same potion is also strongly recommended as a curative measure, after the invasion of the convulsive attack. For our own part, we should regard it as much less useful at that period. During parturition, the accoucheur should endeavor to modify or prevent the influence of the various causes of dystocia; thus, if the contractions assume the character of irregular, tetanic pains, he must attempt to restore them to their, normal and regular type, by a resort to bathing, to the opiates, or belladonna, and to venesection ; for it is an ascertained fact that the excessive agitation pro- duced by these pains is often the forerunner of eclampsia in a nervous and irri- table woman. It were hardly necessary to call attention to the favorable effect that inhala- tions of chloroform might have under these circumstances, both by changing the character of the contractions, and diminishing the irritability of the nervous centres. At the very commencement of the labor, the precaution should be taken to empty the bladder and large intestine, and to relieve the stomach of indigestible food, which might have an unfavorable effect, by vomiting. All these measures are particularly indicated when the patient, under care, had previously suffered from convulsions in her former labors, for she is, by that very fact, predisposed to a return of them. After the delivery, the accoucheur might often prevent this accident, by carefully exploring the state of the womb subsequent to the expulsion of the child aud placenta; and by assuring himself that it is well retracted, and that it 720 DYSTOCIA. contains no foreign bodies, such as coagula, or portions of the membranes or placenta. The curative treatment consists of the general measures that are applicable in all cases, and of the special means, which necessarily vary according to the period at which the puerperal convulsions are manifested. A. General Measures.—At the head of the list of curative means we must place sanguineous emissions, which have been resorted to under every form. To these, therefore, we must first have recourse; but, in the employment of this remedy, several questions, that are important in a practical point of view, are presented for solution. Ought we to employ general or local bleeding? And, if general, which vein is to be opened ? And what quantity of blood should be drawn ? In a large majority of cases, general venesection will first be preferred; and the revulsive application of leeches or cupping will only be resorted to in those instances where the convulsions shall have followed a profuse hemorrhage. Where free bleeding has been practised, and the coma continues, notwithstand- ing, throughout the whole interval between the fits, thus announcing an intense congestion about the encephalon, we might apply leeches with advantage to the mastoid processes, or to the neck, and also, perhaps, around the malleoli. Writers have sharply discussed the question as to what vessels should be opened; and arteriotomy in the temporal, bleeding in the arm or foot, and open- ing the jugular vein, have been extolled in turn. The advantages of blood- letting are very nearly the same, whichever vessel be opened; and, consequently, as venesection iu the arm is by far the most easy, and as we can always obtain there as much blood as may be deemed advisable, this is usually practised, and, as a general rule, should be preferred. It is very important that the vein should be opened largely, and that the blood should flow in a full stream. Should it dribble away, or the jet be very small, the bleeding, Ramsbotham says, is almost useless, and another vein had better be opened at once. The quantity of blood to be drawn varies according to the patient's constitu- tion, the violence of the paroxysms. &c, &c; thus, iu lymphatic individuals, we should, as a general rule, be satisfied with the extraction of fourteen to eighteen ounces; and if the symptoms still continue after this, and it be deemed necessary to keep up the sanguineous emission, it ought to be confined to the application of fifteen, twenty, or thirty leeches behind each ear.1 In plethoric women, after a copious bleeding of sixteen ounces, a second, of ten to fourteen ounces, might be resorted to, two or three hours afterwards, and perhaps even a third; but a fourth is rarely admissible, and we would preferably apply, instead, either leeches to the mastoid, processes or cups to the back of the neck. Bleeding has the double advantage of removing the congestion or irritation of the spinal marrow, and of preventing at the same time the cerebro-spinal con- gestion, which takes place during the fit, and which may produce fatal disorders, or at least become indirectly the cause of a fresh attack. 1 The reader will bear in mind that the leeches directed in the text are of the European variety, which extract a much larger quantity of blood than our own.—Translator. PUERPERAL CONVULSIONS. 72l General bleeding, even when carried so far as to weaken the patient greatly, does not surely prevent congestion of the brain or even effusion; for all these anatomical lesions have been observed in women who died after profuse bleeding by the lancet. On the other hand, when carried beyond certain limits, it may become itself the occasion of a fresh excitement of the spinal marrow, as is observed after all great hemorrhages, which almost always end in convulsions. The particular object, in applying leeches or cups to the nucha or behind the ears, is to supply the insufficiency of venesection, or to avoid any unfavorable effect which the latter might possibly have. Though the gravity of the symptoms, and the fear of congestions and effusions in the brain and spinal marrow, may often call for bleeding, it should not be for- gotten that the impoverishment of the blood of most eclamptic patients contra- indicates a too abundant loss of blood. It is proper, therefore, to bleed sufficiently to remove the congestion of the nervous centres or lungs, and to prevent apo- plectic effusions, but going too far in this direction would involve the most deplorable consequences. Simultaneously with the venesection, it is advisable to produce a salutary derivation to the intestinal canal and skin. The emetics have been recom- mended for this purpose; but, in most cases, they ought to be proscribed, as being calculated to augment the convulsive movements and cerebral congestion by the retchings they determine; still, if there was good reason for supposing that the accidents were partly caused by the pressure of badly-digested food in the stomach, vomiting should be encouraged either mechanically, by tickling the throat, or by the administration of an emetic. Purgatives are much to be preferred, especially when the large intestine is filled with hardened fecal matters. The fact that extreme distension of the bladder has occasionally appeared to be the determining cause of the attack, should always lead us to ascertain the condition of that viscus by percussion, and to use the catheter if it should chance to be found distended. If the patient recovers her intelligence during the intervals, and she can be induced to swallow, we might exhibit castor oil by the mouth in the dose of one or two ounces; or, still better, two grains of calomel every quarter of an hour, until it produces a purgative effect. If, on the contrary, she cannot swallow, a plan advised by Merriman might be adopted; that is, to put the calomel mixed with moist sugar in equal proportions between the lips and alveolar arches, or, if possible, into the mouth, and renew it until several stools are procured. If this latter measure be ineffectual, it will be requisite to act on the lower part of the intestinal canal by administering injections, rendered purgative by the addi- tion of an ounce and a half or two ounces of castor oil, or of the miel mercuriale, and, if necessary, by incorporating with it a few drops of croton oil. There are yet some other measures that cannot be relied on when employed alone; but which, nevertheless, are too important to be neglected. We allude to sinapisms applied successively on the thighs, calves of the legs, and feet, to vesicatories, and to dry cups placed on the back of the neck, and on the lower extremities. I apply them, says 31. Velpeau, to both thighs and the nape of the 46 722 DYSTOCIA. neck, so that they may act whilst we are engaged with the bloodletting, blisters, or leeches. They have appeared to me, remarks M. Prestat, particularly useful in oede- matous women; only it is necessary to watch their effects for a few days after- wards, lest their surface become gangrenous. I place an application Of the large cups of Dr. Junod1 to the lower extremities in the first class of revulsives, as being the most powerful and prompt in their action of any. In a case of eclampsia, that occurred five hours after delivery, the symptoms lasted for thirteen hours; and the patient's condition became more and more dangerous, notwithstanding the employment of all the measures just spoken of. At the first application of these cups, the convulsive paroxysms dis- appeared; at the second, the coma became less profound; and at the third, the patient regained her intelligence. Iu three other cases, the effect was not so rapid, although they appeared to have a favorable influence. These cups are especially applicable when, notwithstanding large general bleed- ings, the application of leeches or scarified cups has failed to remove the symp- toms. Under these circumstances, they have the immense advantage of opposing the cause which seems to drive the fluids towards the brain, by keeping a large amount of blood in the lower extremities. Cold aspersions upon the face and chest, and tickling the nostrils, have some- times had the effect to render the inspirations more easy and perfect, and thus defer the attack of convulsions. Harvey relates the case of a woman in labor, who was awakened from a deep coma by tickling the interior of the nostrils. Denman gives the history of a lady whose every pain was attended by a convul- sion, until he put an end to the latter for the rest of the labor, by sprinkling the face at the beginning of each contraction by means of a feather dipped in cold water. Even if useless, the measure is too innocent a one not to be had recourse to. Such are the measures that ought to be primarily employed; but there are certain others which, without having the same efficacy, may however prove very useful. For instance, when the intervals between the attacks last for an hour at least, and during all this time the patient has recovered her senses, it is advisa- ble to place her in a lukewarm bath, and whilst she is there, to keep compresses, steeped in some iced liquid, constantly applied on her head. This application of cold should be kept up throughout the whole duration of the attack; this measure has often seemed, in our hands, says Madame Lachapelle, to second the venesection beneficially. It is particularly useful when a febrile coma succeeds the eclamptic paroxysm; as also when the occurrence of delirium announces the commencement of a cerebral fever. The antispasmodics, recommended by M. Velpeau in the hysteric form of eclampsia, that is to say, iu the hysteria of pregnant women, appear to me use- less in most cases of puerperal convulsions; and it would only be as a preventive measure, or else in a very slight attack, that they could be resorted to with 1 The apparatus of Dr. Junod consists of a large metallic boot, capable of receiving the greater portion of a lower extremity. The upper part of the boot is so adapted to the limb as to prevent the ingress of air, and a partial or complete vacuum is obtained by the use of an air pump.— Translator. PUERPERAL CONVULSIONS. 723 benefit; besides which, we should lose precious time by depending on them in these grave cases. Compression of the two primitive carotids, which has recently been pro- posed as a remedy for most convulsive affections, has been successfully practised in some cases of eclampsia; and hence it constitutes another measure to which we might recur, without, however, attaching too much importance to its action, for it has failed in several instances. (Journal de Trousseau, Nov. 1840, p. 186.) In my estimation, the opiates ought to be wholly banished from the treatment of a disease which so often terminates in cerebral congestions, at least whenever the condition of the patient is such as to allow of the abstraction of blood; but in the case of an anaemic female, or of one who has already been bled very freely, opium, by acting as a sedative to the nervous centres, might perhaps be produc- tive of some advantage. During the paroxysm, the necessary precautions must be taken to restrain the patient's dangerous movements; but it is not requisite to employ violence for that purpose, as some persons advise; for we have elsewhere stated that there is scarcely any tendency to change the position; and it will be quite sufficient to merely watch over her, without endeavoring to prevent the convulsive move- ments, the intensity of which might thereby be augmented. Particular care is requisite to prevent the tongue from being bitten, since it is very liable to be pushed beyond the alveolar arches, and often becomes wounded by the convulsive contraction of the masseter muscles. To prevent such an accident, it has been advised to place some hard body, the handle of a spoon, for instance, between the teeth, so as to hold them apart; but Madame Lachapelle says this is an almost infallible way of breaking the incisors. Gardien directs a piece of cork to be put between the molars instead, as it would not be attended with this inconvenience; but this might escape from the fingers, and be drawn down, by an inspiratory movement, into the opening of the glottis, and thus suf- focate the patient. A much more simple plan is to push back the tongue behind the alveolar arches with the fingers themselves, at the commencement of each fit; when, the jaws being once closed, the tongue can no longer protrude; it may be contused between the teeth, but that is all. Besides, this little operation may easily be explained to the assistants, who perform it without difficulty, as soon as they have overcome the chimerical fear of being bitten. B. Special Measures.—The course pointed out thus far might be considered as the medical part of the treatment of eclampsia. But when, notwithstanding the employment of these means, the convulsions continue and increase in violence, what is to be done? The pregnant condition being the first cause of eclampsia, it was natural to expect to find the most effec- tual remedy in the evacuation of the uterus. Such, indeed, is the opinion of almost all practitioners, and it was also our own, until within a few years past. Since, however, we have so often seen the convulsions continue for several days after the spontaneous expulsion or the extraction of the fcetus, we have far less confidence in the immediate results of the cessation of pregnancy. As we have already said, the principal cause of eclampsia is to be sought for in a general alteration of the economy; now, although this modification is due to the course of gestation and sustained thereby, it is impossible that it should disappear im- 724 DYSTOCIA. mediately upon delivery. It remains for a longer or shorter time, and the woman returns but slowly to the normal state of the unimpregnated condition. Although lessened, it may still exert its influence, as is proved by the occasional occurrence of attacks several hours, and sometimes even several days, after delivery. To empty the uterus is, therefore, to attack but one of the remote causes of eclamp- sia, by no means the immediate one, and the results to be expected from it appear to me too uncertain to compensate for the serious dangers inseparable from the operations required to effect it. In order to explain our view thoroughly, we shall examine successively the indications afforded by severe eclampsia, according to whether the convulsions are manifested in the course of pregnancy, or during parturition, or subsequent to the delivery. 1. During the Gestation.—Prior to the seventh month, that is to say, before the period at which the fcetus is viable, the treatment must be restricted to the employment of the means above indicated; even though there be an absolute certainty that the fcetus is dead, nothing should be done to induce an abortion, for the time required for the abortive measures to act, and for the expulsion of the product of conception to take place, exceeds by far the ordinary duration of eclampsia, and the woman would be either dead or cured, before their influence could be felt. At a more advanced period two very different cases may present; that is, either the uterine contractions are prematurely and spontaneously developed under the influence of the general convulsions, or the womb remains entirely apart from the general disorders produced by the eclampsia. In the former case the labor has commenced, and we shall treat below of the means to be then employed, upon which most accoucheurs are agreed; but, in the latter, the proper course to follow is far from being so clearly marked out The question naturally arises, what then is to be done, supposing the eclampsia has resisted venesection, the intestinal and cutaneous revulsives, &c.; and supposing that the patient has arrived at the eighth or ninth month, and the labor has not commenced, but still the convul- sions continue and threaten the mother's life. The induction of labor, and forcible delivery, have been recommended under these dangerous circumstances. In regard to the first, we would repeat what we have already said of abortion : the means usually employed to provoke the uterine contractions act too slowly in a case in which we suppose the mother's life to be threatened, by convulsions which have already lasted for a long time, and against which all the resources of therapeutics have been expended in vain. A prompt depletion of the uterus is the only thing likely to afford a favorable chance, and forced delivery is the only means of effecting it. But at a period still quite dis- tant from term, the length of the neck, and the resistance of its unsoftened in- ternal orifice, would render the forcible introduction of the hand very difficult, and the efforts required to penetrate within the womb are very likely to excite, to irritate the organ, and consequently, to increase the general convulsions. These resistances, and the general irritation which they produce, are so great in most cases, that efforts have been made to overcome them by making nume- rous incisions around the circumference of the cervix. Doubtless, when the neck is effaced either by the progress of gestation or by premature contractions, PUERPERAL CONVULSIONS. 725 these incisions may be useful and harmless, since they are practised upon the intra-vaginal portion of the neck only; but in the eighth month, whilst the neck retains its entire length, the greatest difficulties are presented at the internal orifice and upper part of the cervix. To incise the external orifice, would re- move only the least resistance, and I think that no surgeon would have the temerity to apply a cutting instrument to the internal orifice. I have yet no experience in such cases, but am convinced that when the incisions have been successful, it has been in cases of far advanced pregnancy, or when unobserved contractions had dilated the upper part of the cervix. This, happily, is what takes place in most cases of long-continued convulsions, but which we exclude from the supposed conditions. Admitting, however, that a forcible introduction of the hand, whether prepa- ration have been made or not by incisions, can be effected without much difficulty, it must not be supposed that the extraction of the foetus is unaccompa- nied by danger. We have supposed the uterus to be inert; now, although the irritation produced by the hand of the accoucheur and the movements impressed upon the foetus during its extraction, are calculated to excite contractions, is there not cause to fear lest inertia of the organ might result from this too rapid depletion, and become the source of fresh accidents ? If, finally, after having overcome all these difficulties we were sure that the eclampsia would cease, I could understand how such an operation might be under- taken ; but as experience proves the contrary, I think that during pregnancy, however severe the convulsive attack may be, we should restrict ourselves to the employment of general measures. There are certain females who are subject during pregnancy to repeated attacks of convulsions at variable intervals, and in whom, also, each fresh attack is more serious than the preceding. The recurrence of these attacks every eight days or two weeks, compromises increasingly the life of both mother and child, and we might reasonably fear lest another should prove fatal to both in- dividuals. Now, although we have rejected the provocation of labor during the attack itself, we think it proper in the cases just mentioned. But it should be practised only in the intervals of the convulsive paroxysms. 2. During Labor.—The prompt termination of the labor so generally advised, should not, however, be practised except with a certain degree of reserve; and for the sake of clearness in this recapitulation of the indications, we shall en- deavor to solve the following questions in order : What ought to be done when the cervix is dilated or dilatable ? And what is the proper course to pursue when it is neither sufficiently dilated nor dilatable, to permit a prompt artificial termination of the labor ? a. The cervix is dilated or dilatable.—If the head has descended into the excavation and distends the perineum, or presses strongly upon the circum- ference of the uterine orifice, if but one or two attacks have yet occurred, and especially, if there is reason for supposing that extreme sensibility of the cervix or of the soft parts, may have had any agency iu the production of the eclampsia, the forceps should be applied immediately. It is under these circumstances, more particularly, that the immediate termination of the labor prevents a re- currence of the accidents. 726 DYSTOCIA. If the eclampsia is slight, though it has lasted for a certain time, that is to say, if the convulsive attacks are moderate and the intervals between them long; and if the woman regains her consciousness entirely during the interval; if, under these circumstances, the labor is advanced, the dilatation complete, and the head of the child has passed through the orifice and descended deeply into the excavation; if the uterus contracts powerfully, and if the perineum is not too resisting, we think it right to wait for the expulsion to take place naturally. But if, under the same conditions, the pains are feeble, distant, and ineffica- cious, or if the contractions are energetic, but the convulsions are frequent and prolonged, with profound coma during the interval of the paroxysms, we believe that the mother and infant should be immediately relieved from the dangers that threaten them, by the application of the forceps. When, so far from having cleared the os uteri, the head is still retained above the superior strait, especially if the membranes are still intact, the pelvic version would in general appear preferable to an application of the forceps. (See For- ceps.) We say that the version would appear in general, not always preferable. for we know this is at times impracticable, even where the head is still above the abdominal strait. The almost total discharge of the amniotic liquid, and the violent contractions of the uterus, which often participates in the general con- vulsions, and the violent irritation that the organ has to support during the in- troduction of the hand and the evolution of the foetus, sufficiently explain our reserve, as well as the preference that we accord to the forceps in this particular case. Should the face present, and be well down in the excavation, we would like- wise apply the forceps; but, on the contrary, we should have recourse to the pelvic version if it were yet above the superior strait, or even when engaged in this strait, if it happened to be in a mento-posterior position. In the presenta- tions of the pelvic extremity, it is advisable to hasten the termination of the labor, by drawing judiciously and carefully on this extremity. In the presenta- tions of the trunk, the feet are to be brought down; for we would only have recourse to the cephalic in preference to the pelvic version, when the pelvis is greatly contracted; and when the cephalic version is resorted to, it must evidently be followed by a prompt application of the forceps, and if these should fail, of the cephalotribe. b. What is to be done when the cervix is neither dilated nor dilatable ?— If the membranes are not broken, and more particularly if the uterus appears to be greatly distended by a large quantity of water, they should be ruptured, and a discharge of the liquid and a partial depletion of the organ be facilitated, by pushing up the presenting part with the finger; for such a rupture has often proved sufficient to diminish the frequency and intensity of the convulsive paroxysms, and has justified the accoucheur in waiting for the complete dilata- tion of the cervix. But if the distension of the womb is not far from normal, we think that the interest of the fcetus demands that the membranes should be respected, and spontaneous dilatation awaited; when this dilatation progresses too slowly, the ointment, or, still better, the extract of belladonna should be em- ployed, and be smeared over both the internal and external portions of the orifice. PUERPERAL CONVULSIONS. 727 But, supposing the eclampsia is more serious, the coma still continues, and the convulsions have not been alleviated by the rupture of the membranes; and, moreover, the os uteri is not yet dilated, or else is so convulsively contracted as to prevent an introduction of the hand or instruments, are we, under such favor- able circumstances, to abandon the delivery to nature, as some accoucheurs advise? Or, on the contrary, ought we to penetrate forcibly into the uterine cavity, by opening a route by violence, or a cutting instrument ? At the commencement, or even during the first four or five hours of labor, these extreme measures doubtless should not be resorted to; but when the con- vulsions persist, notwithstanding the employment of the most rational means; when ten, twenty, or thirty hours have elapsed since the onset of the symptoms; when the woman's life is compromised by the duration and the constantly in- creasing intensity of the paroxysms, our only hope is in a depletion of the uterus; a forced delivery then appears to us the sole resource, and authorized by the interest of the child even more than by that of the mother. Two plans have been proposed for effecting this object, namely, a forcible in- troduction of the hand into the womb, and the division of the cervix by the aid of a cutting instrument. We shall hereafter revert to the mode of operating in both cases, when describing the difficulties that may be met with in making the pelvic version ; and will therefore only remark here that, by the length of time it demands, by the excitement and irritation thereby produced (all which are assuredly calculated to increase the convulsions), and by the lacerations to which it gives rise, however carefully it may be performed, the forcible introduction of the hand into the womb is very dangerous, and ought to be rejected; and that, unless there is a very feeble resistance at the orifice to be overcome, repeated incisions, made at divers points of the circumference of the neck, ought, in our opinion, to be decidedly preferred. Bat, whatever operative process be employed, the resistance from the os uteri being once overcome, the labor will be terminated by an application of the forceps, or by the pelvic evolution, according as the conditions shall be found more or less favorable to the practice of the one or the other operation; which conditions will be carefully detailed when we shall treat of version and the forceps. Inasmuch as the expectation, recommended by us when the cervix is neither dilated nor dilatable, except in cases of imminent danger to the mother, is op- posed to the generally received opinion, it becomes necessary to defend it. Although regarding in a general way the termination of the labor as a favorable condition, we are far from according to it the happy effect claimed by some authors in its favor. In no case, indeed, in which the eclampsia had existed for a long time before we were called to the patient, have we ever found the termination of the labor to put an end to the symptoms, and very rarely did it ever lessen their intensity. The convulsions continued after delivery with the same frequency and violence as before. In three cases only have we known them to cease after the applica- tion of the forceps; but here it must be said, that having witnessed the com- mencement of the eclampsia, we were enabled to extract the fcetus immediately after the first attack. If, therefore, we regard only the interest of the mother, we think that the 728 DYSTOCIA. intervention of art is justifiable only when the dilatation of the cervix renders it easy and but moderately irritating to the maternal organs; but if the fcetus is living, its life is seriously endangered by a too long continuance in the cavity of the uterus, especially after the rupture of the membranes; and since the termi- nation of the labor, when prudently effected, does not sensibly increase the dangers to which the woman is exposed, we think that the child should be ex- tracted as early as possible. 3. After the Delivery.—The only special indication, presented by the eclamp- sia after the child's expulsion, is to extract the after-birth and all the coagula, together with any portions of the membranes that may have been retained in the uterus; and to remove the sanious matters and detritus by detergent injections thrown up into its cavity. But if the introduction of the hand should prove too difficult and painful, it should be withheld; for the retention of the foreign body would be much less irritating, and consequently less painful, than ill-timed attempts at introduction. Since the use of anaesthetics in obstetric practice, some accoucheurs have thought it right to employ inhalations in the treatment of eclampsia. Calcula- ting upon the power of ether and chloroform to destroy the action of the muscles of animal life, they hoped that they might act in the same way upon the invol- untary and spasmodic contractions resulting from puerperal convulsions. Reasoning a priori, we were inclined to disapprove of their employment in a disease so often complicated with congestion of the brain, and even apoplexy, and were not, perhaps, free from prejudice, thus derived, in reading and analyzing most of the published observations. In the last edition, we, therefore, proscribed their use in the majority of cases, except when the beginning of the convulsion seemed due to some local irritation of an organ whose extreme sensitiveness awakened the reflex action of the spinal nerves. Other facts published by seve- ral colleagues as well as the result of personal observation, have greatly changed our first opinion, so that we are now convinced that when eclampsia comes on du- ring either pregnancy or labor, and the closure or undilatability of the cervix makes it impossible to effect delivery, or when the attacks, having resisted bleed- ing and revulsives, are very frequent, and by their steadily increasing severity threaten the lives of both mother and child, then, we are convinced, the use of chloroform may be of the greatest service. In two cases, we found it to suspend the attacks completely. In one of these cases, two bleedings, purgatives by the mouth and rectum, &c, had been employed without advantage. The cervix was insufficiently dilated, and at 5 A. M., I used the chloroform, repeating the inha- lations at the beginning of each pain, and continuing them until 9 A. M., at which time I was able to apply the forceps. Not a single attack occurred during this interval. After delivery I thought it right to stop the inhalations, and the woman became partly sensible. Some fruitless attempts were made to extract the placenta, and when, an hour after the birth of the child, it was brought away, another convulsion occurred, I immediately resumed the chloroform, and the at- tack was not repeated; short inhalations, however, being made during the hour succeeding. Both mother and child came out safely from the fearful trial. I might borrow similar cases from the theses of 31. Blot and others, but will not dweil further upon this point, reserving its more detailed treatment for the chap- ter devoted especially to the study of anaesthetics in obstetric practice. RUPTURES OF THE UTERUS. 729 CHAPTER III. OF RUPTURES OF THE UTERUS. A rupture of the womb is one of the most dangerous accidents that can happen to a female in the puerperal state. Exceedingly rare during the early months of gestation, it is somewhat more frequent in the latter half of preg- nancy; but it is during the second stage of the labor, especially, that it most fre- quently takes place. Rupture of the uterus has seldom been observed in women bearing their first child. Thus, in seventy-five cases, reported by Churchill, nine occurred in pri- miparae, fourteen in women in their second pregnancy, thirteen in their third, and thirty-seven in their fourth or succeeding ones. The woman's age does not seem to have any marked influence over the produc- tion of this accident. Nevertheless, the organic alterations which constitute a predisposition are more unusual in early life than in advanced age. As the male child is ordinarily somewhat larger than the female, this, accord- ing to Dr. Clarke, would be a predisposing circumstance ; thus, in twenty cases of rupture, mentioned by Dr. M. Keever, fifteen were male children; and of thirty-four cases by Collins, twenty-three of the children were boys. The rupture may be seated either in the body or the neck of the organ. When it affects the cervix, it is highly important to ascertain whether it only involves the sub-vaginal portion, or whether it invades that part situated above the inser- tion of the vagina; because the former is attended with very little danger, and occurs very frequently; indeed, it takes place at nearly every labor just at the instant when the head is clearing the orifice, and it is scarcely ever followed by any unpleasant symptoms. The last, on the contrary, presents the same dangers, and has similar consequences with the ruptures of the body. Therefore, we need only mention here the lacerations that are limited to the orifice, and which do not extend beyond the vaginal insertion ; and all that we are about to say con- cerning uterine ruptures refers exclusively to those in the body of the womb and in the supra-vaginal portion of the neck. These latter are the more frequent, and they are located somewhat oftener on the posterior than on the anterior face. § 1. Causes. A rupture of the uterus always supposes a distension of the organ, and this distension is most frequently dependent on pregnancy. The uterine walls become softened, in consequence of the modifications they undergo ; their thickness is a little diminished at certain points, and they become more supple, more elastic, and therefore better calculated to support a slow and gradual pressure; for owing to this suppleness, they can yield without rupturing, though their distension renders them less fitted to sustain a sudden and forcible shock. By this disten- sion, and the increase in volume to which it gives rise, the uterus is forced to ascend above the superior strait; and thenceforth it is no longer protected by the 730 DYSTOCIA. osseous walls of the pelvis, and, consequently, is more exposed to external vio- lence, from which it was shielded during the non-gravid state. Coming, from its situation, in immediate contact with the abdominal parietes without the inter- vention of any other body, it is subjected to the unequal pressure which the rapid and irregular contraction of the abdominal muscles during any violent ef- forts may make upon it. Pregnancy, and the modifications thereby impressed on the uterus, are there- fore the essential predispositions to rupture of the uterus ; but, independently of these conditions, which exist in all gravid women, there is a number of .other circumstances which have a more immediate influence over the production of this accident; and which authors have designated under the titles of the predisposing and the determining causes. 1. Predisposing Causes.—Under this head we must include everything that can augment the distension or diminish the resistance of the uterine walls, as, for instance: A. A great abundance of the amniotic liquid, the presence of several chil- dren, &c. B. The extreme thinness of the uterine walls, which is met with in certain women, and which cannot be accounted for. c. An enfeeblement of the uterine parietes, dependent on causes which have operated at a more or less remote period, such as falls, blows, &c; the contused walls inflame, become softened, and ulcerate; sometimes the rupture comes on during the same pregnancy, at others, several gestations may succeed it without any accident, and yet a rupture take place at a subsequent one. The enfeeblement may likewise result from divers softenings; such as those designated by 31. Dezeimeris as the atrophied, the apoplectiform, the inflamma- tory, and the gangrenous ramollissements, and those produced by organic altera- tions. We must add another circumstance, which is, in truth, very unusual, but whose influence has been fully demonstrated by several well-attested instances; namely, those women who have undergone the Caesarean operation, and who have had the rare fortune to escape the grave dangers that attend it, seem more disposed than others to uterine rupture in the following pregnancy: thus, Dr. Kayser has brought forward six cases in his excellent thesis, in which the patients, who had before been operated upon safely, have been compelled to sub- mit to gastrotomy, in consequence of a rupture of the womb; three of these women died. D. All the organic alterations, and all the degenerations of tissue of which the uterus may be the seat; such as the scirrhous, fibrous, or encephaloid tumors. The softening and ulceration of these morbid masses may render that portion of the walls they occupy thinner and weaker; oftener, on the contrary, they aug- ment the thickness and even the consistence of the uterine tissue, but still act as predisposing causes of ruptures, at least during parturition, in the following way : the point thus affected not contracting whilst all the others are in action, the resistance made by it would be wholly passive; and hence, whatever be its strength, it cannot hold out against the contractions of all the rest of the organ, the action of which, being aided by that of the abdominal walls, weighs with all its force, as it were, on that portion which does not participate in the general RUPTURES OF THE UTERUS. 731 action ; and if we suppose that any obstacle whatever prevents the ready engage- ment of the foetus, the uterine effort, which is incapable of overcoming the resist- ance it encounters in clearing the superior strait, is felt at the point which does not contract, and consequently this latter becomes ruptured. And jt is by a similar mechanism that the irregular or partial contractions may produce a rup- ture, by leaving some one point of the uterine walls in a state of inertia, whilst all the others are contracting:. During the labor, we must add everything that may render the parturition difficult, or require unusual and long-repeated contractions on the part of the organ. In this respect, all narrowing of the pelvis, every tumor that obstructs the excavation, all resistances offered by the cervix uteri, whether dependent on an agglutination of the lips, a degeneration of its tissue, or a state of spasm, or a considerable obliquity of the body, and the malpositions, as well as the malfor- mations of the fcetus, may become causes of rupture of the uterus. The ruptures of the uterus which take place during labor almost always occur after the rupture of the membranes. Still, James Hamilton reports a case in which the membranes were found entire at the autopsy. 2. Determining Causes.—A number of causes may serve to produce a rupture under the influence of some one of these predispositions; all of which, however, can be classified under two principal heads, namely, the external or traumatic, and the internal causes. 3. External or Traumatic Causes.—It is not without some hesitation that I venture to say a few words here about the traumatic lesions to which the womb is exposed as a cause of rupture; for it is well known that, at every period of life, this organ is liable to be injured by a projectile thrown by gunpowder, by any murderous instrument, or by the horn of an infuriated animal. But it must be remembered that the increased size of the organ, during gestation, exposes it then more than ever to this variety of lesions; though the consequences and the indications for treatment are, in other respects, nearly the same. Again, we must add that perforations and lacerations of the uterus often result from ill- directed obstetrical manipulations. The womb is also greatly exposed to compression or violent contusion of its walls, when it is developed by the product of conception. This compression may be mediate, that is to say, dependent on exterior causes, such as falls or blows on the abdomen, the pressure of this region by the backing up of a coach against a wall, or the passage of its wheels over the belly; or it may be immediate, that is, due to the violent contraction of the abdominal muscles. The effects of mediate compression are generally of little consequence, owing to the mobility of the uterus, the suppleness of its walls, and the point d'appui which the latter find in the surrounding parts. Nevertheless, they sometimes are followed by disas- trous consequences : thus, it is stated, in the old Journal de Midecine, that a woman had a rupture of the womb at the seventh month of her gestation, in consequence of having been pressed between a wall and a carriage. As before stated, the contusion of the ventral parietes seldom produces an immediate rup- ture ; but the bruise and consecutive inflammation of the uterine structure may determine an ulceration, and then a perforation at some future period. The ruptures by immediate compression, or those which result from the vio- 732 DYSTOCIA. lent contraction of the abdominal muscles, seldom occur without the pre-exist- ence of some one of the alterations of the uterine walls, considered above as predisposing causes. They generally follow a fit of coughing, sneezing, or vomiting, or take place during a paroxysm of anger; but they may likewise be occasioned by the patient's attempts to raise some burden, and by the forcible bending of the body backward, which latter cannot occur without the recti muscles of the abdomen becoming closely approximated to the vertebral column during the forward curvature of the trunk; in all these movements the womb is forcibly compressed between the abdominal muscles, which contract vigorously, and the posterior plane of the abdominal cavity. A rupture has been known to occur at all stages of gestation, from the earliest months up to full term, under the influence of some one of these causes. 4. Internal Causes.—Authors have incorrectly considered the enormous dis- tension of the uterus during pregnancy as being capable of producing a rupture; for, although this distension is a predisposing cause, yet, however great it may be, it cannot of itself give rise to such an accident without the previous existence of an organic alteration. The same is true of the violent and convulsive move- ments of the fcetus, whose impetus is too inconsiderable to occasion a rupture; and besides, the womb is fully protected against its influence by the amniotic liquid and the suppleness of the walls. During labor, the uterine contraction is the most frequent determining cause; aud though the walls of the organ were altogether passive in the course of gesta- tion, they here play the principal part in the production of the rupture. After the membranes are ruptured aud the waters entirely discharged, the walls of the uterus are applied directly upon the fcetal ovoid. Now, in the doubled up condition of the various parts of the child, numerous projections and irregularities are presented, which make the resistance at its different points very unequal. Consequently, some parts of the uterus are more or less stretched over the projecting parts, and, to use Madame Lachapelle's expression, some of the muscular fasciculi act in a wrong direction, whilst others, finding a firm support, contract with greater energy. The equilibrium of the forces is then, says 31. Taurin, broken at several points of the womb, and the organ contracts irregularly. The non-compressed, healthy, and thicker parts, contract with greater power, and draw upon the parts in the vicinity; the latter, already distended by the fcetal projections, become still thinner, their resistance yields more and more, and at last, incapable of longer resistance, they give way under the more powerful contractions of the neighboring parts. Such would be the course of affairs, more especially, in an unfavorable position of the foetus,—one of the shoulder, for example. We would add further, that when the labor is prolonged greatly, the pressure of the fcetal projections upon the walls of the uterus may cause their inflamma- tion, ulceration, or even gangrene, all of them circumstances likely to facilitate rupture. Deformities of the pelvis, by presenting a mechanical obstacle to the passage of the foetus, also constitute a predisposition to rupture; but even here, the con- traction is the determining cause. In some other cases, the hard and uuequal RUPTURES OF THE UTERUS. 733 projections presented by the irregularly contracted circumference of the pelvis may produce a direct rupture of the lower segment of the uterus, or of the walls of the cervix. Thus, we may readily conceive that a too great anterior projec- tion of the sacro-vertebral angle, as also the prominent ridge sometimes presented by the superior and posterior face of the symphysis pubis, might bruise, or even tear, the part of the uterus which is strongly compressed between it and the head of the fcetus. 31. Taurin mentions a case in his thesis in which M. P. Du- bois attributed to this compression a rupture comprising a part of the vagina, the whole anterior surface of the neck, and which extended up the left side of the body of the uterus. The child's active movements are as foreign to the laceration that takes place in parturition as to those that occur during pregnancy. For, according to the observations of M. Duparcque, if this movement is effected during the relaxation of the walls, their suppleness and extensibility enable them to yield to this force; but if, on the contrary, it takes place while the contraction lasts, the resistance which they then present would require a far greater impetus to overcome it than any that can result from even a convulsive movement of the fcetus. The con- traction is therefore the sole determining cause; but, for it to produce a rupture, its action must be favored by one of the predisposing circumstances before indi- cated, the influence of which is easily understood. These spontaneous ruptures hardly ever take place except in labors at term, and appear impossible in abortions at four or five months. A case which re- moves the smallest doubt as to the possibility of such an accident within the first six months of gestation, has, however, been communicated to M. Danyau by 31. Caste!neau. A woman died almost suddenly in consequence of a profuse hemor- rhage, and it was found that the neck of the uterus and the vagina were ruptured, the former through its entire length and the latter at its upper part. The acci- dent occurred, in all probability, during contractions which expelled the ovum very rapidly; for although no portion of it remained in the uterus, the organ presented every appearance of one which had attained the usual development at five months of gestation. However, it must not be forgotten that rupture of the womb has often occurred during parturition, from the imprudent manipulations made with a view of ter- minating the labor. For how often has an application of the forceps, a resort to version, or a difficult extraction of the placenta performed by inexperienced hands—how often have all of them been followed by the early death of the patient, and a laceration of the organ been detected at the autopsical examina- tion! In fact, cases of the kind are mentioned by nearly all authors; and Madame Legrand. the midwife in chief of La Maternite, informed me that several women are brought to the hospital every year to die, the victims of such attempts made in the city. I have seen a uterus, the lower two-thirds of whose body on the right side had been torn away by the embryotomy forceps; and, in another case. I found at the post-mortem examination a perforation in the right superior part of the body of the womb, produced by the attempts which a practitioner had made to separate a firmly adherent placenta. Facts of this nature cannot be repeated too often, for they are calculated to render young physicians, who intend to practise midwifery, more cautious; and to convince them that, to have 734 DYSTOCIA. attended two or three women in labor is not all that is needed to render them capable of performing the most difficult operations of our art. § 2 Symptoms. The signs of rupture of the uterus are easily made out; for most frequently the laceration takes place suddenly after some violent effort that has necessitated a forcible contraction of the abdominal muscles. It is manifested by an exceed- ingly sharp pain just at the point where the accident occurred, which makes the patient scream out from the intensity of suffering. This acute, or, as Desormeaux describes it, agonizing and cramp-like1 pain, is accompanied by a sound of tearing or cracking, loud enough, in some cases, to be heard by the surrounding persons. This pain soon changes to a sensation of numbness, and is followed almost immediately by swooning; the patient becomes pale, her pulse sinks, and she falls into a state of syncope. These primary phenomena are the only ones that are manifested when the pregnancy is not far advanced, and when the uterus has not ascended high enough to be easily accessible; or, else, when the ovum, having engaged in the lips of the wound, plugs it up in such a way as to prevent any effusion into the abdominal cavity. A deceitful calm may thus succeed the storm, and the symptoms be only renewed after several hours, or even days, when the uterus, by contracting, shall expel the parts it encloses into the abdominal cavity. In the opposite case, and more especially in the advanced stages of gestation, we can readily detect the softening and depression of the hypogastric walls by an examination of the patient; for, instead of feeling the hard, globular tumor formed by the womb in this region, we simply find the yielding, depressible walls of the abdomen, and still lower the more or less re- duced and distorted neck of the uterus. The patient who, at the instant of rup- ture, or shortly after, experienced a gentle heat diffusing itself through the abdomen, now feels some strange movements, or an unusual weight at a point where she never had them before; and the accoucheur himself detects the pre- sence of the child in a spot where it should not be, and he can now distinguish its movements and the prominences it offers much more clearly than usual. But these active motions of the fcetus soon cease to be apparent, though their fiual disappearance is ordinarily preceded by an unusual and almost convulsive agitation; most generally, a little blood escapes from the vulva, in consequence of the detachment of the placenta, but this phenomenon may be wanting, espe- cially in first pregnancies. Where the accident occurs during labor, the pains, that were hitherto strong and energetic, disappear at once. The most conclusive signs are furnished by the touch; thus, during gestation, the finger can detect a change in the position of the womb, and the want of the 1 According to Dr. Roberton, when a rupture takes place in consequence of a contraction of the pelvis, it is preceded by crampy pains and a sensibility to pressure at a circum- scribed point of the hypogastrium. This crampy pain is caused by a compression of the uterus between the child's head and the promontory of the sacrum, or some other promi- nent osseous part. A pain of this nature existed in a high degree in a woman, in whom the anterior lip of the cervix uteri was considerably tumefied, and was also situated much lower than the head : Dr. Roberton succeeded in relieving it, by pushing up the tumefied lip during the interval between the contractions. RUPTURES OF THE UTERUS. 735 volume which it generally has at the stage of pregnancy the woman supposes herself to have arrived at Sometimes it can even feel a part of the fcetus situated externally to the womb, and depressing the upper part of the va<>ina. During the iabor it finds the bag of waters to become suddenly collapsed, or no longer projecting through the os uteri, and yet without the escape of any liquid by the vagina. The presenting part of the child, which, a few moments before, was accessible to the finger, has now gone up, and perhaps disappeared alto- gether; the cervix uteri has shrunk up, and the orifice is much less dilated than it was previously. If an attempt be then made to pass the hand into the uterine cavity, perhaps it will find this cavity wholly obliterated by the retraction of the walls; or pos- sibly it may encounter the intestines there, or else only a part of the fcetus, the rest having escaped into the belly. The seat and extent of the laceration can thus be determined, and, in some instances, the hand may even be made to penetrate through into the abdomen. When all these phenomena are met with, there can be no doubt in regard to the nature of the accident, but it is not always possible to recognize them so clearly; for if the child, instead of being displaced, remains in the cavity of the womb after the rupture, it may happen that the signs furnished by the vaginal touch, and the abdominal palpation, will be altogether wanting. In this case, the diagnosis is very difficult, and the cause of death is disclosed only by the autopsy. § 3. Prognosis and Termination. The prognosis of uterine ruptures is exceedingly unfavorable; for they nearly always prove fatal to the child, aud expose the mother to an almost certain death. Nevertheless, its gravity varies according to the extent and the seat of the lesion, and the consecutive phenomena to which this gives rise. Some cases have been reported in which the great disorder in the organism produced by the rupture, and the escape of the blood, waters, and foetus into the abdominal cavity, caused instantaneous death. But, most generally, some par- ticular phenomena, or symptoms, occasioned by the accidents consecutive to the primary lesion, precede the fatal termination; which latter may result either from hemorrhage, from the inflammations, and suppurations created by the pro- longed sojourn of a foreign body in the peritoneal cavity, or from the operations necessary for its extraction. A. Hemorrhage.—Flooding is the most frequent, and at the same time the most speedily fatal, of all these accidents. Its source is evidently in the torn vessels of the womb, especially when the rupture takes place at the point of the insertion of the placenta; but when this point remains intact, it principally comes from the utero-placental vessels which have been torn by the detachment of the after-birth; since the margins of the rupture, when this occurs at some distance from the placenta, usually furnish but little blood. As a general rule, only a small quantity of it reaches the exterior; while, on the contrary, it is effused abundantly into the belly along with the amniotic waters and the body of the child (which has passed in a great measure into the peritoneal cavity), and the whole distends the abdomen enormously. Again, this effusion is equally profuse 736 DYSTOCIA. in those cases in which the waters have escaped, and the infant lies in the womb in such a way as to prevent its issue. The ruptured margins being hindered from coming together, the lacerated vessels continue to pour out their blood, until the hypogastric walls oppose a resistance to the effusion, which is always too late to prevent death ; and the latter may thus take place without being preceded by any sign that would lead us to suspect the rupture. Again, it may happen, even when the delivery is effected immediately, that the contraction is not sufficiently energetic to obliterate the calibre of the vessels entirely, and the hemorrhage continues long enough to destroy the patient. The effusion ordinarily takes place into the sac of the peritoneum; but when this serous tunic is not implicated in the solution of continuity, the blood infil- trates between it and the uterus, gains the duplicature of the broad ligaments, and may thus get into the cellular tissue of the pelvis and loins. In such cases, a layer of black blood is found interposed between the peritoneum and the womb, where, by becoming exactly modelled on the external surface of the organ, it assumes its form, and may thus by its livid color be mistaken for a gangrenous state of this viscus. (Duparcque.) Nevertheless, the uterus may be ruptured, without being necessarily followed by a profuse hemorrhage; as where the laceration takes place at a point which is moderately provided with vessels, in the vicinity of the neck, for example. On the other hand, it may happen that, the ovum remaining intact after the accident, the fissure becomes filled up in a measure, either by a portion of the membranes or placenta, or a part of the child; or, the body of the infant may be partly driven into the abdomen, whilst the borders of the laceration become so retracted around it that the salutary compression thereby produced prevents a continuation of the hemorrhage. Again, when the entire ovum passes rapidly through the fissure into the peritoneal cavity, the uterus prevents or at least diminishes the bleeding by contracting at ouce, whereby a powerful obstacle to the further discharge of blood is created. b. Inflammation.—When the patient does not die from the loss of blood that immediately follows the rupture, a momentary calm succeeds, but the presence of foreign bodies in the cavity of the peritoneum gives rise to an inflammation of this membrane, which is the more serious as they are the larger; and even where the accoucheur has succeeded, by any mode whatever, in removing the foetus and after-birth, inflammation, though less to be dreaded, may still result from the operation or measures necessary for this extraction, and may speedily terminate in death. C. Escape of an Intestine through, and its Strangulation in, the Fissure.— A considerable portion of intestine has been known to pass through the lacera- tion in the uterus, and to become strangulated by the retraction of the organ. This accident, which would not be suspected, if the fcetus were still enclosed in the womb, or if the latter had completely retracted, might, however, be detected immediately after the delivery; but should it escape detection, it would infallibly terminate in death, as occurred in the case reported by Percy, and reproduced by 31. Deneux. Consequently, whenever there is reason to suspect a rupture of the womb, it is necessary to carry the hand up into the interior of the organ as soon as the delivery is effected, and (following the plan of Rungius) to press back the RUPTURES OF THE UTERUS. 737 intestines into the abdomen, and then keep the hand in the uterine cavity until the organ is sufficiently retracted, and the fissure diminished, to prevent a return of the hernia. D. Recovery.—Some women have recovered from all these dangers; a few have even undergone gastrotomy, and survived the consecutive accidents; while in others, the fcetus and its appendages have escaped bodily into the peritoneal cavity, and have there given rise to inflammatory symptoms which gradually passed off. Salutary adhesions were formed, as a consequence of the inflamma- tion, whereby the fcetus and its appendages were enclosed in a pseudo-membra- nous cyst that isolated them from the surrounding parts; the latter became habi- tuated to this new vicinage, which has continued for a variable period, and sometimes even throughout life. But this cyst, like those which surround other extra-uterine products, may become the seat of a fresh inflammatory action; its walls contract new adhesions with neighboring organs, and we sometimes find ulcerations and perforations occurring, after the lapse of many years*, by which the cavity of the cyst is made to communicate with that of the intestine or blad- der, and the last pieces of the skeleton are finally expelled through the urethra, the rectum, or the oesophagus.1 Where the child remains in the uterine cavity, notwithstanding the rupture, and the contractions do not immediately expel it by the natural passages, the same phenomena may be subsequently manifested; that is, the inflamed and ulcerated uterine tissue contracts adhesions either with the abdominal parietes or with those of some adjacent organ, and the foetal debris then escape through the ulcerated and perforated wall, or else by the natural openings of the excretory organs. (Duparcque.) § 4. Pathological Anatomy. Every portion of the uterus may become the seat of rupture, though there are some parts which are more liable to be affected than others; such are the inferior regions, the fundus, and the lateral portions of the body, and the superior or supra-vaginal parts of the neck. Moreover, the seat of laceration varies accord- ing to the cause that has given rise to it, as also to the period at which it takes place; thus, during gestation, the body is always ruptured, but during labor, on the contrary, these solutions of continuity are met with about the neck or in- ferior portion of the body, which is in general thinner, and not so well supported as the rest of the organ. Where the accident has resulted from some external compression, the walls usually become lacerated towards the lateral parts; when 1 For instances of recovery, see: Peu, Pratique des Accouchements, 341; Hamilton's Out- lines of Midwifery ; James Hamilton, Select Cases in Midwifery, 138; Jos. Clarke, Trans, of Association, vol. i; Douglas, Essays on Ruptures of the Uterus, p. 7 ; Labatt, Dnblin Med. Essays, p. 343; Frizell, Trans, of Association, vol. ii, p. 15 ; Roos, Annals of Med., vol. iii, p. 377; Kite, Mem. of Med. Society, vol. iv, p. 253 ; Powel, Med. Chir. Transact, vol. xii, p. 537; Birch, Ibid., xiii, p. 537 ; Smith, Ibid., p. 373; Maclntyre et Brook, Med. Gazette, vol. vii, et Janvier, 1829; Hendrie, Amer. Journ. of Med. Science, vol. vi, p. 351; Davis, Obst. Med., vol. ii, p. 1070. MM. Keevar and Collins have each reported two cases; M. Duparcque quotes four from French authors. Osiander states that he has met with several cases of the kind, and M. Velpeau mentions several others. 47 738 DYSTOCIA. it has resulted in consequence of a contusion, the bruised point is ordinarily the one that afterwards gives way: and if the rupture has been preceded by any organic alteration, the laceration takes place at the diseased point. It may happen, says M. Dubois, that the part of the uterus affected with chronic dis- ease, instead of being weaker, is really stronger and more resisting than the healthy parts alongside, which are the ones to give way. (Taurin, Thise.) The front and back walls being protected by the anterior and posterior planes of the abdomen, would seem to be perfectly sheltered from such accidents; this, how- ever, is not always the case, for instances have been reported which prove the possibility of ruptures of this kind. According to Dr. Roberton, when the laceration is caused by a narrowness of the pelvis, it may occupy any portion of the womb, though more frequently, perhaps, it involves its posterior inferior part; which is explained, in his opinion, by the pressure that the sacro-lumbar prominence makes on this region. Sometimes, also, it takes place in the ante- rior inferior part, and is then due to the osseous projections located on the inter- nal face of the pubic symphysis. The anterior superior wall is oftener injured by foreign bodies; indeed, it is the almost exclusive seat of ruptures produced by wounds. Nothing can be more uncertain than the extent, form, and direction of the uterine ruptures; since they vary in size, from a little hole that is scarcely capa- ble of admitting the end of the finger, up to a large fissure extending over two- thirds of the fundus, or periphery of the neck, or, indeed, occupying nearly the whole organ. It may have a longitudinal, a transverse, or an oblique direction, or it may affect a circular form, as often happens about the neck; or it may run in a straight line, or in a zigzag course. The divided margins are rarely observed to present a clear and regular section; but, instead, they are most usually found unequal, haggled as it were, contused, aud ecchymosed to a more or less con- siderable extent. If the rupture has resulted from some organic alteration, the anatomical traces of the previous disease are found at the affected point. Lastly, jf the patient has not died till several days after the accident, the autopsical ex- amination will verify the presence of the matters effused into the peritoneum, and the unequivocal marks of a violent inflammation of this serous membrane; be- sides which, the borders of the uterine fissure will sometimes be red, livid, and inflamed, and occasionally even gangrenous. The lacerations of the womb do not always implicate the whole thickness of the organ, for the tunics, that enter into the composition of its walls, do not all possess the same degree of elasticity; and hence it is possible for them to be ruptured separately. Madame Lachapelle says, a fissure of the orifice propagated to the neck, and even to the body of the organ, has very often divided the whole muscular layer, leaving the serous membrane intact. I have particularly observed, she continues, fissures of this kind on the sides of the womb which were covered by the duplicature of the broad ligament, whereby the wound was prevented from extending into the abdomen. 31. Duparcque furnishes a very similar case; and Dr. Collins reports nine others in which the peritoneum was not injured, though the muscular layer of the neck was lacerated to a considerable extent. I have likewise had an opportunity of observing an identical instance in the practice of Professor Velpeau, in which I was enabled to verify the truth of the remark RUPTURES OF THE UTERUS. 739 made by M. Cruveilhier; namely, that the laxity in the adhesion of the perito- neum to the cervix, and to the sides of the uterus, fully explains why this mem- brane is so rarely involved in those cases in which a considerable rent has occurred in the neck, and why the effusion of blood then takes place between the uterine tissue and the peritoneal serous membrane. Cases have occurred in which the blood collected in very large amount, and even the foetus itself, com- pletely expelled from the uterine cavity, has been found in the species of sac formed by the detached serous membrane. In some more rare cases, the muscular structure resists, and the peritoneal layer alone gives way. Where this occurs, the disease can scarcely be recognized during life, for the phenomena that precede death are either those of a hemor- rhage, or of a violent peritonitis; but a large quantity of blood is ordinarily detected at the post-mortem examination, and, by searching for its source, one or more fissures of a variable extent are found in the uterine serous membrane. To the case of this kind reported by Ramsbotham, we can now add several others that have recently been published; one of the most curious of which is that furnished by H. Partridge (Arch, de Med. t. 19), where a great number of lacerations running transversely, were found at the post-mortem examination ; these were more or less curved, and were variable in depth, and they extended from half an inch to two inches in length A shred of peritoneum had been completely detached and hung within the abdomen, thus laying bare the naked fleshy tissue from which it had been torn. § 5. Treatment. The measures that have been proposed for the treatment of ruptures of the womb, may be designated as the prophylactic and the curative. The object of the former is to avert the influence of the causes that have been described as predisposing to this accident; and we refer for an account of those whose ex- istence it is possible to foresee, such as the divers obstacles to delivery, to what has already been said on this subject; and with regard to the others, as it is usually impossible even to suspect their presence, we shall pass them over alto- gether. A rupture of the uterus is only serious from the disastrous consequences which follow it; therefore, the prophylactic measures must be directed, not against the rupture itself, but rather against the consecutive accidents to which it gives rise. The best mode of preventing them is to facilitate the retraction of the organ by immediately extracting the foetus and its appendages; for it has been shown that it is the hemorrhage, and the inflammatory symptoms which follow the child's displacement and subsequent sojourn in the cavity of the abdomen, that are to be particularly dreaded Perhaps the indications for treatment presented under such circumstances will be best illustrated by supposing the rupture to take place at three different periods of the puerperal state, namely : during the parturition; during the latter months of gestation; and during the early stages of pregnancy. 1. During the Labor.—In this case the infant may either remain within the womb, or it may have been driven out of the uterine cavity. A. If the child remains in situ, its extraction, either by the pelvic version or 740 DYSTOCIA. by the forceps, is of course the only admissible operation. When the forceps are used, it is very important, as 31. Dubois remarks, that the child should be fixed in its position by the hand of an assistant applied to the walls of the abdomen, in order to prevent its ascending into the peritoneal cavity through the fissure. The introduction of the blades also demands especial care when the neck is ruptured transversely, in order to avoid passing them into the abdo- men through the rupture. But where any obstacle appertaining to the pelvis or the soft parts opposes its delivery by the natural passages, gastrotomy ought certainly to be performed if the infant is living and viable, and craniotomy when jt is dead, or when it has suffered severely from the slowness of the labor. B. If one part of the child has passed into the abdominal cavity through the fissure, while the other portion of it is still enclosed within the uterus, we must endeavor to deliver it through the natural passages, by acting on the portion retained in the womb, or which has already engaged in the os uteri or vagina. But if the presenting part is high up, and the hand or instruments cannot get a sufficient hold upon it, it will be necessary to search through the fissure after the feet, and bring them down into the vagina. But here another difficulty arises, for the escape of the waters and a part of the fcetus may have determined a con- traction of the womb, and the lacerated margins, participating in this retraction, may be found so closely applied to the child's body as to render a passage of the hand impossible; under such circumstances, we might follow the example of certain accoucheurs, and open a passage by enlarging the womb in the uterus with a cutting instrument, which would be far preferable to the performance of the Caesarean operation. C. Supposing the child has passed into the abdominal cavity, and that the organ has not as yet retracted, that the os uteri is sufficiently dilated or dilatable, and the uterine fissure is still large enough to permit the hand and foetus to pass through, which conditions are scarcely ever met with when the rupture occurs at the cervix, we ought, as in the preceding case, to go after the feet even into the cavity of the abdomen, and bring them back through the lips of the wound, the neck of the uterus, and the vagina, and thus extract the fcetus by the natural passages. After this delivery, the hand should again be introduced into the uterine cavity, with the threefold object of extracting the after-birth, of deter- mining the contraction of the organ, and of preventing the strangulation of a loop of intestine, if any portion of the bowel had engaged in the fissure. Should the placenta have happened to fall into the peritoneal cavity, an effort should be made to extract it without delay, by a fresh introduction of the hand through the rupture. An attempt should be made at the same time to remove the clots which had formed in the abdomen. When such a manoeuvre is impossible, the only resource is in the Caesarean operation ; unless, being fearful of the disastrous consequences of this operation, the accoucheur should conclude to abandon the fcetus in the peritoneal cavity, and allow the mother to run all the dangers to which this determination must neces- sarily expose her. If the child's death were positively ascertained, the arrest of the hemorrhage might perhaps authorize this latter procedure, more especially if he should not see the patient until several hours after the accident; but it would never be excusable if the infant were living, and if he were not satisfied RUPTURES OF THE UTERUS. 741 that the uterus, by being completely retracted, had obliterated the vessels which furnished the blood; for, otherwise, gastrotomy should be resorted to at once. 2. During the latter months of Gestation.— Here, likewise, the extraction of the ovum is the wisest course to pursue; indeed, it is imperiously indicated when the child is living, and the pregnancy has advanced beyond the seventh month; and it may be accomplished by resorting either to gastrotomy, to a forced dilata- tion of the os uteri, or to incisions made directly on the neck of the womb. The Caesarean operation will be preferred whenever the foetus is displaced; but if it is still resident in the uterine cavity, we must endeavor to dilate the os uteri artificially, which will generally be feasible when the patient is near term, more especially if she has previously borne several children; and the introduction of the hand might likewise be facilitated by incising the periphery of the cervix. But these attempts ought to be made with the greatest care, and, should they offer any serious difficulties, and require too much time, we must renounce them at once, and open a passage through the abdominal wall. 3. Inuring the early months of Gestation.—Most of our leading teachers ad- vise us to abandon the patient in these cases to the resources of nature, to abstain from all operations, and to be content with combating the consecutive symptoms as they arise. Three new indications are now presented, says M. Duparcque, namely: 1. To prevent or arrest the disorders of innervation, by raising the morale of the woman, who is instinctively struck with fears and inquietudes, and by administering the diffusible antispasmodics by the mouth, the skin, or the respiratory passages; 2. To combat or prevent the hemorrhage by abdominal compression, by refrigerants, compression of the aorta, &c; and, 3. To prevent or combat the inflammation, which ordinarily follows the displacements of the ovum, by the employment of local and general antiphlogistics. Of Ruptures of the Vagina.—The walls of the vagina may also be lacerated during the labor. But, owing to the differences that exist, according to the portion of the canal these ruptures may occupy, it has been customary to study separately the lacerations at its upper and lower extremities, and at its middle part. In general, the two latter are of little consequence, or, at least, the dangers and indications they present belong rather to the province of the surgeon thau to that of the accoucheur; for, with the exception of thrombus of the vulva, which may, as has been stated, require the intervention of art during labor, all the other lacerations are only unfavorable to the woman, inasmuch as they expose her to vesical or recto-vaginal fistulas, which do not claim our attention here. On the contrary, the lacerations that occupy the superior extremity of the vulvo-uterine canal require a cursory notice, because they, like the ruptures of the lower part of the uterus, may become causes of dystocia. The lacerations of the upper part of the vagina may result either from traction or from direct pressure. The former may be owing to the uterine contraction, to the artifical pressing back of the uterus or presenting part of the child, and to every act of the abdominal walls, and every movement of the trunk, calculated to elevate the womb. According to M. Duparcque, the uterine contraction alone may produce a transverse lacera- tion of the vagina in the following manner: the child's head being wedged in at the superior strait, or more or less engaged in the excavation, and unable to advance any further in consequence of the resistances it encounters, and the 742 DYSTOCIA. womb still continuing to contract, the latter withdraws itself, as it were, from the child. The margins of the orifice are gradually drawn up towards the fundus of the organ, whereby they get clear of the head in a great measure, and sometimes altogether. Whence it happens that the vagina becomes subjected to an active traction, proportioned to the energy of the uterine pains; and consequently, as it offers only a passive resistance to the distension and compression it undergoes, it is gradually enfeebled, and ultimately gives way. The mode in which the efforts sometimes made during version for the purpose of pressing up the presenting part, or for penetrating through the os uteri by main force, so as to carry the hand towards the fundus of the organ, act in the production of these lacerations, is easily understood. And this transverse rup- ture, having once commenced, may extend far enough to separate the uterus almost entirely from the vagina. Those fissures and vaginal perforations which result from direct pressure, are ordinarily produced by an improper application of the forceps, or by the prolonged sojourn of the head at the superior part of the excavation. The signs of this rupture, and the accidents to which it gives rise, are very similar to those of rupture of the uterus, excepting that they are less intense and not so dangerous. The pain is less acute at the time of its occurrence, being sometimes even confounded with the labor pain; and the existence of a laceration is only suspected, some time after, when searching for the cause of the arrest of the labor. Here, likewise, the child may either preserve the place it occupied, or may pass partially or wholly into the abdomen. Most generally there is no displacement when the head had previously engaged in the excavation, and the rupture has taken place either at the junction of the vagina with the cervix or else at some point above the head. Nevertheless, should the laceration be very extensive, the head may remain fixed in the excavation, while the trunk is car- ried back into the abdominal cavity by the subsequent retreat of the womb, the orifice of which, being no longer retained by the vaginal connections, mounts up and retracts towards the fundus of the organ, thus abandoning the foetus which it cannot expel. It seldom happens that the Whole child escapes into the abdo- men, and, when this does occur, it always results from pushing up the head during the ill-directed efforts to effect the delivery. But, whether this passage is partial or complete, it ordinarily takes place in such a way that the pelvic ex- tremity engages first in the lacerated orifice. A considerable portion of intestine has sometimes been known to escape through a rupture of the vagina; it is evident that in such cases reduction should be effected as soon as possible. Although it would seem that this opera- tion ought not to be attended with difficulty, it has occasionally proved impos- sible. Burns quotes from Dr. Kerver a case of rupture of the vagina complicated with the escape of a portion of intestine an ell long. It was impossible to reduce it, and gangrene ensued. The faeces passed by the vagina; but, after some time, were discharged by the anus, and the patient recovered. The prognosis is much less unfavorable than that of uterine ruptures; because there is far less danger from the hemorrhage and consecutive inflammations, and, besides, it is always possible to extract the fcetus by the natural passages. This extraction through the vagina is, therefore, the only indication which RHEUMATISM OF THE UTERUS. 743 presents. If the head remains in its place, the forceps must be applied; but where any other part presents, we must search after the feet through the rent in the vagina, which is to be enlarged with an instrument, if it be not free enough or should offer any resistance. The Caesarean operation ought not to be resorted to, even when the foetus has passed wholly into the peritoneal cavity, except when retraction of the pelvis renders its delivery through the natural passages absolutely impossible. CHAPTER IV. RHEUMATISM of the uterus. Rheumatism of the uterus, although studied for a long time in Germany, was scarcely known in France, until M. Dezeimeris published in his journal (/' Experience) a series of facts that were previously known to, and put forth by, the German authors. About the same time, M. Stoltz, who was acquainted with the works of our neighbors on the subject, devoted particular attention to this affection at the Clinical Hospital of Strasbourg, and communicated the result of his observations to his pupils. One of them, Dr. Salathe, has quite recently defended a thesis on this subject; and from his work, as also from the bibliogra- phical researches of 31. Dezeimeris, I extract the following account of this dis- ease, which is unknown to French nosologists. According to Radamel, rheumatism may attack the uterus in the non-gravid state; but we have only to study it here as occurring in pregnant females, in whom it may appear at all stages of the puerperal condition. Therefore, after some general remarks on the disease itself, it will be necessary to point out the influence that it may have over the gestation, the parturition, and the lying in. Causes.—Every circumstance calculated to favor the development of the rheu- matic affections in general, may likewise prove a source of rheumatism of the uterus: thus, a momentary or a prolonged exposure to cold and moisture, inade- quate clothing, or sudden changes from a very high to a very low temperature, and all those other atmospheric constitutions which have been enumerated by medical authors, either as predisposing or as determining causes of rheumatism, may likewise produce that of the womb. But, besides these general causes, there is one peculiar to the disease under consideration; that is, the suscepti- bility of this organ to the impression of cold under the attenuated integuments of the abdomen during the latter months of gestation; for the belly is only covered at that particular point by very light clothing, which is far from fitting closely, and the lumbo-sacral region is often but imperfectly protected by the short jackets worn by the patient. Symptoms—Rheumatism of the uterus is very often manifested in persons who are constitutionally predisposed to the rheumatic affections; and it may coexist with a general disorder of the same nature, though in the majority of cases the womb, together with its appendages, and the adjacent parts, is alone affected. Again, it has oftentimes resulted from a sudden cessation of a rheumatic pain at 744 DYSTOCIA. some other point, which is speedily transferred to the uterus. But, whatever may have been the mode of its attack, this disease exhibits some well-marked peculiarities, by which it can easily be recognized. The principal symptom is pain, or a distressing sensation, which involves the whole or a part of the womb, without any violence having been exerted on the organ; its intensity varies from a simple feeliug of heaviness to the most painful dragging sensation; and it may occupy either the entire womb, or only one of its parts, such as the body, the fundus, or the inferior segment. When the rheumatism is fixed in the fundus uteri, the pain is particularly apt to be felt in the sub-umbilical region; it is augmented by pressure, by the contraction of the abdominal muscles, and sometimes even by the simple weight of the bedclothes; and in many cases the patient is unable to bear any movement whatever. If seated somewhat lower, she suffers from acute dragging sensations, that run from the loins towards the pelvis, the thighs, the external genital organs, and the sacral region, along the uterine ligaments. Finally, when the inferior segment participates in the affec- tion, the seat of it can be detected by the vaginal exploration, which gives rise to the most acute sufferings. But, of all the causes that may exasperate these pains, there are none more distressing than the incessant movements of the child. Like all rheumatic pains, those of the uterus are metastatic, and they occa- sionally pass rapidly from one point of the organ to another; often, indeed, they disappear at once, and pass off to some other organ. This is particularly apt to occur when the pain was originally located at some other point, and measures have been employed to recall the affection to the part primitively attacked. They present frequent and variable exacerbations in their duration and inten- sity, according to the stage of the disease; sometimes they are followed by remis- sions, during which the patient experiences only a vague sensation of weight iu the part. The uterine pains are usually accompanied by a recto-vesical tenes- « mus, which is the more distressing as the former are the more energetic, and are seated nearer the inferior segment. The patient is then tormented by a con- tinual desire to empty her bladder; the emission of urine is attended by a smarting sensation, and sometimes by acute sufferings, while at others it is even wholly impossible; and in many cases the attempts to move the bowels prove equally ineffectual. 3Iost of the German authors attribute this double recto-vesical tenesmus to a rheumatic affection that is not always exclusively limited to the womb, but which also invades the neighboring organs. But 31. Stoltz appears disposed to believe that it is rather the result of the close sympathy existing between these adjacent parts; for, if these new pains were occasioned by a rheumatism of the rectum or bladder, those of the uterus ought to disappear altogether, or at least should be diminished. (Salathe's Thesis.) Analogy would lead us to suppose that an unusual heat and tumefaction must exist in the affected parts; but the difficulties in detecting these characters are self-evident, although their existence is quite probable. Such acute pains, seated in so important an organ, would naturally produce considerable general reaction; and it is found that this disease, like the greater RHEUMATISM of the uterus. 745 number of the inflammatory affections, most usually commences by a slight chill, which lasts for a quarter of an hour or twenty minutes; the fever that follows it diminishes, and sometimes disappears altogether, during the interval between the paroxysms; but, pending their duration, it is usually quite intense, the pulse is frequent and hard, the face excited and flushed, and the tongue is red and dry; the patient complains of thirst, the skin is hot, and she often suffers from an extreme agitation and restlessness. Towards the end of the paroxysm, a profuse perspiration generally breaks out, which seems to be the prelude of a notable amelioration. Then these general phenomena become moderated, to- gether with the uterine pain, but they reappear with the latter, after a variable period, ranging from a few hours to several days. 1. Influence of Rheumatism over the Progress of Gestation.—The .paroxysms are apt to be followed by uterine contractions in those cases in which they have persisted for some time, or have been very severe; and in this manner they may serve to bring on a premature delivery. The patient experiences some acute and tensive pains, but this feeling of tension is not uniform ; for it attains, in turn, a high degree, and then becomes weaker in the same proportion, progressing in this way with shorter and shorter intervals. At first the uterus is indurated to a partial extent, but afterwards throughout; the os uteri dilates, though its dila- tation is at first slow and difficult, and its ulterior progress does not seem to cor- • respond with the intensity of the pains. An abortion is then imminent, but it is far from being so frequent as might be supposed; aud when it does occur, it is more frequently observed in the febrile than in the apyretic form of rheuma- tism. The orifice has been known to dilate to the extent of an inch in diameter, and then the bag of waters, that had previously engaged in this opening, insen- sibly retreated, the os uteri again closed up, and the delivery did not take place. Consequently so long as the dilatation of the os uteri does not amount to two inches, we may reasonably hope to make the labor retrograde. These uterine rheumatic pains may simulate those of parturition, and thus lead the accoucheur to suspect that labor has regularly commenced, when in fact such is not the case. The characters of the rheumatic pain, furnished in the following paragraph, will aid in preventing such an error. It is probably to some mistakes of this kind that we must refer those pretended instances of prolonged gestation, as well as those cases in which genuine labor was developed, and afterwards suspended during several weeks, and even months. 2. Influence of Rheumatism over the Labor.—As a general rule, a rheumatic affection of the womb retards the progress of the labor, and sometimes even ren- ders the spontaneous expulsion of the child wholly impossible. Besides the general phenomena already pointed out, the disease here gives rise to the follow- ing peculiarities : lst. It is well known that the normal uterine contraction only begins to be painful when it has accomplished the greater part of its course, and when it is at the point of distending and dilating the uterine orifice ; in other words, the true labor pain only commences at the instant when the power-of the body of the womb overcomes the resistance of the neck. In rheumatism, on the contrary, the uterine contraction is painful from the very first, and prior to any action upon the cervix; hence the cause of the pain is not in the violent distension of this 746 DYSTOCIA. orifice, but rather in the uterine contraction itself, in the other morbid conditions, and in the altered relations of the nerves and contractile fibres of the uterus. 2d. In a normal labor, the contractions begin at the fundus, and terminate at the inferior segment of the womb; in rheumatism, instead of starting at the fundus, they begin in the painful point, and are not regularly propagated towards the cervix. Again, the rheumatic pains exist prior to the contraction of the womb, and then speedily acquire a high degree of intensity under the influence of this latter. At times, their violence promptly arrests the contractions, even before they have traversed their ordinary cycle. They are then rapid, short, and become more and more distant. 3d. Towards the end of labor, at the time when the uterine action ought to be aided by the voluntary contraction of the abdominal muscles, the woman re- frains from exerting these under the fear of augmenting the pains, whereby an excessive slowness in the labor results. The patient is found in a state of ex- treme anxiety, and the frequency of her pulse, the heat of the skin, the thirst, and vesical tenesmus, are all greatly augmented. Where these sufferings are much prolonged, she falls into a state of swoouing. which often proves service- able, as the pains are suspended while it lasts; a profuse perspiration has then been observed to take place, which had the most salutary influence over the ulterior progress of the parturition. But at other times the uterus becomes more and more painful, and it is rather in a state of permanent contraction, or of fibrillar vibration, than of normal contraction; the pulse is accelerated, and the woman is affected with a metritis, which renders the labor extremely painful. 3. Influence of Rheumatism over the Puerperal Functions.—The reader will anticipate from the foregoing, that rheumatism of the womb may prove a source of difficulty in the delivery of the after-birth, by determining irregular or partial contractions of the organ immediately after the expulsion of the child; but that subject does not claim our attention at the present time, and it will be reverted to hereafter. In the healthy state, the uterus retracts after the delivery, and thereby prevents the development of hemorrhage. But in rheumatism, this re- traction of the organ is very imperfect, and it remains much larger than usual; the after-pains are then very distressing, and are prolonged for some time; the uterine vessels are less compressed than usual, and profuse floodings may thence result. On the other hand, the suffering state of the organ diminishes both the lochial discharge and the lacteal secretion; and this, together with the persist- ence of the abdominal pains, and a manifestation of the phenomena of general reaction, may be mistaken for a peritonitis which does not really exist. Prognosis.—Rheumatism of the womb is not a disease capable of determining the loss of the mother's life; nevertheless, from the pain that it occasions,-and the errors it may give rise to in practice, it does not the less merit a careful study; because, during pregnancy, it may prove to be a source of abortion, and, though it is not often manifested until after the sixth month, yet it is always an unfavorable circumstance to the child to be born before term. We have already spoken of the unfortunate influence it may have over the course and character of the labor pains; in fact, it has often rendered an artificial delivery imperative. It may also complicate the delivery of the after-birth, and disturb the order of the phenomena that constitute the lying-in. At that period it has often been DISEASES THAT MAY COMPLICATE LABOR. 747 mistaken for true inflammatory symptoms; and, consequently, has been combated by measures that were more dangerous than useful. As regards the period of manifestation, it is generally more unfavorable when it occurs at an early stage of the gestation; both because it then has a greater influence over the pregnancy, which has not become firmly established, and be- cause it has a tendency to return several times before term. Besides which, most women, who have been affected during the gravid state, likewise find it to reappear again in the course of their parturition, which is thereby rendered laborious. Treatment.—lst. The measures that have most frequently been attended with success when administered for this disease during the gestation are: general venesection; the intestinal revulsives, such as castor oil and ipecacuanha; bathing, narcotized lotions over the abdomen, opiated mixtures, and sudorific drinks; and, in those cases in which the uterine affection had succeeded the sudden disappear- ance of a rheumatic pain in some other organ, the application of revulsives over the part primarily affected. 2d. During the labor, the same means are employed; but if they fail, and the degree of dilatation of the os uteri be such as to permit an artificial intervention, either the forceps or version should be resorted to, ac- cording to circumstances. 3d. After the delivery, sudorific drinks, opiated unctions over the belly, and baths; and, when the lochial discharge has failed, leeches to the vulva, and ipecacuanha combined with opium. CHAPTER V. OF CERTAIN DISEASES THAT MAY COMPLICATE LABOR. Independently of the various accidents just studied, which have a special relation to pregnancy and parturition, there are yet some other affections whose existence at the time of labor may render the delivery dangerous, difficult, or perhaps altogether impossible, without the intervention of art. Thus, an hemop- tysis, a hematemesis, or an aneurismal tumor; asthma, syncope, the presence of a hernia, or the loss of strength in a woman who is enfeebled by some chronic disease, may individually complicate the delivery; and, therefore, they claim the particular attention of the accoucheur. A. When the patient under care happens to be affected with hemoptysis or hematemesis, and the hemorrhage is inconsiderable, there is nothing to be done; but if it does not abate, or if it suddenly augments in quantity during the pains of childbirth, we must endeavor to remove the patient from the danger that threatens her, by terminating the labor as soon as the dilatation or the dilatability of the os uteri will permit, by an immediate application of the forceps or the pelvic version, according to the particular conditions in which the parts of the child and those of the mother shall be found. B. The same indications for treatment also present where the patient has a moderate-sized aneurism, more especially if it occupies one of the large vessels of 748 DYSTOCIA. the abdomen and chest. In fact, the reader must foresee how greatly the tumor would be exposed to rupture, during the violent strainings to which the woman involuntary gives way during the second stage of the labor. Chronic diseases of the heart, whether consisting in an hypertrophy of the organ, or simply in alteration of the valves or contraction of the orifices, are but too often, as 31. Aran has recently demonstrated, the cause of sudden death, not to call for some special attention during labor. It would seem to me very impru- dent to allow the expulsive stage to continue too long in such cases, and I should think it right to terminate the labor artificially as soon as possible.1 c. The same course is to be pursued in all cases where any considerable ob- stacle to the respiration is found to exist; as happens in asthmatic persons and iu women of small stature, in whom the uterus is so enormously distended as to press up the diaphragm and lungs towards the upper part of the chest, and in whom the respiratory functions have, on this account, been disordered during the latter mouths of pregnancy. . ' D. Where a hernia exists, every one must understand, says Desormeaux, what disastrous consequences might result from the violent throes of the latter stages of labor; and how much these tumors must then be exposed to an increase of size, and how liable they are to become strangulated. The accoucheur ought to prevent these accidents, by reducing the hernia as soon as possible, if it is redu- cible ; endeavoring to return it during the interval between the pains ; and, when the contraction comes on, he will make a strong compression over the hernial opening by his fingers, or, still better, with a convex pad, to prevent its coming down. But if it is irreducible, he should apply a convex pad, or merely support the tumor with the palm of his hand, so as to prevent the expulsion of new parts during the pain. Finally, if, notwithstanding all these precautions (which the accoucheur ought to attend to himself, unless he has an assistant upon whom he 11 was requested to assist at'the autopsy of a female, forty years of age, who died sud- denly during labor. She was the mother of three children. For seven years past, her respiration had been very difficult, and she coughed habitually. Both the dyspncea and cough had increased of late, and the sputa were sometimes streaked with blood; a few hours after the membranes were ruptured, and during a pain, whilst rest- ing one hand on the edge of a bed and the other on the arm of an assistant, she fell dead without uttering a cry. At the examination, about three pints of serum were found in both pleura?; the lungs were healthy, but compressed ; a considerable amount of fluid was also contained in the pericardium. On another occasion, one of my pupils requested my attendance at the autopsy of a woman twenty-eight years of age, who died suddenly, immediately after the delivery of her fourth child. For three or four years past she had suffered from violent palpitations, and the slightest exertion, especially going up stairs, even slowly, put her very much out of breath; she coughed continually, and now and then spat a little blood. The labor was easy and rapid; she did not appear fatigued, and inquired the sex of her child. Whilst the accou- cheur was tying the cord, he remarked a few convulsive movements, but hardly had time to run to her, before she was dead. The uterus was firmly contracted. The abdominal viscera were healthy, as also were the lungs, though the latter were engorged with blood; the heart was small, and very flaccid; the mitral valve was much thickened, and the auriculo-ventricular opening would barely admit the extremity of the little finger. There were hardly five ounces of serum in the peritoneal cavity. (Francis Ramsbotham, Obst. Med. Surg., p. 608.) DISEASES THAT MAY COMPLICATE LABOR. 719 can rely), the hernia becomes strangulated, he should immediately terminate the labor, as in the foregoing cases. E. There are certain very delicate or very irritable females who are apt to fall into a state of syncope from the occurrence of the most trivial pain. In such cases, where the faintings are dependent either on a restricted diet, on a pre- vious hemorrhage, or on some former disease, it is necessary to keep up the patient's strength by some light nutritive articles of diet, such as broth, and by a little generous wine or cordial. If these measures prove to be insufficient, and the swoonings are renewed so often as to threaten her existence, we must termi- nate the labor. However, this measure is not to be prematurely resorted to, for these syncopes may be owing to some trifling cause or nervous condition, without there being that extreme debility, which alone, says Gardien, can authorize this ultimate step to be taken. Desormeaux says, I have seen such faintings renewed at every pain, in a woman who was pregnant with twins; and they lasted throughout the interval from one pain to another, so that the patient was only aroused from that state by the effect of, and during the time of, the contractions; nevertheless, the labor terminated spontaneously and happily for both the mother and child. Baudelocque gives the history of a woman who died during labor after re- peated syncopes; but the autopsy proved that these latter, as also the vomitings and diarrhoea that accompanied them, had been produced, not by the labor, but by the presence of a calculus, about the size of a small nut, in the gall bladder. It is really very difficult to accept such an explanation as this, especially as so many examples of quite as sudden death are on record, of which no other ex- planation can be given than such as attaches to the phenomena of the labor itself. Dr. Davis relates a much more extraordinary case of the kind: a poor woman had been five hours in labor at the Charity Hospital; the membranes were ruptured, and a large quantity of the waters escaped, but from that moment the patient became excessively feeble; experiencing an urgent desire to empty the bowels, she seated herself on the vessel, and made some straining efforts, when she fainted away; the attendants immediately placed her in a horizontal position, and they had scarcely time to get her into bed before she died. Nothing what- ever was detected at the autopsical examination that could give a clue to the cause of this sudden death. F. When the patients are exhausted by an antecedent disease, whether acute or chronic, and when frequent and long-continued vomiting has affected nutrition greatly, and diminished the strength considerably, I should think it prudent not to allow the expnlsive stage to continue longer than an hour or two. The efforts required to terminate the second stage, might, in some cases, exhaust the re- maining strength, and bring on immediately after delivery a rapidly fatal col- lapse. To the cases already known I might add another. The young wife of a medi- cal friend had been affected with such obstinate vomiting during the last three months of her pregnancy as to be unable to retain anything on her stomach. A constant febrile movement was the consequence, accompanied by nocturnal paroxysms and extreme wasting and debility. She finally reached the term of 750 DYSTOCIA. her painful pregnancy. The labor lasted ten hours in all, and the expulsive stao-e, during which I was obliged tj be absent, four hours. Immediately after the spontaneous termination of the labor, the unfortunate lady fainted, and although hemorrhage was prevented by the favorable contraction of the uterus, she expired in three-quarters of an hour, notwithstanding the internal and ex- ternal employment of the most powerful tonics. SECOND DIVISION. OBSTETRICAL OPERATIONS. In the preceding division we carefully detailed the various indications pre- sented by the divers causes of dystocia hitherto studied; each of which, as the reader has seen, requires a different operation. We now propose to take up the consideration of these obstetrical operations in this second division of our fourth part. CHAPTER I. OF VERSION. Version is an operation by which one of the two extremities of the child is brought to the superior strait: it therefore exhibits two varieties, in one of which the operator proposes to bring down the feet, and hence this is called the pelvic or podalic version; while in the other he attempts to deliver by the head, which is on that account denominated the cephalic version. The cephalic version was almost exclusively practised from the time of Hip- pocrates until that of Ambrose Pare, that is to say, down to the latter half of the sixteenth century. Celsus advised that when the child is dead, and the head cannot be reached without too great difficulty, the feet should be sought after. Aetius and Paulus Aegineta were the first among the ancients to re- commend pelvic version when the child is living. But since the days of Pare, or rather since those of Guillemeau, his pupil, the pelvic version has been recommended as applicable to all cases; and the cephalic reduction was almost entirely forgotten, until towards the end of the last century, when Flamand, and, somewhat later, Osiander, exaggerating, doubtless, the inconveniencies, difficulties, and disastrous consequences resulting from the pelvic version, pro- posed a return to the precepts of Hippocrates; and suggested the cephalic one in almost all cases where the hand alone is sufficient to terminate the labor. The doctrine of the Strasbourg professor was favorably received in Germany, but was too severely criticised by the school of Paris. Indeed, Baudelocque scarcely speaks of it, and Gardien restricts its application to a very limited number of cases, while 3Iadame Lachapelle formally rejects it. But we shall OF VERSION. 751 see hereafter, when studying the respective value of these two operations, that at the present day it would be improper to embrace either opinion exclusively; for some cases are better suited to the cephalic version, while there are others, on the contrary, where the pelvic one is alone practicable; consequently, both operations should be retained in practice, leaving to the judgment of the ac- coucheur to determine the cases in which the one or the other ought to be pre- ferred. Both operations may be performed shortly before labor, during labor before the membranes are ruptured, or during labor but not until after the membranes are ruptured. In the latter case they almost always require the hand to be passed into the womb, whilst in the former, this is very rarely necessary, inas- much as the presentation can be changed by placing the woman in a suitable position, and applying pressure through the abdominal walls. This constitutes version by external manipulation. ARTICLE I. VERSION BY EXTERNAL MANIPULATION. Version by external manipulation was vaguely referred to by Hippocrates, and more distinctly advised by Jacob Rueff and 31ercurius Scipio, yet it passed into oblivion until the commencement of the present century (1812), when Wigand addressed to the Academies of Berlin and Paris, a memoir comprising a complete history of the operation. Wigand's paper was probably lost in France, since it is mentioned in none of our classical works, and we remained ignorant of the wise counsels of the German accoucheur. I ought, however, to add, that, in op- position to the views of Baudelocque, Madame Lachapelle, Capuron, and others, M. Velpeau had indicated (1835) the propriety of performing cephalic version in some cases by means of external manipulation. M. Lecorche-Colombe, also (1836), both advised, and several times executed this operation at the Clinique, and I, myself, in previous editions of this work, discussed more clearly than my countrymen, the cases in which it seemed to me that it might be performed with advantage.1 It should, however, be said that no one amongst us had treated the question as fully as M. Mattei, who, although exaggerating the advantages of the opera- tion, and needlessly multiplying the indications for it, had, at least, the merit of again calling attention to a too much neglected subject. Indeed we probably owe to the exaggerations of our countrymen, the ability to read in French, the excellent translation madeby MM. Belin and Hergottof Wigand's paper. Thanks to this translation, as well as to the clinical teaching of Professor Stolz, the doctrines of the Hamburg professor will soon be popular in France. 11 am, therefore, astonished to read in Mr. Belin's translation, that M. Cazeaux, in his edition of 1853, leaves us ignorant of both when and how the operation ought to be per- formed, and that I had been content with saying, in reference to cephalic version, that ex- ternal manipulation, wisely conducted, had quite frequently been successful in changing the position of the trunk—this, too, when no less than five pages of my book are devoted to discussing the indications of the operation. 752 DYSTOCIA. External manipulation, performed with the object of bringing to the superior strait, one of the foetal extremities originally more or less remote from it, has been advised: 1. Before labor; 2. During labor and before rupture of the membranes; 3. During labor and after rupture of the membranes. A. Before Labor.—Some accoucheurs have advised that external manipulation be resorted to in the last fortnight of pregnancy, and we have, ourselves, done so after the example of 31. Lecorche-Colombe. 31. 3Iattei, however, advises, of late years, that the version be performed from the sixth or seventh month. We think this can readily be done in most cases, at least where the presentations are transverse or oblique, though we believe that generally the operation will prove useless. When, in fact, the longitudinal axis of the foetus is replaced in the axis of the superior strait, the form of the uterus, which, as shown by 31. Hergott, is very probably the cause of the faulty position of the child, remains unchanged, so that the latter will gradually resume its primitive position; after a few days the extremity, which had been brought to the superior strait, no longer being found there. I have seen this happen several times. Therefore, as the bandages devised for compressing the sides of the abdomen with the view of lessening its transverse diameter and retaining the foetus in the position given it, would be insupportable for two months, 1 agree with Wigand, that it is better to await the commencement of labor. Still, I would not say that it were useless to examine carefully all women during the latter months of gestation, in order to determine the form and obliquities of the womb, the position of the fcetus, the greater or less amount of fluid and whatever other circumstances might affect the presentation of the child at the commencement of labor. When carefully performed, this examination will rarely lead to an immediate operation, but will often have the effect to awaken the attention of the accoucheur to difficulties which, at a later period, he may be able to correct in time. Especially ought such an examination to be made when a faulty presentation had been discovered in preceding pregnancies, for were this found to be again the case, the woman would be advised to avoid all shocks or great fatigue, which might lead to premature rupture of the membranes. She ought to be strongly advised to observe the utmost quiet from the appearance of the first pain, aud to call her physician as soon as possible. In case of considerable anteversion, the uterus should be kept raised during the day by a broad belt around the abdomen supported by suspenders, whilst, at night, she ought to lie upon the back. When there is lateral obliquity, the decubitus should be upon the opposite side. We have nothing farther to say in regard to version before labor. B. During Labor and before Rupture of the. Membranes.—Under these cir- cumstances is it, that version, by external manipulation, has been especially lauded by Wigand and German writers, and then only is it, that it seems to us to possess incontrovertible advantages. We may readily conceive, that the mobility of the fcetus at that time, immersed as it is in the amniotic fluid, ought strikingly to facilitate the movements sought to be executed; whilst, on the other hand, the possibility of rupturing the membranes as soon as the operation has succeeded, affords a sure means of avoiding a relapse. OF VERSION. 753 With the exception of some special cases of which we shall have to speak hereafter, it seems to us indispensable, as a general thing, that the membranes should remain entire. A second condition regarded by Wigand as very im- portant, is the persistence and regularity of the uterine contractions. If too feeble, spasmodic, or irregular, they ought, before any thing else is done, to be stimulated in the first case, and made regular by opium or chloroform in the second. "I recollect several cases," he says, "in which the head, after having been forced down by the very violent contractions, rose again above the superior strait, until the very irregular contractions were made regular by the use of opium." Cuntra-indications.—Besides the irregularity of the contractions, which it is always easy to remedy, version by external manipulation is necessarily excluded by all circumstances requiring a prompt termination of the labor. Thus, hemorrhage, convulsions, syncope, rupture of the uterus, prolapsus of the cord, fcetal monstrosities, &c, are so many contra-indications to the operation. The case is the same with twin pregnancies, which makes it very difficult to diagnose the presentation of both children, and in which it is not always easy to know whether the pressure is exerted upon both extremities of the same fcetus. Positions of the Child, in which Version by External Manipulation ought to be performed.— As was stated on page 647, et seq., the presentations of the vertex and pelvis are liable to certain irregularities or inclinations, which, in the great majority of cases, are corrected spontaneously when the membranes are ruptured, but which not unfrequently continue or facilitate the production of presenta- tions more unfavorable still. In this case, the presenting part, head or pelvis, has no disposition to engage in the superior strait, but strikes against one of its borders. The longitudinal axis of the fcetus is not in the direction of the axis of the pelvis, but is more or less inclined to it. At other times, what is still more serious, it lies transversely, so as to form a trunk presentation; now, it is especially in these oblique or transverse positions of the fcetal axis, that version by external manipulation may be performed with advantage, and we shall borrow from Wigand the course to be pursued. 1. Preliminary Measures.—The first precaution is to make as sure as possible of the position of the child and the exact situation of the head and pelvis. With- out entering into the details already given whilst treating of each presentation, - we recall briefly that the accoucheur ought to make use successively of abdo- minal palpation, whereby he recognizes the fcetal inequalities, of the touch, performed whilst the patient is standing and whilst lying on the back, and finally, of auscultation. He will take especial note of the form of the uterine tumor, of the greater or less protrusion of the bag of waters, and of the im- possibility of reaching any part of the child by the finger in the vagina. The position the woman should take, varies according to circumstances. Generally, she ought to lie upon the side in which is situated the part of the child which it is desired to bring to the opening. Thus, if this part be the head, and it rests on the left ilium, the patient should lie on the left side. The lateral decubitus ought not to be carried too far, but just so as to direct the umbilicus slightly to the left. To give the abdomen a solid support, a thick and hard cushion, or a cloth several times folded, should be placed beneath, and 48 754 DYSTOCIA. against which the woman must be careful to press strongly, at the same time assisting herself with her hands. The change of position should be made between the pains, lest the displacement of the child in connection with the uterine contraction should occasion rupture of the membranes. If the diagnosis has not been clearly made out, the patient will lie upon the left side, this being the position appropriate to the greater number of cases. Decided anteversion, with the head resting upon the crest of the pubis demands the dorsal decubitus, the pelvis being at the same time slightly raised, and the abdomen supported by a broad bandage in the hands of assistants. The position of the accoucheur will be various and sufficiently indicated by the operation he is about to undertake. Both the bladder and rectum ought, of course, to be emptied. Mode of Operation.—In some cases of simple obliquity of the child, the mere position, aided by the cushion placed beneath the side of the abdomen, has proved sufficient to accomplish the reduction, though most frequently, especially in transverse presentations, external manipulation becomes necessary. The accoucheur ought always to endeavor to cause that extremity of the child to descend into the strait which is nearest the opening of the pelvis. Breech presentations are not so unfavorable but that we may, in some cases, give up the attempt to bring the head down first, in order to avoid too long continued and perhaps hurtful efforts. Suppose, then, the child to be in the left cephalo-iliac position of the right shoulder. The operator, being to the right of the bed and wishing to depress the head, places his right hand upon it, and whilst endeavoring to make it descend, he, at the same time, endeavors to raise the pelvis by pressing it up- ward with his left. Acting thus in opposite directions with his hands, and endeavoring to preserve accordance in his motions, he makes light frictions on the two extremities of the child; if these be not successful, he will press more strongly, always acting at the same time on both extremities. As soon as the cephalic extremity is brought to the superior strait, a few moments should be allowed to pass in order to be certain that it is well fixed there; then the membranes ought to be ruptured, so that the contraction of the womb may keep the child in its new position. When the head happens to be in the neighborhood of the uterine orifice, as in oblique or inclined positions of the vertex, it will suffice to press with a single . hand upon the part of the abdomen corresponding with the breech, whilst two fingers of the other hand, passed into the cervix, slide the head over the edge of the strait and rupture the membranes at the proper moment. It is easy to understand the modifications required by the operation, when it is decided to bring the breech, instead of the head, to the superior strait. The change once made, the delivery is left to nature, though, if difficulties should occur, the usual means will be employed for their removal. External manipulation may be practised with any amount of dilatation of the cervix, though it were best, in general, not to rupture the membranes until the dilatation is pretty well advanced. When, at the commencement of labor, the accoucheur detects an oblique position of the head or breech, or a presentation of the trunk, he ought first merely to put the woman in a proper position, and OF VERSION. 755 by means of a folded cloth or hard cushion placed under the side of the abdo- men, make pressure upon the part of the child which he wishes should engage. At the same time, he insists upon absolute immobility, especially during the pain, and if after waiting five or six hours, these measures have not sufficed to change the presentation, he will have recourse to external pressure as already described. When the conversion is effected, the membranes ought to be ruptured at once, provided the dilatation of the cervix is advanced, but if otherwise, the woman should be merely kept upon her side aud proper pressure maintained upon the abdomen. Sometimes, notwithstanding these measures, the child re- sumes its faulty position, and then the whole operation has to be repeated, and the membranes broken immediately after. During Labor and after Rupture of the Membranes.—Under these circum- stances, version by external manipulation is advisable only in oblique positions, when the head or breech are very near the cervix, the membranes broken only a short time before with a certain amount of water remaining in the uterus, and the child possessing considerable mobility. Even then, it were proper to be very careful and not continue too long attempts, whose least inconvenience would be the loss of precious time. For my own part, I would prefer, if the dilatation of the neck allowed it, to take advantage of the favorable conditions and perform the pelvic version. For a stronger reason, would I be disposed to advise the same thing to be done in transverse presentations of the trunk. Flamand did not restrict the rule to bring down the head in trunk positions to the cases just indicated; but he was also in favor of the performance of the cephalic version, even after the rupture of the membranes and the discharge of the amniotic liquid. He has even gone so far as to point out the particular manoeuvre for each one of the distinct presentations admitted by him, for the child's anterior, posterior, and lateral planes. (Journ. Complement, des Sciences Medicales); but we deem it useless to enter into his long details, more especially since they may all be comprised in this: to grasp the presenting part, push it up above the strait, and then carry it as far as possible towards the side opposite to where the head is found; and afterwards get hold of the head, and bring it down, if the efforts made by the other hand through the abdominal walls have not proved sufficient to make it descend into the excavation. Flamand himself acknowledges that this operation seldom succeeds, excepting "when some region of the neck or upper part of the thorax presents at the strait. For our own part, we believe it would be difficult, even under such circumstances; however, it is barely possible, especially if there is still some water in the uterus; and the contractions are not very energetic; still, under the circumstances, we should think it right to endeavor to effect the object. But where a long time has elapsed after the rupture of the membranes and the total discharge of the amniotic liquid, and the womb is strongly contracted, we do not hesitate to re- commend the pelvic version in preference; and particularly so, iu those cases in which some region of the lower half of the trunk presents at the centre of the strait. In common with many of our contemporaries, we had hitherto advised cephalic version in cases of contracted pelvis, from a fear of the difficulties to which an arrest of the head above the superior strait would give vise. An interesting me- 756 DYSTOCIA. raoir, by Dr. Simpson, having again directed our attention to the advantages and disadvantages of pelvic version, we subjected the known facts to a careful exa- mination, and now confess that the reading of the memoir has greatly changed our opinion. We are, at present, convinced that the dangers of pelvic version, in cases of contracted pelvis, have been much exaggerated, and do not hesitate to recommend this operation in preference to cephalic version, whiv.li would prove very difficult after a complete evacuation of the waters, and, after all, would re- quire the forceps to be applied. Still more strongly would we prefer pelvic version, if the pelvis were one of the kind in which the narrowing affects one side much more than the other • that is to say, one in which the sacro-vertebral angle, though projecting strongly forward, is, at the same time, turned to one side, as in the oblique-oval pelvis of M. Naegele, for it would enable us the more easily to direct the back, and the large occipital extremity of the head toward the most roomy side of the pelvis. When a trunk presentation is complicated by the descent of an arm, the cephalic version, recommended by Ruffius (humeri repellendi ut cadet caput), Rhodion, aud others, should, in my estimation, be wholly rejected; since the necessity of a previous return of the arm would then render the version by the head exceedingly difficult, if indeed, as before stated, the premature rupture of the membranes did not constrain us to abandon it altogether. Consequently, the pelvic version would appear to be far preferable iu cases of this kind. Presentations of the Pelvic Extremity.—"Partisans, as we are, of the version by the head," says Flamand, " we are not prepared to propose it in these cases indiscriminately, notwithstanding we are that way inclined. But after a consi- deration of the'following suppositions, we do not doubt that every unprejudiced accoucheur will follow our advice, and attempt this operation. " Supposing that a monstrosity were to present without any lower extremities whatever, or one having only a couple of little stumps near the buttock, too small to furnish a sufficient hold for the accoucheur's hand to draw down the breech, and at the same time the mobility of the foetus indicates the possibility of bring- ing down the head, who would hesitate to attempt the operation 1" For our- selves, we should not hesitate to leave the delivery entirely to the powers of nature; for what would be gained by drawing on the pelvic extremity ? Have not the precepts of 31adame Lachapelle. of Desormeaux, of Dubois, and others, taught us, that all tractions on this extremity are more hurtful than beneficial ? And would not some of those disadvantages that Flamand and his followers refer to the delivery by the breech, and on which they rely for advising the cephalic version,—would not they result in consequence of such imprudent tractions? ■l Supposing a woman has but three inches and three lines in her sacro-pubic diameter, and that in former labors she has lost several children that were deli- vered by the breech; and besides, that the fcetus appears sufficiently movable at the time of, or shortly after we are obliged to rupture the membranes—an attempt to effect the version by the head is warrantable." We likewise believe that, in such a case, the accoucheur would be justified in making this attempt before the membranes are ruptured; but after the discharge of the waters, it appears to us that this operation must be impracticable in a large majority of cases; and we should then prefer well-conducted tractions on the OF VERSION. 757 trunk of the child, using every exertion to keep up the flexion of the head at the moment when the latter reaches the superior strait. The observations of 31adame Lachapelle, and those published more recently by Dr. Simpson, afford a satisfac- tory reason for our preference, even in those cases where the pelvic contraction results from the direct forward projection of the sacro-vertebral angle; and this precept would be still more applicable, if one of those pelves described by 31. Nsegele, under the name of the oblique-oval, were to be met with. For the trac- tions then made on the breech would have the effect of turning the child's back, and, as a consequence, the large occipital extremity of the head, towards the widest part of the pelvis. To recapitulate. Version by external manipulation ought to be attempted in oblique or transverse positions of the body of the child, only during labor, and, if possible, before the membranes are ruptured. Should, however, but a few moments have elapsed since the rupture took place and a certain amount of water remain in the womb; if, in short, the child is still movable, and the part to be brought down very near the cervix, some attempt may yet be made with tins object; but, should difficulty be met with, pelvic version must be employed instead. If the faulty position of the child has been discovered before labor, the pre- ventive measures already mentioned should be had recourse to, and external manipulation left until labor has begun. ARTICLE II. OF PELVIC VERSION. This is an operation whereby the pelvic extremity is brought to the superior strait, from which it had been more or less removed. As stated in the preceding article, this result may be obtained by external manipulation performed before the membranes are ruptured. We gave a formal statement, however, of contra-indications for this method eveu though the mem- branes be intact. It frequently happens that the accoucheur is not called to the patient until long after the waters have been discharged, and then first discovers the faulty position of the child. As in all such cases, pelvic version by internal manipulation is indispensable, we shall have to study the subject with the greatest care. In the first place will be given the general rules applicable to all cases of this operation, and afterward the peculiarities presented by each of the presentations of the vertex, face, and trunk. Before operating, it is well, however, to observe certain precautions which may facilitate the process at a later period, and espe- cially is it necessary to bear in mind the conditions necessary for the performance of the operation. § 1. Precautions to be Observed. Before studying the general rules for the performance of pelvic version, we will point out briefly certain precautions to be observed by the operator, and which apply to all cases. 758 DYSTOCIA. 1. In the first place, the accoucheur ought to apprise the patient of the opera- tion he is about to perform, to make her understand as clearly as possible the necessity for resorting to it, and to calm her anxiety, and remove any fears as to the unfavorable consequences it may have either upon herself or the child. 2. As soon as the woman shall have consented to the operation, she is to be placed in a suitable position, which position varies very much in different countries, and even according to individual accoucheurs. The following is the one generally preferred in France : the woman places herself across the bed, one side of which rests against a wall or some tall piece of furniture; several pillows are then piled up under her back, so as to keep the upper part of the body moderately elevated; and that the sacrum, by resting on the free side of the bed, may leave the vulva and perineum entirely exposed. The lower extre- mities are moderately flexed, the feet resting on two chairs, and supported by two assistants standing on the outside of the limbs. When the patient is very intractable, or fears that she cannot control her movements, another assistant holds the pelvis in a fixed position by grasping the iliac crests. In England, women are usually delivered on the side; and they are placed in the same position, whenever it becomes necessary to resort to any operation; the precaution being taken, however, to bring the breech to the side of the bed, and to place a cushion between the knees, for the purpose of keeping them apart. It were well worth while, in some cases at least, to adopt this position. When, for instance, the dorsal region of the foetus is directed backward, the lateral de- cubitus sometimes allows the hand to reach the feet with greater facility; in the dorso-anterior position, on the contrary, turning is more easily effected whilst the patient lies upon the back. 3. As the little bed on which women are delivered is often too low, and therefore incommodious for the operator, some practitioners direct a mattress to be placed on a bureau or any other article of furniture of a proper height, to which the patient is to be transferred. In most case's, the accoucheur will, no doubt, be obliged to go down on his knees or sit on a low chair, which position is often inconvenient; but, after all, it does not render the operation itself much more difficult, and it is far better for the operator to be a little annoyed than to frighten the patient by all these preparations. I repeat, that to turn the bed in such a way that one of its sides will be supported against the wall, and to place the woman crosswise on it, taking the precaution, if necessary, to elevate her breech by slipping a pillow under the first mattress, is such a simple affair, that she will scarcely perceive it, and it will not disturb her in any way. 4. The accoucheur ought to throw off his coat, as the forearm has to be intro- duced into the parts as far up as the elbow. He should, also, put on an apron to protect himself from the discharges that escape from the woman's organs; and he will, likewise, have a proper number of napkins prepared and placed at the foot of the bed to wipe his hands, and to envelope the body of the child as it shall be extracted. 5. Before operating, he should again ascertain the child's position. We need only refer here to the diagnostic signs in each presentation, that have been pointed out in describing natural labor. 6. The position being clearly recognized, it will be necessary to decide on the OF VERSION. 759 choice of the hand, by which the version is to be performed. In the presenta- tions of the vertex, face, and breech, we introduce that hand, which, being held midway between pronation and supination, has its palmar surface turned towards the child's anterior plane; while, in those of the trunk, we introduce the hand having the same name as the presenting side of the foetus (the right hand for the right side, and the left hand for the left one), whenever we intend to per- form the pelvic version. As to the cephalic version, it is difficult to lay down any general rule for the particular hand to be used, since this varies according to the particular case. The hand and forearm chosen are then covered by some fatty substance, with a view of facilitating their introduction, and, at the same time, of protecting them against the contagion of any diseases the woman niight be affected with. Care should be taken to grease only the dorsal surface of the hand, which alone comes into contact with the mother's parts, the palmar face having to apply itself to those of the foetus which are too slippery already. f 7. In those cases in which the version is rendered indispensable by some acci- dent that threatens the life of the mother or child, and, consequently, where it is not possible to choose our own time, we evidently have to operate as soon as the gravity of the case renders it advisable; but in those in which a malposition of the infant constitutes the whole difficulty, as in the trunk presentations, for example, the operator (if attendant on the patient from the commencement of her labor) should bear in mind that, when the bag of waters is still intact, or else so recently ruptured that a considerable quantity of water still remains in the uterine cavity, the introduction of the hand and the evolution of the fcetus are much easier than at any other time; and, consequently, he ought to select that moment for operating, provided always the os uteri is sufficiently dilated. § 2. Necessary Conditions. In order to perform the pelvic version, it is requisite that the os uteri be dilated or dilatable; thftt the presenting part be not engaged too deeply in the excava- tion, and more particularly that it has not cleared the neck of the uterus; finally, except in trunk presentations, most authors require that no disproportion exist between the size of the head and the dimensions of the pelvis. 1. It is necessary, we say, that the os uteri be sufficiently dilated or dilatable to permit the ready introduction of the hand, and the free passage of the child. The neck may be considered as being properly dilated, when its orifice offers nearly two inches in dianjeter; but it may be much less open, and yet the ver- sion be still possible, because it is then often sufficiently dilatable. In the latter case, the cervix is thick, soft, supple, and easily distended; it is neither tense nor contracted, and the finger, on being passed over the divers points of its cir- cumference, finds that it does not resist in the least, and that it admits of being readily enlarged. This dilatability of the uterine orifice is particularly apt to be met with, when the presenting part cannot engage in the os uteri after the mem- branes are ruptured, on account of its volume or bad position; because, being no longer sustained, the margins then relapse towards its centre, and thus diminish its size. 2. The second condition is, that the presenting part be not too deeply engaged 760 DYSTOCIA. in the excavation, aud more especially that it has not cleared the cervix. It will presently be seen that, before endeavoring to enter the uterus, the hand of the accoucheur ought to push the part, which is already more or less engaged in the excavation, above the superior strait. Now, it is evident that if this part had cleared the os uteri, it could not be returned without the womb being pressed back at the same time, and consequently without exposing the utero-vaginal at- tachments to laceration. 3. When the pelvis is contracted, most French accoucheurs proscribe pelvic version. Although we also at one time adopted this view, we now think that it should be reserved for those cases only in which the narrowing affects all the diameters of the pelvis, or in which the sacro-pubic diameter is excessively shortened. An attentive examination of this question has convinced me that Madame Lachapelle, Dr. Simpson, of Edinburgh, and 31r. Radfort, of Manches- ter, were right in preferring pelvic version to the application of the forceps in some cases. We shall discuss this important practical point in the following chapter, but we feel justified in saying at present that version may be practised with advantage : 1, in the oblique-oval contractions of M. Naegele; 2, in those direct sacro-pubic contractions which present a diameter of at least three and a quarter inches, especially when the foetus is dead; 3, in the antero-posterior contractions of the inferior strait complicated with a considerable narrowing of the sub-pubic arch. (See Forceps.) § 3. General Rules of the Operation. The operation, in the performance of the podalic version, is composed of three principal stages, namely, the introduction of the hand, the evolution of the child, and the extraction of the latter. 1. Introduction of the Hand.—The patient having been properly placed, the operator sits down or-rests on one knee before her, then presents his hand at the entrance of the vulva, and endeavors to introduce it by pressing gently from before backwards, and slightly from above downwards. If the vulva is very large, the fingers are held together and introduced, flat first, taking care to depress the anterior-perineal commissure with the cubital border of the hand; but, if the vulva is very narrow, the fingers are introduced one after another, and then brought together in such a way as to form a kind of gutter, in which the thumb can slip along their palmar concavity, and thus enter imperceptibly. The hand thus forms a cone, the base of which is still at the exterior, while its apex endeavors to penetrate up into the vaginal cavity. The wrist is then slightly depressed, in order to accommodate the direction of the hand to the line of axis of the inferior strait; and, as the fingers penetrate deeper, it is de- pressed more and more, so as to make the hand describe a curve with its con- cavity anterior, corresponding to the pelvic axis. The introduction is facilitated by gently and moderately rotating the hand on its own axis, with a view of effacing the folds of the vagina. Whenever possible, the introduction into the vulva must be made during the interval between the pains. Ant. Dubois gave a different precept, and taught that it was preferable to make the introduction while the pain lasted; for, said OF VERSION. 761 he, the woman, being engrossed with the uterine pain, will not perceive that caused by the entrance of the hand. But every one who has attended a female in labor, and has made the vaginal examination during the contraction, must be convinced of the error of this celebrated accoucheur. The fingers, having reached the upper part of the vagina, may find the os uteri either freely dilated or sufficiently dilatable. In the former case they can be made to penetrate into the organ without any difficulty, by placing them be- tween the internal surface of the uterus and the presenting part of the child; but, in the latter, they are to be introduced one after the other, in such a manner as to form a cone, the extremity of which is entered in the orifice. Then the hand is pushed along, imparting to it at the same time some gentle rotatory move- ments, and separating the fingers a little from each other, so as to make a mode- rate and uniform pressure on the various points of the periphery of the cervix. When the services of an assistant can be obtained, he should be directed to place both hands over the fundus of the uterus, in order to prevent it from being pressed up by the efforts made to introduce the hand; if there is no assistant, the other hand of the accoucheur is placed over the fundus to perform the same office. The os uteri ought to be entered during the interval of the pains. As soon as the hand has reached the cervix, it is necessary to ascertain that we have not been mistaken about the position; and, in case an error has been committed and the wrong hand has been introduced, it should be withdrawn at once, and re- placed by the other, if there is reason to anticipate much difficulty in the version; that is to say, if the membranes have been ruptured a long time, the pains are strong, and the waters are wholly discharged; for we ought not to add to the difficulties that already exist by the choice of the wrong hand. But, under op- posite circumstances, we might use the hand first introduced, so as to spare the patient the pain and repugnance which the introduction of a second one always occasions her. When the hand arrives at the os uteri, the membranes may either be still intact, or they may have been ruptured for a long time. Supposing the former to be the case, the question arises, are they to be ruptured before passing any further ? It is far better to insinuate the hand between the external surface of the membranes and the internal one of the womb, and thus get it up to the point where, from the child's position, we know the feet ought to be found; and only rupture the membranes at the moment when the lower extremities are seized, or at least not until after the whole hand has penetrated into the uterine cavity. By thus leaving the membranes unbroken until the feet are grasped, we prevent a too rapid discharge of the amniotic liquid, for the forearm being placed in the orifice of the neck obliterates it completely; and we have the great advantage of reaching the fundus uteri much more easily, of turning the feet more promptly, and of practising the second stage or evolution of the fcetus more readily, the latter being yet movable in the surrounding waters. If the hand finds the placenta attached to one side of the organ, as it advances between the internal surface of the womb and the external one of the membranes, it is very necessary to avoid its detachment, which might be done by passing around its margin; 762 DYSTOCIA. Fig. 98. and, where this is impracticable, to rupture the membranes at the inferior bor- der of the placenta.1 The introduction of the hand is far more difficult when the membranes are broken, for the presence of another foreign body stimulates the contractions still more. It is then advisable to suspend all attempts, as much as possible, and only renew them when the pains are a little calmed. The first step in the process is to get hold of the presenting part, and push it up a little above the superior strait; then it is to be carried towards one of the iliac fossae, where it is sustained, first by the palm of the hand, and afterwards by the anterior surface of the forearm. This pressing back, which is easy when the foetus is still somewhat movable, becomes impossible when the waters are entirely discharged; in this case our efforts should be limited to gliding the hand between the neck and the presenting part. The mode of reaching the feet varies according in this figure the head has been pushed to the particular position. Some accoucheurs up into the left iliac fossa, and one hand . . . . . . . . , gets hold of the feet while the other sup- bave laid it down as a general rule to pass the ports the organ externally. hand around the side of the child that is directed towards the mother's loins, and then slip it along its back and breech, and down along the posterior surface of the lower extremities to the feet. For, by following an opposite course, and laying it flat on the anterior surface of the foetus, and thus guiding it directly to the feet, nothing would be easier than to mistake the hand for a foot, or an elbow for the knee, in the folded up condition of the superior and inferior extremities. There are some cases in which this direction may be followed, but in many others it is useless or impossible to take this precaution: useless, when a considerable quantity of water still remains in the cavity of the uterus ; and impossible, where the membranes have been rup- tured for a long time, and the uterine walls are forcibly retracted on the child's trunk; for then we must be content with slipping the hand flat along the ante- rior plane of the foetus, being careful not to confound a foot with a hand. 2. Evolution of the Fcetus.—Having succeeded in finding the feet, the hand grasps them in such a way, that the index finger is placed between the two in- ternal malleoli, the thumb on the external surface of one leg, and the three fingers on the external side of the other. Such at least, is the direction given by many medical authors, but in practice, we cannot always do what we would, and it is only necessary to be certain that we have a firm hold of them. (See Fig. 98.) It is sometimes difficult to seize both feet at the same time; and we must then be satisfied with a single one, provided the search after the second is 1 This plan is recommended by Peu, Smellie, Deluerye, Hamilton, Boer, Naegele and Madame Lachapelle. The latter has even been careful to suggest another precaution; namely, to rupture the membranes during the relaxation of the uterus, lest its contraction drive out a large portion of the waters. • OF VERSION. 763 The same position, in which the version is com- menced by drawing down the feet. attended with considerable difficulty. The feet are then drawn upon in such a way as to double up the foetus on its anterior plane. During the performance of this evolution, which is always to be done during the interval between the pains, the other hand should be placed over the part of the abdomen where the head is found, and by pressing up the latter should en- deavor to make it ascend towards the fundus of the womb. It sometimes hap- pens, as just stated, that only one foot can be brought down into the vagina, and if this is the anterior or sub-pubic one the operation might be terminated with- out going in search of the other; but if, on the contrary, it is the posterior foot, we should, after having secured it with a fillet,1 introduce the hand anew, and follow the internal border of the limb already extracted, up to the root of the opposite leg; whence, by tracing out the latter, we finally get to the other foot, which is to be brought down in a line of abduction. In some cases it is much easier to seize the knees which present to the hand of the accoucheur, and they might then be drawn upon without inconvenience for the purpose of effecting evolution. 3. The extraction is the only stage of the version performed during the uterine contraction. In fact, as the latter facilitates the tractions made on the pelvic extremity, and likewise serves to keep the head flexed on the chest, the ac- coucheur would be justified in terminating the labor, without waiting the return of the pain, only when there was a complete inertia of the womb conjoined with some accident requiring a prompt delivery. At first, we must draw on the sub-pubic limb as much as possible, because we thereby encourage the rotation of the anterior plane of the child towards the mother's loins, and we are better enabled to press the parts backwards; that is, to get them in the direction of the axis of the superior strait, which they have to traverse. As the lower extremities are delivered, the whole extent of the disengaged parts are grasped by the two hands, taking care to place the thumbs on the pos- 1 The fillet usually consists of a piece of tape, one or two fingers' breadth wide and a yard long, made into a loose slip-knot, which is applied above the ankle ; when the foot is still in the vagina, the knot is placed on the dorsal surface of the hand, and then, by grasp- ing the foot, it is slipped over it above the malleoli, and afterwards tightened by drawing on the two extremities of the tape that hang down at the vulva. When the foot is high up in the vagina, it is often very difficult to apply the fillet: in this case, M. Van Huevel pro- poses substituting for it a long forceps, the upper extremity of whose branches terminate in a half ring placed at right, angles upon the stem. When the forceps are closed, we have a complete ring, by means of which the leg is seized above the malleoli. But why should instruments be so multiplied without absolute necessity? 764 DYSTOCIA. terior part of the limbs, the index and medius on their external surface, and the ring and the little fingers on their anterior surface. When the breech appears at the vulva, it is necessary to ascertain the state of the cord; for that purpose, a finger is to be slipped up to its umbilical insertion, when, if it be found tense, Fig. 100. Fig. 101. The version is here completed, and the occi- Management of the cord, put, which was placed in the left iliac fossa, at the commencement of the operation, will now come down behind the right acetabulum. the thumb is joined to the finger, and by making a gentle traction on its placen- tal extremity, by both, the loop it forms will be enlarged (Fig. 101). If the cord has slipped over one leg, and got into the fissure between the thighs, it will likewise be necessary, after having drawn slightly on it, to disengage the child's posterior limb, and place the cord in contact with the perineum. In case the version has been demanded by an unfavorable position, and the child has been restored to a natural one by the pelvic evolution, the rest of the travail is left to nature; provided always the force and frequency of the pains are such as to give us reason to anticipate a speedy delivery. But if the uterine con- tractions are feeble or slow, or if the severity of the symptoms endanger the life of either the mother or the child, the tractions must be kept up, and the patient be encouraged to aid them with all her remaining strength. The hips, loins, and lower part of the chest soon come down; and, as this delivery progresses, the accoucheur's hands ought to embrace as many parts as possible, constantly seizing those that are nearest to the vulva, and taking care always to act on the bones, not on the soft parts. The arms are apt to become stretche 1 out along the sides of the head, and thus descend with it into the excavation; when their disengage- ment must be effected in the following manner: we commence with the poste- rior one, which has only the resistance of the soft parts of the perineum to over- come, and therefore will offer less difficulty than the sub-pubic arm. The same OF VERSION. 765 hand is again used by placing its index and middle fingers on the posterior and external side of the arm, just beyond the humero-cubital articulation, while the thumb rests on the anterior internal plane of the humerus, where it acts like a splint; the axillary space is thus found lying in the interval that sepa- rates the thumb from the two fingers (Fig. 102). The trunk having been enveloped in a napkin is next carried up in front of the pubic symphysis, either by the other hand, or by an assistant. Then the fore and middle fingers, acting over the whole extent of the arm and a part of the forearm, bend the latter down over the side of the head and face towards the chest, on the side of which it is ulti- mately placed after its complete disengagement. The sub-pubic arm is next delivered by support- ing the child's trunk upon the other forearm, and depressing it towards the anus, while the hand, not the one engaged in the previous operation, is introduced in a state of forced pronation; that is, turned over on its radial border in such a way The delivery of the posterior arm. that the thumb can be still applied on the internal, and the index and middle fingers on the posterior surface of the arm; and then this is brought down over the side of the head, face, and front of the chest, as was the posterior arm. In ordinary cases, the head descends flexed into the excavation, the occiput being turned towards some point adjacent to the symphysis pubis, and the dis- engagement is effected spontaneously if the pains are tolerably strong and fre- quent; and if necessary to facilitate it, we have only to carry the trunk up in front of the symphysis. But should it happen that the expulsion of the head is somewhat delayed, we must aid it by introducing two fingers on the sides of the nose, and two others on the occiput, and then, by means of the latter, the opera- tor pushes up the occiput, while he draws down, on the contrary, with those implanted on each side of the nose, and thus determines a movement of flexion which secures the delivery of the head. The difficulty would be much greater if the face was turned forward, and the occiput backward; though even here, if the head is not very voluminous, and the pelvis is large, we might effect its de- livery by depressing the trunk on the perineum, and by drawing down the face in the pubic arch, with the fingers planted on the sides of the nose, so as to flex the head; or, on the other hand, by carrying the trunk up in front of the pubis, we might, in some exceptional cases, succeed in delivering the occiput first at the anterior perineal commissure. § 4. Of the Difficulties that may be met with in performing the Pelvic Version. In common simple cases, the manoeuvre is accomplished in the way we have just described ; but it very frequently happens that the operator encounters diffi- culties in its performance, dependent either on the mother or on the child, which next claim our attention. Those which the mother's organs may present, are an 766 DYSTOCIA. excessive narrowness of the vulva, an obstinate resistance at the uterine orifice, the spasmodic contraction, and the mobility of the body of the womb, and the insertion of the placenta over the os uteri. Those appertaining to the foetus, are a shortness of the umbilical cord, the unusual volume of the shoulders, the cross- ing of the arms behind the neck, and the extension of the head. A. Narrowness of the Vulva.—Unless the narrowness of the vulva results from the persistence of old adhesions, it is seldom so great, even in first preg- nancies, as to constitute a serious obstacle to the introduction of the hand. The only precaution to be taken, is to pass in the fingers one after the other, and to make the hand enter gently and carefully. b. Resistance of the Uterine Orifice.—The causes and principal indications of the resistances which the uterine orifice may offer to the spontaneous expulsion of the child, have already been studied (page 604, et seq.); and it is possible that these same difficulties may be met with in the performance of the version. Here, also, the retraction may be seated at the external or the internal orifice of the neck. Two conditions may be met with when the external is the only one affected; that is, the pelvic evolution may be necessitated, either by a trunk pre- sentation, or else by some accident which, by compromising the life of the mother or child, renders a prompt termination of the labor imperative. In the former case, whatever be the cause of the contraction, or of the non-dilatation of the ori- fice, all the means calculated to facilitate the dilatation will be brought into use ; such as venesection, if the patient is plethoric, tepid bathings, fumigations, and unctions with the extract of belladonna on the periphery of the cervix; and, where these remedies have been employed without success, we should act as in the following case. In the latter case, the necessity of terminating the labor promptly does not permit us to rely on the employment of the means just enume- rated, because their action is not developed for some time; and our only resources are in a forced introduction of the hand, or multiple incisions on the neck. We have hitherto stated that, as a general rule, the repeated incisions of the cervix appear decidedly preferable to a forcible introduction of the hand, which latter is always a slow, difficult, and very painful operation, whilst the instrument is not even felt by the patient; besides, it is not dangerous, and its results can be more certainly relied on. It is, however, very necessary to take in consideration the nature of the accident which, in this state of the cervix, demands the inter- vention of art; for, in this respect, hemorrhage or eclampsia may present very different indications. In the former, it is very probable that the contraction of the orifice is slight, and capable of being overcome without much difficulty; besides, should it fail, the attempts at forcible introduction would have the effect to irritate the organ and excite the contraction of the fibres of the fundus, whose inertia had probably caused the flooding which demands the termination of the labor. But, during an attack of eclampsia, there is every reason for supposing that the contraction of the orifice is due to the convulsions, with which every muscle of the body is affected. Hence, it is not of a character to yield readily to attempts at introduction, and, in case of insuccess, it may be feared lest, by irri- tating the very sensitive fibres of the neck, they might have the effect to increase the general convulsions which we wish to remedy. Therefore, we should, in this case, give preference to incisions. OF VERSION. 767 When the spasmodic contraction is confined exclusively to that portion of the uterine walls which constitutes the internal orifice in the non-gravid state, the hand, after having, penetrated the external one without difficulty, is suddenly arrested by an obstacle that it cannot surmount. This retraction is apt to take place, in the presentations of the cephalic extremity, around the child's neck after the head is free, but it is oftener observed in the trunk presentations. The measures that we shall presently point out for combating the spasmodic contrac- tion of the body of the womb, are equally applicable in cases of this kind. c. Insertion oft he Placenta on the Neck of the Utures.—As is well known, this circumstance is an habitual cause of hemorrhage, and often requires the pelvic version. When the placenta is only attached by one margin to some point of the uterine neck, the hand is introduced at the part which is not covered, and the version presents nothing peculiar. But a different course has been advised rela- tively to the introduction of the hand, where the insertion takes place, centre for centre, and no portion of the circumference of the placenta is detached. Thus, it has been recommended to perforate the centre of the after-birth, and introduce the hand through this opening; but this appears to us a difficult and dangerous process, because : lst, a great number of umbilical ramifications are then necessarily torn, and a hemorrhage produced which may speedily prove fatal to the child; 2d, the force necessary to effect this perforation is sometimes suffi- cient to drag upon, and then detach, the periphery of the still adherent placenta; and, 3d, the central opening made in the after-birth will seldom be spacious enough to permit the child's trunk and head to pass freely; whence it may hap- pen that the frictions made by the movable parts of the foetus against the mar- gins of this opening, will facilitate a displacement of the arms and an extension of the head. Consequently, unless the patient's strength be already exhausted by the flooding, or the placental adhesions be very strong, we would rather detach some point of the circumference of the placenta, and thus get the hand between its external face and the internal wall of the uterus. True, by operating in this manner, we should lacerate a certain number of utero placental vessels, and thereby add to the sources of hemorrhage, but we would succeed in saving the child's blood; besides which, the hand and forearm, at first, and then a little later the trunk of the foetus, by becoming applied over the mouths of these ves- sels, would compress them like a tampon, and thus put an end to the hemorrhage. D. Violent Contraction of the Body of the Womb.—This is a condition that always makes the version very painful and very difficult, and, in certain cases, may even render it impossible; it is, therefore, a sufficient reason for preferring an application of the forceps when the cephalic extremity presents. But, in a case of trunk presentation, version would be the only practicable measure; and even that might be rendered wholly impossible by the retraction of the uterus. Here, likewise, venesection and tepid bathing prove very useful; and the em- ployment of the opiates is particularly indicated, for the aqueous extract of opium, when administered in injections, or by the stomach, in the dose of three-quarters of a grain to two grains, or an equivalent quantity of laudanum, is usually found sufficient to overcome the resistance of the body of the womb. Under such cir- cumstances, Dewees highly extols a resort to general bleeding, carried to syncope ; and he makes the patient stand up during the operation, whenever possible, so as to produce this effect more speedily. 768 DYSTOCIA. I had an opportunity of putting the advice of the American accoucheur into practice, for the first time, on a lady in la Rue du Four-Saint-Germain, to whom I was called in consultation by Dr. Treves. The child presented by the left shoulder; notwithstanding which, ergot had been administered, in consequence of an error of diagnosis, and the uterus was so contracted on the trunk of the child, that an introduction of the hand was altogether impossible. I made the patient get up, and had her supported by two assistants; the vein was opened, and I permitted the blood to run until the woman fainted ; when she was imme- diately replaced on her bed, and the version was effected without difficulty. If these measures fail, and the child be still living, there is evidently no other resource than to wait and hope for a spontaneous evolution from the expulsory efforts of the uterus. If it be dead, the section of its neck, according to the plan of Celsus, and a separate extraction of the trunk, and afterwards of the head, ought to be immediately practised, with a view of sparing the patient the disas- trous consequences of a prolonged and usually a uselessly prolonged labor. (See Embryotomy.) Again, the contraction of the uterus very frequently renders the efforts made during the version to turn the anterior plane of the foetus backwards ineffectual; and where this is the case, it is not advisable to operate on the trunk, by pushing it back and drawing it down alternately, endeavoring to impress a slight rotation on it each time, as certain accoucheurs have recommended; for that would very often be impossible, and, besides, by being carried too far, it would expose the child's neck to torsion ; for the head, being held by the contraction of the fundus uteri, might not participate in the rotation impressed on the trunk. It is much better, therefore, to renounce it altogether and permit the face to come above. Inhalations of chloroform have been recommended by some persons, as possess- ing the immense advantage of quieting these spasmodic contractions of the uterus, and of rendering versions easy, which were previously impossible. I have no personal experience in this matter, but upon interrogating that of others, I find that they have obtained very different results. Thus, whilst 31. Stoltz thought that he had remarked an increase in the frequency and force of the contractions, and Mr. 31urphy states that he had never before met with so much difficulty in a case of turning, although the patient was completely under the in- fluence of the chloroform,-we find Dr. Denham affirming that in ten cases in which chloroform had been administered previous to the version, its use had faci- litated the operation, and that its happy influence was especially remarked in the case of a woman in whom the introduction of the hand, though attempted fruit- lessly before the inhalation, was effected with the greatest ease immediately after- ward. The facts as yet known are too contradictory to enable us to judge of the effi- cacy of chloroform in these cases. For even in those in which its use was fol- lowed by a relaxation of the uterus, is it certain that this occurrence, which often takes place spontaneously and suddenly, was anything more than a simple coin- cidence? There seems some reason for thinking so, when we recollect the cases in which it produced no effect. It is, therefore, an undecided question. How- ever, I should hasten to add, that 3Ir. Simpson, aud other most conscientious men, admit that the inhalation of chloroform must be pushed to its fullest extent, and n» OF VERSION. 769 be continued for a long time, before it affects the muscles of organic life. 3Ir. Simpson attributes the suspension of normal labor to the abuse and excess of in- halation. If such be the case, is it not reasonable to suppose that it would be necessary to carry the use of chloroform beyond the limits of prudence, in order to terminate the abnormal and almost tetanic contractions, and then is there not cause to fear the occurrence of one of those terrible misfortunes which some sur- geons have had to deplore ? E. Mobility of the Body of the Uterus. According to M. P. Dubois, sufficient stress has not been laid upon this difficulty; because, if unattended to, it may absolutely prevent the introduction of the hand as far as the fundus uteri. That is, the hand, being wedged in between the uterine and fcetal surfaces, attempts in vain to get at the feet, since the womb, the hand, and the trunk of the child then form a whole which turns on itself, but the hand does not progress into the inte- rior of the uterine cavity. To remedy this obstacle, it is only necessary to have the fundus of the organ kept steady, by directing an assistant to place both hands over its superior and lateral parts. F. Shortness of the Cord.—Whatever be the cause, the cord when very short may become stretched, during the tractions on the pelvic extremity, and even to such an extent as to occasion its rupture. This accident is to be prevented by cutting the cord, when the tractions made on its placental portion are not suffi- cient to relax it. G. Volume of the Shoulders.—As the loins become free at the vulva, the shoulders engage at the superior strait; when it happens, in certain cases, that the tractions, which up to that time had been efficacious, cease to be so any longer, and some resistance is experienced in completing the delivery. This resistance is dependent solely on the fact that the bis-acromial diameter of the shoulders corresponds to the diameter of the superior strait; and consequently, from its width, encounters some difficulty in clearing the latter. But this is easily relieved by imparting some oblique movements to the portions of the child already disengaged, which carry the breech successively towards the groin of one side, and the sacro-sciatic ligament of the opposite side ; whereby the bis-acromial diameter is inclined, and its two extremities are made to engage in the excavation one after the other. H. Crossing of the Arms behind the Neck.—It sometimes happens that one of the arms (ordinarily, the sub-pubic one) is found crossed behind the neck, when about to be delivered. We have advised that an attempt be made to bring the child's posterior plane around in front; but, in order to accomplish this, it is necessary to make the trunk undergo a considerable revolution, during which the arms, that are not involved in the movement, might be displaced by rubbing against the womb, and thus become crossed between the neck and the posterior face of the symphysis pubis. It is highly important to bear in mind that, ac- cording to the observation of Duges, this crossing of the arms may take place in two wavs; namely, they may be crossed behind the neck, after having been first raised up on the sides of the head, and then the overlapping is effected from above downwards and from before backwards, relatively to the foetus; or it may occur from below upwards, the arms then mounting up along the child's posterior plane, and becoming placed under the occiput. This latter circumstance may be 49 770 DYSTOCIA. produced in the following way: as the arms are usually located on the sides of the thorax, they may not participate in the movement of rotation impressed on the trunk, in making an attempt to bring the anterior plane of the foetus towards the mother's loins; and, consequently, one or both of them may thenceforth be found placed on the child's dorsal plane. Then, supposing the tractions on the breech are continued, the arm will become arrested against the symphysis pubis, while the trunk descends or is extracted, in such a way as to be still there when the back of the neck reaches that point. These two cases can be distinguished from each other by remarking that, when the crossing of the arms has taken place from above downwards, and from before backwards, the inferior angle of the scapula is removed to a considerable distance from the median line of the spine; while, on the contrary, it will be quite close to it when the crossing has occurred from below upwards along the back of the fcetus. The diagnosis is important, since the disengagement of the crossed arms evidently cannot be effected in the same manner in both cases; because, as a general rule, the arm has to be brought down in an opposite direction to the course it followed in becoming displaced. Thus, in the latter case, it must be made to descend along the back, by hooking the elbow with one or two fingers; in the former, it will be first brought over the occiput, and then down along the side of the head, face, and sternum. This latter disengagement is sometimes exceedingly difficult, for the occiput, being strongly pressed against the symphysis, seldom leaves free space enough between it and the os pubis for the operation. When this occurs, it has been recom- mended to press up the chest forcibly, with a view of making the occiput go up- wards, and thereby releasing the arm. It would certainly be better, after having disengaged the posterior arm, to impress a movement of rotation on the whole trunk and head of the foetus, on its longitudinal axis, which would carry the occiput and the arm to be disengaged into the hollow of the sacrum. I. Arrest of the Head.—Both contraction of the pelvis and extension of the head may render difficult the delivery of the cephalic extremity. Buf as we have already pointed out what is proper to be done in the former case, we need not revert thereto again. When the expulsion of the foetus is left to the powers of nature, the head de- scends, moderately flexed, into the excavation, and most generally its disengage- ment presents no marked difficulty. But when it becomes extended in conse- quence of improper tractions on the breech, its long diameters are brought into correspondence with the diameters of the pelvis, and its further delivery is thereby rendered impossible. Of course, in this state of extension, the occiput may either be found in front (though this seldom happens), or it may be found behind, the face being above, which is by far the most common.1 1 The extension of the head, during version, is far more common in those cases where the occiput is turned towards the sacrum. The reason of which will be readily under- stood by giving attention to the following circumstances, namely: the tractions are natu- rally made downwards and forwards, while the os uteri, which has a constant tendency to retract, is directed somewhat downwards and backwards; whence it results that the anterior lip of the womb presses strongly on that portion of the child which is turned towards the pubis. Consequently, when the occiput is in front, the resistance offered by this lip has a tendency to flex the head still more; but, on the contrary, when it is behind, the chin is almost inevitably caught by the anterior lip, and the head is thereby extended. OF VERSION. 771 When the occiput is in front, the flexion of the head is effected without trouble; for it is generally sufficient to place two fingers on the sides of the nose, or else on the lower jaw inside of the mouth, and then depress the chin by a moderate traction on this part; whilst two fingers of the other hand are passed Fig. 103. Fig. 104. The mode of flexing the head, by drawing down the chin and pushing up the occiput. Mode of rotating the face into the hoUow of the sacrum. in under the symphysis and implanted on the occiput, so as to press up the latter above the superior strait. (Fig. 103.) When this manoeuvre does not prove successful, * has been recommended, before having recourse to the forceps, to introduce the hand into the hollow of the sacrum and grasp the face with its palmar concavity, in order to bring down the head into its normal position by effecting a forced flexion. When the occiput is behind, and its delivery is not possible, either by flexion or extension (see page 440), it is advisable, says Madame Lachapelle, to change the position of the head and carry the face back into the hollow of the sacrum; and, for that purpose, to introduce that hand into the sacral concavity whose palm would embrace the occiput most easily (the right, when the face is a little to the right, at the same time that it. is in front; the left, when it is somewhat to the left; though, if the face were entirely above the pubic symphysis, the choice of the hand would be a matter of indifference); then the fingers, after having passed behind the head, are slipped over one side of it, and pushed for- ward as far as the mouth, by gliding along the nearest cheek (Fig. 104). The hand is then forcibly inclined on its cubital border, having the palmar surface in front; next, it draws the parts on which the extremity of the fingers is ap- plied, that is to say, the face, downwards and backwards towards the coccyx, when nothing further remains than to flex the head and extract it as in ordinary 772 DYSTOCIA. § 5. Appreciation of Version. Version, when performed under favorable circumstances, that is to say, when the membranes are intact, or have been ruptured within a short time, and the child, surrounded by a considerable amount of fluid, still possesses a certain mobility, is, in general, an easy operation, and but slightly hazardous either to the mother or the fcetus. Unhappily, it must be confessed that these fortu- nate conditions are rarely met with in cases wherein we are obliged to perform the operation. With the exception of shoulder presentations, none of the malpositions of the child require the intervention of art, until, after waiting for a longer or shorter time subsequent to the rupture of the membranes and the complete dilatation of the cervix, it is ascertained that the natural efforts are insufficient. Shoulder presentations themselves are rarely detected certainly before, or very shortly after, the rupture of the membranes, so that unless an experienced accou- cheur should have attended the woman from the commencement of the labor, he is not called in consultation until after the waters have been discharged for a long time. It is, therefore, mostly necessary to act under unfavorable circumstances. Now, it should not be forgotten that the requisite manoeuvres, which are serious as regards the maternal organs, are especially fatal to the child. Thus, 31. Ftiecke, who has collected 3120 cases of version, finds that 600 women out of this number perished, that is to say, 1 in 10-4; and 1756 children were lost, or 1 in 1-28. This mortality of the children is truly frightful, and yet, consider- ing the accidents which, in certain of the cases, necessitated the version, and which of themselves destroyed the foetus, I think that these results are correct, so far as the influence of the mere operation is concerned. I have often heard the venerable Capuron say, that in difficult cases, two-thirds, and, perhaps, even three-fourths of the children perished ; and the results of my own practice corre- spond fully with his observation. Churchill, who states 542 cases of version, gives a mortality of 1 in 3 for the children, and 1 in 15 for the mothers. It is true, that he makes no distinction between difficult cases and others. The above mentioned difficulties, which, unfortunately, are very common, ex- plain sufficiently this result. With experience, and especially with great care, it is always possible to overcome them, and, at the same time, spare the mother the grave lesions of the vagina and of the body and neck of the uterus which an unpractised and brutal hand often occasions; but we cannot always prevent the violently contracted organ from being exceedingly irritated by the forcible intro- duction of the hand, nor the irritation from becoming the starting-point of puer- peral inflammations, nor the physical and moral shock to the patient from being so great as to terminate her existence. It is only necessary to have followed the manoeuvre in difficult cases to under- stand the dangers to which the fcetus is exposed. Throughout the operation, the umbilical cord is liable to be compressed more or less severely, and the efforts required to disengage the upper and lower extremities, expose them greatly to fracture. Finally, the tractions exerted upon the pelvic extremity, whenever an obstacle prevents a ready engagement of the head, may very easily give rise to lesions of the upper part of the neck and medulla oblongata incompatible with the regular establishment of extra-uterine respiration. OF VERSION. 773 It is very difficult, from an examination of the published statistics, to form an exact idea of the frequency of the cases in which version may be required. These cases, in fact, are not the same in all countries, nor for every accoucheur in the same country. Besides, as the statistics were, for the most part, collected in hospitals, it is evident that we would have a very incorrect proportion by de- ciding upon a mean from the figure of the versions performed in any one institu- tion, because this figure represents not only the versions required by the patients already admitted into the establishment, but also the difficult cases brought there at the last moment from the city. The following resume, to which, however, I attach but a very secondary im- portance, will at least serve to show the differences in the statistics according to the localities. Thus, whilst in England, but 145 cases of version are mentioned for 39,539 deliveries, or 1 in 269, the French practice gives 400 versions for 37,479, or 1 in 93J, and the Germans have performed it 337 times in 21,516, that is to say, in one case in 63f. § 6. Of Version in Vertex, Face, Breech, and Trunk Presenta- tions. After the minute detail into which we have just entered in describing the general precepts that are applicable to all cases of version, it will only be neces- sary to point out the peculiarities attending this operation in each of the ten positions admitted by us. Presentations of the Vertex.—Whenever the vertex presents, the child will be placed in such a way that its occiput is directed either towards one of the points on the right lateral half, or towards one on the left lateral half of the pelvis; that is, either in the left or the right occipito-iliac position. 1. Left Occipito-iliac Position.—In conformity with the precepts above given, we would here introduce the left hand; which, after having reached the os uteri, is to grasptthe head in such a manner that the palmar face of the four fingers shall be applied on its posterior (left) side, aud the thumb on its anterior one the sinciput being lodged in the palmar concavity. Then, during the interval between the pains, the head must be pressed up towards the left iliac fossa; after which, the thumb is brought alongside of the index, and the hand is passed suc- cessively along the left side of the head and neck, and behind the shoulder and elbow; in a word, it is made to traverse the whole left lateral plane of the foetus down to the breech. While this movement is being effected, it is advisable to keep the head in the iliac fossa where it was originally placed, by constantly pushing it up, first with the thenar eminence of the hand, and afterwards with the front surface of the forearm. Having gained the nates, the hand, which up to that time had been kept in a state bordering on supination, is changed into one of pronation, in order to pass around the breech; when it descends on the posterior aspect of the lower extremities, extends the legs, and reaches the feet, which it seizes as firmly as possible. Or, as stated above, we might guide the hand along the anterior plane of the fcetus, and thus get directly at the feet. (Fig. 98.) In drawing down the feet, we must be careful to curve the child's trunk in 774 DYSTOCIA. the line of its natural flexure; whilst the other hand, placed over the left iliac fossa, pushes the head towards the fundus uteri, and thus facilitates the evolution of the foetus. This evolution being once effected, the left occipito-iliac position is found to be converted into a right lumbo-iliac one. The subsequent progress of the delivery offers no special indication. 2. Right Occipito-iliac Position.—In this case, the right hand would be chosen in preference, by which the head is to be grasped, as in the preceding case, and then to be pushed up towards the right iliac fossa; the hand traverses the right lateral or posterior plane of the fcetus, and, after having seized the feet, converts the second position of the vertex into a first of the breech, or, in other words, into a left lumbo-iliac one. The rapidity with which the extraction is to be effected, must depend upon the gravity of the accident which has rendered it necessary. Presentations of the Face.—In the face presentations, we use the left hand in the right mento-iliac, and the right one in the left mento-iliac positions. The four fingers are to be applied on the posterior cheek, the thumb on the anterior one, and the face will be lodged in the palmar concavity; the head, after having been pushed above the superior strait, will be carried if possible towards the left iliac fossa in the right mento-iliac, and towards the right iliac fossa in the left mento-iliac positions; and then the evolution will convert the former of these positions into a right lumbo-iliac, and the latter into a left lumbo-iliac position. Presentations of the Pelvic Extremity.—When the pelvic extremity presents, and any circumstance whatever demands a prompt termination of the labor, it is not, properly speaking, a version that the accoucheur has to practise, but rather a few simple tractions on the presenting part. If the feet or the knees offer at the uterine orifice, or hang in the vagina, the accoucheur merely seizes and draws on them, conforming to the rules above given; but where the lower extremities are stretched out along the child's anterior plane, and the breech alone presents, the course to be pursued varies a little, according as this part is more or less engaged in the excavation. Thus, when the nates are still above the superior strait, or at least are so little engaged that it is easy to press them up, we must act in the following manner : taking care to introduce the left hand in the left lumbo-iliac positions, and the right hand in the opposite ones, the buttocks are first seized by the whole hand, and gently pushed up into that iliac fossa towards which the child's back is turned; then the feet are sought out, by following the posterior aspect of the lower ex- tremities, and they are brought down so as to draw upon them and terminate the third stage of the version. When the nates have reached the pelvic floor, the index finger of one hand is placed in the posterior groin, and the same finger of the other hand in the anterior one, and then, having both fingers curved like a hook, we draw on the buttocks until the feet are entirely clear. Lastly, if the breech is so far engaged as to be no longer capable of being pressed above the superior strait, and, nevertheless, has not yet descended low enough to be caught by the fingers, a blunt hook is employed, which is to be applied from without inwards on the anterior groin, if it is possible to make it slip up between the anterior hip and the symphysis pubis (Fig. 105); in the contrary case, it is passed OF VERSION. 775 between the two thighs, and made to penetrate from within outwards on the in- ternal part of the limb; but, in this latter case, it is necessary to protect the genital parts, the scro- tum in particular, by one or more fingers previously introduced, lest they become embraced by the concavity of the instrument. Presentations of the Trunk.—We have fre- quently repeated that the trunk presentations, of themselves, require the intervention of art; and that it is requisite to change the position of the child as soon as the conditions necessary to this evolution are met with. In the preceding article, we endeavored to point out those conditions under which we think an attempt to effect the cephalic version ought to be recommended; notwithstand- ing which, the pelvic version is very often prac- tised, either because such attempts have proved ineffectual or because it is deemed advisable not to resort to them. Nevertheless, before laying down the rules of the operation, we must remark that the accoucheur only resorts to the pelvic version in these cases in order to remedy the defective presentation ; and The mode of using the blunt hook in consequently that, as soon as he shall have con- the breech positions. verted this latter into one of the breech, he should abandon the rest of the labor to the expulsory efforts of the uterus, unless some accident, serious enough to threaten the life of either the mother or the child, should require a more rapid delivery. As before stated, the trunk presentations are two in number, and each side of the fcetus may present at the superior strait in two different positions: in the first of each, the head is in the left iliac fossa, and in the second it is in the right iliac fossa. The rule heretofore followed in the choice of the hand is not applicable to the trunk presentations; for here we would introduce the right hand in the positions of the right lateral plane, and the left in the positions of the left lateral plane; after which the operation is conducted in the following manner : A. First Position of the Right Shoulder (left cephalo-iliac).—The right hand is to be introduced into the parts in a state of supination, when, after having endeavored to push the shoulder above the superior strait, and a little towards the left iliac fossa, it is directed towards the right sacro-iliac symphysis, above which the child's feet are found; the latter will then be seized and brought down into the vagina. In doing this, it is not necessary to bend the foetus in the line of its natural flexure, as in the vertex and face positions, but we may draw immediately on the feet and bring them into the excavation; for this lateral evolution, or bending on the side, is much more speedily accomplished, and it is not attended with any inconvenience. The feet, being once in the vagina, the operation is terminated as in all other cases. B. Second Position of the Right Shoulder (right cephalo-iliac).—Here, like- 776 DYSTOCIA. wise, the right hand is introduced in a state of supination. The shoulder is seized and pushed up towards the right iliac fossa, and then the hand traverses the posterior plane of the foetus, by passing backwards and to the left; when it Fig. 106. Fig. 107. The introduction of the hand in the second position of the right shoulder. Mode of seizing the feet in the same position. Fig. 108. reaches the nates, it gets around them by being changed into a state of pronation, and then comes forward and to the left to grasp the feet, which are next brought down into the vagina. (Fig. 107.) c. First Position of the Left Shoulder (left cephalo-iliac).—The left hand is introduced in a state of supination, and then, after pressing the shoulder upwards and a little to the left, it is directed along the child's back towards the right posterior part of the pelvis, where it is passed around the breech by turning to a state of pronation, and is next brought forward and to the right, so as to seize the feet. D. Second Position of the left Shoulder (right cephalo-iliac).—The left hand, intro- duced in a state of supination, pushes the shoulder above the superior strait and some- what to the right; and then, passing towards the left side and posterior part of the uterus, it goes in search of the feet, which are found there.1 Trunk Presentations with a Descent of the Arm. (Presentations of the arm or hand, of authors.)—We have heretofore Mode of seizing the feet in the second position of the left shoulder. 1 As the reader will see, this operation is very simple; though it must be acknowledged, however, that, in those cases in which the dorsal plane of the foetus is directed forwards, it renders this plane liable to be turned backwards after the evolution of the child. Con- sequently when we cannot succeed in turning the belly posteriorly during the traction, it OF VERSION. 777 stated that the descent of the hand in the shoulder presentations, is nothing more than an attendant circumstance of these latter. Consequently, whether the hand has been carried along by the gush of waters which escaped when the membranes were ruptured, or whether it has been drawn down by the accou- cheur himself, in order to make out the diagnosis, it constitutes an obstacle of minor importance, and even one which may render the pelvic version more easy; hence, so far from attempting to push back the arm into the uterus, we ought to apply a fillet on the wrist, not for the purpose of drawing upon the latter, but to prevent it from returning whilst searching after the feet in the ordinary way. " Our object in applying this fillet," says 31adame Lachapelle, "is to keep the hand at the exterior, lest the arm should take a wrong direction ; as also lest, being stretched out as it is, it will not follow the rotation that turns the sternum of the foetus posteriorly, when, by being arrested by the pubis, and by ascending along the child's back, it might become crossed behind the neck." Finally, let us add, that the hand, or rather the arm, materially aids in accomplishing the rotation of the trunk, since it offers an additional hold for the tractions made on the body, and obviates the necessity of delivering one shoulder, which is very often painful. After what has just been said, the reader will doubtless be astonished in look- ing over the older writers, to observe the alarm occasioned by the so-called pre- gives rise to all the inconveniences hitherto pointed out, as occurring in those instances in which the face looks towards the pubis. In order to remedy these difficulties and their attendant dangers, M.Velpeau recommends that the positions in which the back is in front (the first of the right shoulder, and the second of the left) be converted into the dorso-posterior positions before attempting the evolution. Thus, he would endeavor to convert a second position of the left shoulder into a first of the left, by making the head pass above the pubis, or above the promontory of the sacrum, according to whether it was originally placed nearer to the anterior arch of the pelvis, or to the right sacro-iliac symphysis; he would then terminate it, as if it had primitively been a first position of the left shoulder. " Should the membranes have been long ruptured," adds M. Velpeau, "the womb strongly contracted, and the child not to be moved but with very great difficulty, there is a third manoeuvre that ought then to be pre- ferred ; it consists in pushing the shoulder up with the right hand from behind forwards, as if to make the spine turn upon its own axis; then trying to reach the right side by passing along the front of the chest, while the womb is forcibly pushed backwards with the left hand ; lastly, in taking hold of the feet, the right one first, so as to bring them down in the first position."—Meigs' Translation, p. 447. We have alluded to this manoeuvre, only because the author's name might give it some importance in the eyes of young practitioners. But in our estimation it ought to be re- jected altogether. In fact, one of two things must then happen ; for either the uterus is forcibly retracted (when this conversion, if persisted in, appears to us impracticable and dangerous), or else the womb is inert, and it would therefore be useless. As we have already stated (page 768), the reason for dreading a-persistence of the child's anterior plane in front, is not because it cannot be turned backwards during the traction, but be- cause there is reason to fear lest the hea-d, by being arrested by the contraction at the fundus of the uterus, may not follow the movement of rotation impressed on the thorax, whereby a torsion of the neck might result. Again, if the organ is inert enough to admit of the preliminary conversion advised by Velpeau, it would doubtless be sufficiently so to enable the accoucheur to direct his tractions in such a way as to bring the occiput in front, and the face into the hollow of the sacrum, without hazard. i 778 DYSTOCIA. sentation of the hand or arm, and he will be still more surprised at the barbarous procedures employed by them for its management. They were evidently mis- taken with regard to the cause of the difficulties that are often met with in the performance of the version under such circumstances. However, it must be acknowledged that, although a presentation of the hand is nothing more than a variety of the shoulder presentation, yet the descent of the forearm, and more especially of the arm beyond the vulva, constitutes an exceeding unfavorable complication. Because, where this hangs down at the exterior, or nearly so, it must necessarily happen that the presenting shoulder is already forcibly engaged in the excavation; an engagement that can only take place when the whole of the waters have been discharged for some time, when the uterine contractions have been exerted for a long while on the body of the child, and when the walls of the womb have become firmly retracted on the surface of the fcetus. More- over, the prolonged contact of the foetal inequalities is then very apt to bring on the spasmodic or tetanic contractions of the body and the neck of the uterus, which are justly considered as constituting one of the most serious complications; for they equally prevent the return of the presenting part, the introduction of the hand, and the evolution of the foetus. Consequently, we are not to operate on the part that may present in these difficult cases; for a return of the arm into the uterine cavity is then impossible, and of little service; to draw on it strongly, under a hope of engaging the doubled up trunk in the excavation, and of making it perform a kind of artifi- cial evolution, is to commence a manoeuvre that cannot be carried through, and which must greatly augment the existing difficulties; to go in search of the other arm, so as to subsequently pull upon it with a view of making the de- scended shoulder return, presupposes an introduction of the hand, which would be almost as difficult as searching after the feet; and, lastly, to scarify the arm or amputate it, is a barbarous measure when the child is living, and most gene- rally useless when it is dead. We repeat, it is not there that the genuine obstacles to the delivery are to be found; but it is rather against the violent contraction of the body and occasion- ally of the neck of the womb, that we are to act, by employing the measures recommended above. Should these fail, the course to be pnrsued will neces- sarily vary, according to whether the fcetus be living or dead. If still living, and the mother's condition does not absolutely demand a prompt delivery, we should hope, and wait for a spontaneous evolution. (See Natural Labor.) But, if her life is seriously compromised, though the child be yet alive, its viability may be considered as destroyed, and embryotomy be resorted to. (See Em- bryotomy.) The reasons for this course will be still more urgent when there is a certainty of its death. THE FORCEPS. 779 CHAPTER II. OF THE FORCEPS. The forceps is a kind of pincers composed of two blades, very similar to each other, and which are specially intended to be applied on the bead of the fcetus. The honor of inventing this instrument has been attributed to several persons; but, at the present day, it is clearly established that the forceps was invented by a member of the family of the Chamberlens, who, during the first half of the seventeenth century, pursued the censurable course of holding it as a secret, by the aid of which they promised to terminate the most difficult labors. It would appear, however, that it soon became known to some of the English practitioners; for Drinkwater, who practised the art of midwifery from 1668 to 1728, made use of instruments which, if we may judge from the description given of them by Johnson, closely resembled those employed by the Chamberlens. In 1670, one of the Chamberlens came to Paris for the purpose of selling his secret; since, according to the account of Mauriceau, he had proposed to the king's chief physician to make known his instrument for a remuneration of ten thousand crowns. As Chamberlen believed his process was applicable to all cases, he unfortunately promised to effect the delivery in a woman whose pelvis was deformed to an extreme degree, and on whom 3Iauriceau had deemed the Caesarean operation to be necessary. Consequently, as the French accoucheur had foreseen, all the attempts of Chamberlen to accomplish the delivery proved ineffectual, and he returned to England, abandoning all the glittering hopes of fortune that he had expected to realize on arriving at Paris. It would seem that he afterwards made a journey to Holland, about the year 1693, and com- municated, or rather sold, some of his instruments to certain accoucheurs there, among whom Roonhuysen, Ruysch, and Bockelman, are particularly mentioned. In fact, it is almost certain that the famous lever of the former of these physi- cians had no other origin, and was only a slight and defective modification of the instrument he obtained from Chamberlen. However this may be, the for- ceps was likewise held as a secret for a long time in Holland, and it was not until sixty years afterwards, that is, about the year 1753, that Visscher and Van de Poll brought Roonhuysen's lever into general notice.1 Palfyn, an accoucheur of Ghent, has also been incorrectly considered as the real inventor of the forceps. He made several trips to London and Germany, with a view of finding out this wonderful secret; which, according to Mauriceau, had furnished Chamberlen an income of more than thirty thousand livres per 1 We may remark that the instrument described by these last-named authors, under the title of Roonhuysen's lever, was not the one which the latter had bought of Chamberlen, for it is composed of a single curved iron blade. In 1747, Rathlauw published a de- scription of an instrument that be had received from Van der Swam, a pupil of Roonhuysen, which was composed of two blades, having fenestra in them, and joined at their extremity by means of a pin. 780 DYSTOCIA. annum (an enormous sum for that period); and it is probable that it was in con- sequence of the information obtained in these two countiies, that he designed the draw-head (tire-tHe), subsequently presented by him to the Academy of Sciences at Paris.1 Chamberlen's forceps underwent a number of modifications after it became public property, that were generally unimportant; and fortunate indeed was it when the so-called improvements did not render it more awkward and dangerous than before. But the middle of the eighteenth century opened a new era in the history of this instrument; for, about this period, two illustrious obstetricians, Levret in France, and Smellie in England, were struck with the necessity of accommodating the shape of the forceps to the direction and form of the pelvic axis; and, as a consequence, they thus enlarged the field of its application. Chamberlen's forceps was straight, and therefore only applicable when the head was low down in the excavation, and close to the perineum; but both of these gentlemen endeavored to render it capable of being applied to the head when still above the superior strait; and for that purpose they gave it a curve in the direction of its long axis, so that the anterior border presented a concavity and the posterior one a convexity. It is impossible to ascertain which of the two had the priority in originating this important modification of the forceps; for, though it is certain that Levret had such a curved instrument in 1747, and that Smellie did not announce his until 1751, yet the latter expressly declares that he had invented it several years previously. Hundreds of modifications have been proposed since the days of Levret and Smellie, nearly all of which have fallen into oblivion ; some of them were quite ingenious, but they imperfectly attained the end their authors had in view; and others were really destitute of value or utility. Consequently, we shall restrict what we had intended to say concerning its history to these few lines, and shall only describe the forceps now generally used throughout France, which is none other than that of Levret, very slightly modified. The forceps is composed of two branches, each of which may be divided into 1 This presentation, made at a time when Chamberlen's forceps were scarcely known in France, unjustly obtained for Palfyn the reputation of being its inventor. But, in our day, the question can no longer be considered doubtful, for, independently of the numberless proofs that establish the claims of the Chamberlens, they have recently been confirmed, says Dr. Edward Rigby, by a discovery made in the county of Essex. It appears that Dr. Peter Chamberlen purchased, towards the end of the seventeenth century, the estate of Woodham, Mortimer Hall, near Maldon in Essex, which continued in the family till about 1715, and was then sold to Mr. Wm. Alexander, who bequeathed it to the Wine Coopers' Company. About the year 1815, the tenant in occupation discovered, in the floor in the uppermost of a series of closets, which are built over the entrance-porch, a trap-door. In the space between the flooring of this closet and the ceiling below were found, among a number of empty boxes, a cabinet, containing a collection of old coins, divers trinkets, many letters from Dr. Chamberlen to different members of his family, and some obstetric instruments. These instruments, which were given to Mr. Carwardine by the lady of the mansion, and described by Rigby, exhibit the successive attempts made by the Chamber- lens, before they succeeded in perfecting their forceps. THE FORCEPS. 781 three parts, namely: the blade, the handle, and the point of junction, or the lock. The blade is intended to be introduced into Fig. 109. Fig. 110. Fig. 111. the mother's parts, so as to embrace the head of the'fcetus; presenting, therefore : 1. A curvature on its flattened aspect, the in- ternal concavity of which is destined to be applied to the side of the foetal head, while its external convexity slips along the concave walls of the pelvis; 2. A curve on its edge, having the con- cavity anteriorly, which is made for the purpose of accommodating the form of the instrument to the direction of the pelvic axis; and to render an application of the forceps practicable even when the head is retained above the superior strait. The blade is usually provided with a fenestra, which serves to diminish the size and weight of the instrument, and has the further advantage of . . . ° 109. The male bvanch. 110. The female permitting the parietal protuberances to engage in branch, m. The forceps locked. the void thereby produced, which engagement compensates, to a certain extent, for the thickness of the branches. The old forceps were provided with a kind of bead around the periphery, and the internal face of the blades, which was made quite prominent, and was intended to obviate the slipping of the head. But the contusions of the scalp, produced by this raised border, have led to its removal, and those now in use have the inner surface of the blades polished down with a file. Both handles of the instrument are usually bent to a slight degree at their extremity, in the form of a hook. One of them is much more curved than its fellow; and has, near its end, a hollow button, which unscrews and serves for the lodgment of a sharp hook, while the curve of the other scarcely reaches a right angle, so that we find the forceps, a blunt and a sharp hook, in- cluded in the same instrument. The handles and blades are just alike on both branches, which differ from each other only at their middle or articular part, where one of them is provided with a pivot and the other with a mortise, made either in the middle or on the side of the instrument, by means of which they can be firmly locked after their application. The branch bearing the pivot has received the name of the male (Fig. 109), and the other, having the mortise, that of the female branch, or blade (Fig. 110). The delicacy of certain ac- coucheurs has been shocked by these denominations, and they have endeavored to substitute for them the titles of the left and the right blades ; but I cannot understand why the old names of the pivot blade and the mortise blade should not be retained ; though I would willingly accept those of the left and the right ones if it were clearly understood which ought to be called the left and which the right. But unfortunately such is not the fact, for M. Velpeau designates that blade as the right one which 3Iadame Lachapelle has called the left, and vice-versa. This discrepancy of terms creates great confusion in the mind of the reader, which we shall endeavor to avoid by retaining the names of the male and the female blades. some time since, Dr. Simpson proposed a new forceps, which deserves men- 782 DYSTOCIA. tion, if only on the score of its originality. Every one has seen those circular pieces of leather with which children lift bricks, by first wetting them and then pressing them strongly upon the brick. Now, the ingenious Edinburgh professor conceived the idea of applying a nearly similar piece of leather to the convexity of the child's head projecting into the excavation, and producing its adhesion to the scalp by exhausting the air from between them by means of a pump, the body of the pump also serving as a means of traction and drawing the head out- side of the genital parts. This instrument is very ingenious, but I doubt much whether it will ever come into general use. When the head is in the cavity of the pelvis, I think that the common forceps would be applied much more easily ; when it is high up, the application of Dr. Simpson's instrument would be very difficult, besides whieh, its form would give an improper direction to the first tractions. I would also add, that if violent tractions were necessary, it might cause a separation of the scalp and a dangerous effusion of blood. We shall divide our remarks on the subject of the forceps into three distinct articles : in the first of which will be found the precautions thnt ought always to be taken before proceeding to an application of this instrument; in the second, we shall point out the general rules applicable to all cases ; in the third, the direc- tions peculiar to each position, and shall close the whole by some general consi- derations on its employment and mode of action. ARTICLE I. PRELIMINARY PRECAUTIONS. The woman is to be placed in the position before recommended for the per- formance of version ; the lower extremities being supported by two assistants standing on the outside of the limbs, and having the pelvis firmly held, so as to prevent her from giving way to any involuntary movements that might annoy the operator; of course, the breech ought to be brought to the edge of the bed. The patient should be placed in this position whenever nothing particular pre- vents, and more particularly when the head is high up, though it is not so neces- sary when the latter is at the inferior strait. In fact, if she found it impossible to change her posture, we might permit her to remain horizontally on the bed; but it would then be requisite to employ the old straight forceps, or else resort to Smellie's, which is very short, and the blades slightly curved. The English practitioners place the patient on her left side, the position in which the women of their country are usually delivered, taking care, however, to bring the pelvis nearer to the edge of the bed than usual. An assistant, standing on the opposite side of the latter, holds the patient steady, while another raises up and supports the right knee and thigh. But whatever be the position, one attendant is parti- cularly charged with the duty of preparing and handing the blades to the accou- cheur, as he may want them. In order to spare the female the disagreeable sensation produced by an impres- sion of cold, it is customary to warm the instrument by dipping it into hot water. Some care is requisite not to leave it there too long, and, before using, it should THE FORCEPS. 783 be passed through the closed hand so as to be certain there is no danger of its burning the soft parts ; the external surface of the blades should then be smeared with butter, cerate, or oil, with a view of rendering the introduction more easy. Baudelocque has laid down a precept that has been followed by most succeeding authorities, and to which it is advisable to conform; namely, to exhibit the for- ceps to the patient, concisely explain to her its use, its object, and its mechanism, and to make her understand its harmlessness. " It has not been my fortune," says Madame Lachapelle, " to meet with any one who was not tranquilized by such an explanation, and I have often known persons in their second labor to solicit their application from having experienced the relief they afforded in the first." Everything being prepared for the operation, we must next ascertain the posi- tion of the head with the greatest possible care; for even though it had been recognized at the commencement of the labor, the former diagnosis ought to be confirmed by a fresh examination, lest the head may have changed its position since then. By this exploration, the size of the head, its reducibility, and its softness, the perfect or defective confirmation of the pelvis, the degree of con- traction, if any exists, &c, will be made out as far as possible; and, as the dila- tation or the dilatability of the os uteri is even more indispensable here than in the case of version, we must be certain that this condition exists. After which we are to proceed to the introduction of the blades. We shall pursue the course followed in studying pelvic version, first stating the general rules of the operation, and treating in another article of the peculiarities presented by each particular case. ARTICLE II. GENERAL RULES. 1. The instrument ought only to be applied on the head of the fcetus, whether the latter be flexed or extended, that is to say, in the vertex and face presenta- tions; or whether it alone remains behind, presenting by its base after the deli- very of the trunk. Certain obstetricians have recommended the instrument to be applied on the pelvis in the presentations of the pelvic extremity, where from any cause it may be desirable to terminate the labor promptly. But the bones of the pelvis are too deficient in solidity, and their articulations offer too feeble a resistance to be able to support the pressure made by the forceps without hazard. Besides, it would be difficult to get the breech in the hollow of the blades, with- out carrying their points above the iliac crests against the soft walls of the.abdo- men, thereby producing a more or less serious contusion of the abdominal organs. As a general rule, the breech presentations do not appear to me to warrant the use of the forceps. I am aware, however, that M. Stoltz recommends its em- ployment under such circumstances, and I am induced to believe that M. P. Dubois would not hesitate in resorting thereto, in some cases where direct trac- tions on the pelvic extremity might be difficult. 2. The blades should be applied as nearly as possible on the sides of the head, 784 DYSTOCIA. in such a way that the concavity of (heir margins shall be directed towards that part of the head which is to be brought under the symphysis pubis.—This rule is not always feasible, for it will be seen hereafter that it is impossible to carry it out in some cases of transverse positions, in which we are obliged to seize the head over the forehead and occiput; but these exceptions are rare, and the operator should endeavor to follow the rule in all cases. When the forceps is thus applied, each blade bears on the lateral parts of the cranium ; the parietal protuberances are found in the opening of the fenestrae, at the point where the blades are the most widely separated from each other; and the occipito-mental diameter corresponds very nearly to a line drawn from the extremity of the blades towards the pivot. 3. As a general rule, the posterior blade ought to be introduced first.—As the head is placed in a transverse or diagonal position in a vast majority of cases, one of its sides will look forwards and the other backwards, and, therefore, one of the blades will be at the fore and the other at the hinder part of the pelvis, since we have just seen that it is requisite to apply them on the sides of the head. Now it is the one that goes to the back part of the pelvis that we recommend to be generally introduced first. In theory, this is even admitted as the absolute rule, since it is considered to be the most generally applicable; for everybody acknowledges that the positions in which the occipito-frontal diameter corre- sponds to the left oblique one of the pelvis are the most frequent of all. But it must be borne in mind, that in practice there is no invariable law, and the one we lay down is subject to very numerous exceptions. If desirable, however, to establish a universal principle for the operation, we might say, that the blade, the application of which presents the greatest difficulty, ought to be introduced first. After all, it must be left to the skill and tact of the accoucheur to decide at the bedside of the patient which branch must be introduced first, for it is out of the question to anticipate, in a book, or even to imitate on the manikin, all the pecu- liarities that may there influence his decision. For instance, when the head is high up in the excavation, it would sometimes be better to reverse the rule, and introduce the anterior blade first. 4. The male blade is always to be held in the left hand, and is to be applied at the left side of the pelvis; the female blade is to be held in the right hand, and is a/ways to be applied at the right side of the pelvis. 31. Hatin has lately suggested a method which bears considerable resem- blance to that employed by Flamand in some exceptional cases. It consists in the introduction of both branches by the same hand. The left hand, prefer- ably, is carried to the fundus of the uterus, or at least to the parts to which the forceps are to be applied. The first branch having been introduced along the hand which serves as a guide, the latter, without quitting the head of the foetus, passes around it, and places itself on the opposite side, to receive and guide the second branch of the instrument. This process, represented by M. Hatin to be the easiest, and especially the least dangerous for both mother and child, does not appear to me to possess all the advantages claimed for it by Flamand and 31. Hatin. As 31. Stoltz judi- ciously remarks, it can have no advantage except when the head is movable, or THE FORCEPS. 785 Introduction of the first branch. previously rendered so, above the superior strait, in which case we have already seen that pelvic version is prefer- able, even though the pelvis be slightly contracted. When the head is wedged in the superior strait, or more or less en- gaged in the excavation, it seems to me that the ordinary process is incontestably superior. 5. The free hand, or the one not engaged in holding the blade, should ahcays be introduced first, so as to direct the latter.—When the head is at the inferior strait, it is usually sufficient to insert two or three fin- gers between the side of the head and the pelvis (see Fig. 112); but whenever it is high up, the entire hand must be introduced into the vagina, taking the precaution to place the ends of the fingers be- tween the head and the os uteri, so as to be certain that the blade, by slipping along the palmar surface of the hand will get into the uterine cavity, and not pass externally to the cervix, perforate the cul-de-sac of the vagina, and penetrate into the peritoneum. The convex surface of the blades glides along the palmar surface, and the convex margin along the cubital border of the hand; in a word, this previous intro- duction of the latter is intended to protect the vaginal wall from the contact of the instrument. 6. At what part of the pelvis should the blade be first introduced ?—This question has been variously answered : thus, Baudelocque directs it, in nearly all cases, immediately on the point where it is to remain after the locking. Levret (and 31. Velpeau adopts nearly the same view) recommends that the two blades be introduced at the posterior quarter of the pelvis; that, in the diagonal posi- tions, one of them be left in front of the sacro-iliac symphysis, but that the other be brought forward opposite to the cotyloid cavity which corresponds with the anterior side of the head, by making it traverse the whole lateral half of the pelvis from behind forwards. Lastly, Madame Lachapelle has proposed a mixed method, composed, in part, of both of the preceding: namely, both branches are first introduced in front of the sacro-sciatic ligament, and then the one which should remain posteriorly is pushed directly up to the sacro-iliac articulation; but the other is brought forward at once opposite to the cotyloid cavity in the following manner : " I insinuate the extremity of the blade just in front of the sacro-sciatic ligament; then, as it passes in, I gradually depress the handle be- tween the thighs, until it is inclined much below the level of the anus; by this manoeuvre, the point of the blade is made to describe a spiral movement, 50 786 DYSTOCIA. which is directed and completed by the fingers introduced into the vagina. By this movement, the blade is carried upwards and forwards at the same time, so that it is made to pass around the head in an oblique direction, which would be represented by a line extending along the interior of the pelvis from the sacro- sciatic ligament to the horizontal branch of the pubis." This mode of procedure is also adopted by M. P. Dubois, and is the one which appears to us the easiest of all. It should be understood, however, that it is only applicable when the head is already engaged in the excavation. The reader will see, hereafter, that above the superior strait the branches are applied on the sides of the pelvis with- out any particular reference to the position of the head. Finally, some of the German accoucheurs recommend the blades to be placed on the sides of the pelvis in all cases, without regard to the position of the head. This precept is followed as a matter of necessity when the head is high up. But when engaged in the excavation, it will be found better in the majority of cases to follow the rule which we have given. 7. The second blade is always introduced above and in front of the first; so that, in some instances, the male branch is found over the female one, as in Fig. 113 ; /. e., between it and the symphysis pubis. It will then be necessary, in locking the blades, to cross the handles, by making the female one pass above the male. Attempts have been made of latter time to avoid this crossing, and a particular kind of forceps has been devised by Tureaux, Tarsitani, and some others, for the purpose, which can be made to lock whatever may be the re- lative position of the handles. Fig. 113. Introduction of the second branch. ting it in a slight degree. This is doubtless an advantage, but its importance has cer- tainly been greatly exagge- rated. 8. No force should ever be used in pushing the blades up. —The obstacles met with du- ring their introduction are near- ly always created by folds of the scalp or vagina, in which the point of the blade becomes en- tangled; or else the difficulty is owing to the circumstance that the blade, being improperly di- rected, is not pushed up in the line of the pelvic axis, and con- sequently strikes against the va- ginal walls. These are easily obviated by varying the direc- tion of the instrument a little, or by carrying its handle to- wards one or the other thigh, and by depressing or eleva- Force is always useless and may be injurious. Thus, THE FORCEPS. 787 the two branches the mortise (Fig. if the point of the male blade was arrested by a fold of the scalp, the instru- ment should be partially withdrawn, and its handle be carried towards the right thigh, whereby the extremity of the blade would be somewhat removed from the head, and could thus pass beyond the obstacle; but if, on the contrary, it were arrested by one of the transverse folds of the vagina, the handle should be car- ried towards the left thigh, so as to make the point rest against and slip over the head. The introduction of the second branch is generally the most difficult, and the difficulty is generally greatest when it is necessary to introduce it the first. When attempts, prudently made, prove fruitless, there should be no hesitation in withdrawing both branches, and beginning again with the one which before was introduced last. It were much better to renew the operation two or three times, than to strive pertinaciously against difficulties which could never be surmounted without endangering to a greater or less extent the life of the fcetus, or the inte- grity of the maternal organs. In withdrawing the branches, they should be made to describe a curve the opposite of that which they followed during their introduction; the handle of the male branch, for example, should be gradually raised above the pubis, and reclined obliquely upon the left groin. 9. In general, the locking is easily effected, by bringing together after their introduction and adjusting the pivot in 114), when an assistant turns the former; but this part of the operation demands a perfect parallelism between the two portions of the forceps which, unfortunately, does not always occur. For it frequently hap- pens that the pivot does not fit into the mortise exactly, either because one or both blades are turned outwards, or because one has penetrated deeper than the other. In the former case, we should endeavor to correct the deviation gently, by grasping the handles with the whole hand, and in the latter by withdraw- ing or pushing up one of them. But in none of these attempts should much force ever be used; for when considerable difficulty is met with, it is probably owing to an improper adjustment of the instrument, and it is far better to extract one or even both blades than to force their locking. 10. We must be satisfied that the head is properly secured, and that it alone is included in the clams of the instrument.—To be convinced that no part of the mother's organs is pinched between the head and the forceps, it is only requisite to make a moderate pressure on the handles, after the locking, when, if the patient does not complain of pain, the operation may be continued without The forceps applied and locked. 788 DYSTOCIA. danger; if the contrary is the case, the forceps ought to be unfastened, and the included part be removed by the finger. A few gentle tractions made by the forceps, without compressing the head too much, will serve to show whether the latter is properly secured, and that the instrument does not slip. 11. The tractions ought to be made in the direction of the pelvic axis.—If the bead is at .the superior strait, we must first draw downwards and backwards as much as possible; then, as it descends into the excavation, the handles are gra- dually elevated, so that, by the time it reaches the inferior strait, they are found directed forwards and somewhat downwards ; and the tractions will then be made in this latter direction. But, whilst the head is undergoing its movement of extension, the instrument must be carried up in front of the symphysis pubis, and afterwards of the abdomen, so that, after the complete delivery of the head, the forceps shall be lying almost horizontally over the woman's belly. In performing the tractions, the right hand is placed near the clams and above the instrument, the left hand in front of the articulation and beneath. But, as soon as the disengagement is to be effected by raising the instrument above the pubis, the position of the hands must be changed, and the left one always be placed in front of the pivot, but above, and the right one below the extremity of the branches. The tractions are to be made during a pain whenever possible, and the patient should be encouraged to bring the abdominal muscles into play, in aid of the uterine contractions and the efforts of the accoucheur. As soon as the head has cleared the inferior strait, and when it only has the resistance from the soft parts to overcome, the vulva being at the same time freely dilated, all tractive force should, as a general rule, be abandoned, and the rest be left to the powers of nature ; for the mere presence of the head at the external parts, by the tenesmus it gives rise to, will most certainly bring on a sufficient degree of contraction to effect the delivery. Be satisfied, then, with facilitating the process of extension, by carrying the handles up in front of the pubis during the mother's bearing down efforts; the dilatation of the vulva, being thus slow and gradual, will be accomplished with- out any danger of rupture, especially if you are careful to sust an the perineum, or, still better, to have it supported by an assistant; for, had you continued the tractions, such a rupture could scarcely have been avoided. 31adame Lacha- pelle even advises the instrument to be withdrawn altogether; but I think it is better to leave it in situ, for the double interest of the patient and the accou- cheur; of the patient, because, in some cases, a few tractions may yet be neces- sary; and of the physician, because, if he remove the forceps from prudential motives, and with a view of saving the parts, before the final delivery of the' head, he might be regarded by the woman and her attendants as a bungler, who had failed in his operation. He should, therefore, leave it applied, and allow the patient to expel it and the head together. In cases attended with difficulty, we might doubtless draw on the handles with a certain amount of force; but the example of some practitioners who, taking a point of support by placing a foot against some solid body, hang, as it were, on the handles of the forceps, and then pull away with ail their strength, should never be followed. It is only necessary to use the arms, and the operator should THE FORCEPS. 789 take such a position that his body would always arrest any sudden slipping of the blades. In fact, it is this precaution which sometimes renders an application of the forceps so excessively fatiguing to him. 12. In the oblique or transverse positions, snch a movement of rotation is to be imparted to the head as shall bring the concave margin of the blades directly in front.—This rotation ought to be performed during the tractions, just as the head is approaching or clearing the inferior strait. But there' is no occa- sion for any violent exertions, for most generally the head turns in its descent, carrying the instrument along with it in the rotation. Sometimes, also, an appli- cation of one or both blades is all that is necessary to effect this change. ARTICLE III. SPECIAL RULES. We have already stated that the forceps may be applied in the vertex and face presentations, and on the head when left behind after the delivery of the trunk. Its application is, therefore, to be studied in these three varieties; and, as the greater or less elevation of the head greatly influences both the course to be pur- sued and the degree of facility with which the operation is accomplished, we ghall examine those cases successively in which it has reached the inferior strait, in which it is still engaged at the superior strait, and in which it is entirely above the latter. § 1. Application of the Forceps in Vertex Positions, when the Head has reached the Inferior Strait. The vertex, having descended to the inferior strait, may be found in corre- spondence with the various points of its circumference; and, therefore, to meet every possible case, we shall have to admit eight principal positions of it: thus, the occiput may be in relation with both extremities of the coccy-pubal diameter (the occipito-anterior and the occipito-posterior positions) ; with both extremities of each oblique diameter (the left anterior and the right posterior occipito-iliac, and the right anterior and the left posterior occipito-iliac positions) ; and with both extremities of the transverse diameter (the left and right trans- verse occipito-iliac positions). A. Occipito-anterior Position.—In this position, the occiput is placed behind or under the lower part of the symphysis pubis; the sides of the head corre- sponding to those of the pelvis. The male blade will here be introduced first, because it will be found underneath in the locking. Two or three fingers of the right hand having been passed into the vagina, this branch is seized by the left hand, either with the fingers, like a writing-pen, or, still better, with the whole hand (though in both cases close to the pivot), and it is held inclined obliquely over the right groin; the point of the blade is then entered at the vulva in the direction of its axis, and is slipped up along the palmar surface of the fingers; as the blade is passed into the vagina, the handle is gradually de- pressed between the woman's thighs (of course, always approaching towards the median line) in such a way as to direct the point of the blade in the direction of 790 DYSTOCIA. Fig. 115. the axis of the excavation. The blade is thus directed at once upon the side of the head, and along that of the pelvis, where it is ultimately to be placed. While this manoeuvre is being effected, the convex border of the blade ought to rest upon and glide along the ring finger of the right hand, which is in the vagina, whilst at the same time its concave surface should bear exactly on the convexity of the head, and follow its outline. The female blade is then introduced in the same manner precisely. Two or three fingers of the left hand are first passed in on the right side of the pelvis; the branch being held obliquely by the right hand in front of the left groin, with its point resting on the palmar surface of the left hand, is presented at the vulvar orifice; and, as its extremity is made to enter, the handle is depressed, and brought towards the median line by degrees, the blade being thus passed up on the right side of the pelvis, with the same precautions as in the former case. When both blades have penetrated to the same depth, they ought to be parallel with each other, the pivot corresponding to the mortise exactly; and the locking is then completed without diffi- culty. As the head is at the inferior strait, the first tractions will have to be made in the direction of the axis of this strait, that is to say, a little down- wards and forwards; then, as soon as the occiput has passed under the sub- pubic ligament, and the head has commenced its movement of extension, the instrument is to be gradually carried upwards in front of the symphysis and abdomen. B. Occipito-posterior Position.—The blades are applied and locked as in the preceding case. But here, notwithstanding the head is at the inferior strait, we are not to draw in the line of axis of this strait; because, in these occipito-poste- rior positions, the occiput has to be delivered first at the anterior perineal com- missure. (See Natural Labor.) To effect this object, it is necessary to carry the handles a little upwards at the very outset of the tractions, so as to flex the head on the chest more completely; being careful to operate in such a way that the artificial aid may bear particularly on the larger extremity of the head. When the occiput has gained the perineal commissure, the traction is discon- tinued, or rather, if there is any further occasion for it, we may draw mode- rately, at the same time depressing the handles of the instrument towards the anus. C. Left Anterior Occipito-iliac Position.—In this position, one side of the head looks forward and to the right, the other backward and to the left; and the blades are to be applied in a corresponding manner on the sides of the head. The posterior blade, which should be entered first, will at the same time be on the left, and, therefore, the one that is always passed on the left side of the pelvis, that is to say, the male blade, will be introduced first. This is held in the The forceps applied on the child s head in the occipito-anterior position, at the inferior strait. THE FORCEPS. 791 Fisr. 116. left hand just in front of the right groin ; and its point, placed in front of the left sacro-sciatic ligament, is to be pushed directly backwards as far as the sacro- iliac articulation, whilst the operator depresses the handle and draws it towards the median line. In carrying the handles down between the mother's thighs, it is highly important to keep the blade slightly everted. Being once intro- duced, the handle is given to an assistant, who holds it near the internal surface of the left thigh. The female blade is to be placed behind the right cotyloid cavity, where the side of the head is found, by making it describe the spiral movement alluded to when speaking of the general rules of the operation. The operator accomplishes this by taking it in the right hand, in the usual way, and entering the point of the blade just in advance of the right sacro-sciatic ligament; then, pushing it in this direction for about an inch, he suddenly changes the position of his hand so as to get hold of the instrument from above, when, by strongly depressing its handle along the internal surface of the left thigh, he makes the blade execute a see-saw movement, by which it is at once carried from the right sacro-sciatic ligament up opposite to the cotyloid cavity of the same side; and then the locking is effected. (Fig. 116.) During the early tractions he should endea- vor to rotate the head so as to bring the oc- ciput behind, and then under the symphysis pubis. The rest of the operation is completed as in the first variety (a). D. Right Posterior Occipito-iliac Position, —The forceps are applied here exactly in the same way as they were in the preceding case; the blades being entered, the one behind and to the left, the other in front and to the right (see Fig. 116); their concave margins look- ing towards the forehead. As this latter part must be brought in front, the object of the rotation will be to get it behind the sym- physis pubis, and the occiput into the hollow of the sacrum;1 and the labor is then terminated just as in an original occipito-posterior position (b). Application of the forceps in the right posterior occipito-iliac position. (4th posi- tion.) !No attempt should be made, in the occipito-posterior positions, to bring the occiput in front; for although it is true that this movement is accomplished in natural labors,yet in them the trunk, on which the contraction of the womb is still exerted, participates in the rotation of the head. But, should we attempt to imitate this movement by the forceps, it is nearly certain that the child's body would be so firmly retained by the retracted uterus that it could not participate in the rotation, and that an excessive twisting of the neck, with the mortal lesions following in its train, would be the almost inevitable consequence. There- fore, as a general rule, the forehead should be brought behind the symphysis pubis; but this is not always possible, as the following case of my own will exemplify. A young woman, pregnant with her first child, having reached her full term without ac- cident, was taken with her first pain on the 29th of October, at nine p. m. The pains, though feeble, were yet so frequent as to prevent her sleeping. At six o'clock on the morning of the 792 DYSTOCIA. E. Right Anterior Occipito-iliac. Position.—In this case, the female blade is entered just in advance of the right sacro-iliac articulation. Then the male 30th, I found the neck completely effaced, and the thinned edges circumscribing an orifice of about the size of a dime. The pains occurred every ten minutes. I found the vertex presenting, but could not make out the position. The pains continued all day, the 30th, but quite as feeble and distant. At four o'clock in the evening they became stronger and more frequent, and at eight o'clock, the diameter of the orifice was rather less than that of half a dollar. The membranes being flattened and applied closely to the head, enabled me to dis- cover the biparietal (coronal) suture running directly from before backwards, and on several different occasions I distinctly felt the anterior fontanelle presenting directly forward and corresponding nearly with the upper third of the posterior surface of the pubis. I had to deal with what had never before occurred to me, a direct occipito-sacral position, engaged in the upper third of the excavation. I hoped in vain for its spontaneous conversion into a posterior diagonal position, for, notwithstanding very frequent and powerful contractions, things were still in statu quo the next day, the 31st, at six o'clock. The orifice was at this time dilated to the size of a dollar. At noon, the dilatation was almost complete, and fi- nally, at two o'clock, the head assumed a diagonal position. I detected very positively the anterior fontanelle in front and to the left, and hoped that the movement of rotation would continue. I was doomed to be disappointed. I then ruptured the membranes, but this was followed by the escape of but a few spoonfuls of fluid. At four o'clock, the anterior fon- tanelle had approached, I thought, somewhat nearer the left extremity of the transverse diameter, and I encouraged the poor patient to believe that her labor would soon be termi- nated ; bnt, unfortunately, instead of continuing to pass backward, the anterior fontanelle underwent a movement in the opposite direction, and, notwithstanding all my efforts to push it back, it again came forward, and fixed itself opposite the horizontal ramus of the pubis, from which it did not stir afterward. At ten o'clock in the evening, things being in the same condition, I determined to apply the forceps, as much in the interest of the mother whose strength was exhausted, and who begged me to deliver her, as in that of the child. The head was then very near the inferior strait, and the forceps were applied without difficulty upon its sides. I made traction, with the object of disengaging the occiput in front of the perineum, but the contractions were feeble, and the woman being exhausted with fatigue, was unable to assist the efforts of the uterus, and being thus reduced to the mere tractions with the instrument, I could not make the head advance. In spite of all my efforts, I was unable to overcome the great resistance of the perineum which was very thick and unyielding, so that my attempts were altogether fruitless. If I abandoned the operation, I had nothing to rely upon but the resources of nature, which here were, unfortunately, powerless, or else the performance of craniotomy. I had wailed long enough to test the pow- ers of the organism, besides which, a more prolonged expectation would not be devoid of danger to both the mother aud child. Therefore, before deciding on craniotomy, I deter- mined to try whether it would not be possible to bring the occiput in front. I left off the tractions, and rotated the forceps on its axis, and carrying the head along in this movement, 1 had soon directed the concavity of the edges of the instrument toward the internal surface of the left thigh. I then withdrew the instrument and found that the longitudinal suture was directly transverse. Introducing the female branch behind and to the left side, I used it as a lever, and succeeded with it in bringing the occiput almost directly behind the right acetabulum. The male branch was then placed behind the left acetabulum, and the forceps being locked after uncrossing the branches, I brought the occiput first behind, then beneath the symphysis pubis, and finished the extraction of the head by the usual movement of extension. The child was born in an evident state of congestion. I allowed the cord to bleed be- fore tying it, and it was soon restored. Two weeks afterward it was strong and well. The lying-in was unattended with accidents and the mother recovered quickly. The whole duration of the labor was fifty hours. THE FORCEPS. 793 Fig. 117. blade is introduced in front of the left sacro-sciatic ligament, and is made to describe the spiral movement before indicated, by which it becomes placed opposite to the left cotyloid cavity. The movement of rotation will be effected from right to left, and the occiput be brought under the pubic arch. F. Left Posterior Occipito-iliac Position---The blades are introduced in a similar order, and in the same way, as the preceding case. The movement of rotation is also effected in the same direction, but here it will bring the forehead instead of the occiput behind the symphysis. The handles of the instrument are next carried up a little in front of the pubis, with a view of freeing the occiput first at the anterior perineal commissure. After this is accomplished, the handle is to be depressed towards the anus, so as to assist the head in its movement of extension. G. Left Transverse Occipito-iliac Position.—In this variety, the occiput corresponds to the left extremity of the transverse diameter of the pelvis; one side of the head looks directly forward, and the other backward. Here also the posterior blade is to be introduced first: now to distinguish which will be the posterior one under such circumstances, we must ascertain to what part of the pelvis the present posterior side of the head will correspond after the rotation shall have been completed. As this process of rotation, in the transverse positions, must always bring the occiput in front, the left, or posterior side of the head, will then look towards the mother's left ilium, and consequently the left or male blade is entered first. This blade is, therefore, pushed towards the left sacro-iliac articulation, and when it has penetrated to the proper depth it is pressed into the hollow of the sacrum by bearing on its concave mar- gin with the fingers already in the vagina. The female blade is next to be passed up by means of a spiral movement, behind the right acetabulum; and then the hand in the parts must endeavor to work it towards the median line, by pressing on its convex margin, so as to get it just behind the symphysis pubis. From the extent of the rotation to be effected, of course the accoucheur must be very careful to operate slowly and gently. When the head is in a tranverse position, it is occasionally still high up in the excavation, even though it has, in a great measure, cleared the superior strait; and when this occurs, it is often exceedingly difficult to apply one of the blades in front and the other behind; in some cases even we are obliged to enter them on the sides of the pelvis, that is, to seize the head by the forehead and occiput. This is always an unfavorable circumstance; although it may possibly happen that the mere application of the instrument will be sufficient to give the head an oblique or even a direct antero-posterior direction ; and when this movement does not take place at the time the blades are entered, it is often effected after- The forceps applied and locked in the left transverse occipito-iliac position. 794 DYSTOCIA. wards by their locking, or during the first tractions. Again, when the forceps is thus applied, the head may occasionally clear the inferior strait in a transverse position; but, having reached the vulvar orifice, it then turns between the blades, or as I have several times observed, carries the instrument along with it in the movement, of rotation, in such a way that, when the occiput is turned forwards, the concave border of the blades looks towards one side. In this latter case, some practitioners recommend the instrument to be withdrawn as soon as the head has nothing but the resistance of the soft parts to overcome, and, if neces- sary, to reapply them to the sides of the head. I think it would be better to remove the forward or sub-pubic blade only, for its presence might retard the process of extension, but to leave the perineal one applied, because, in case of necessity, it may act as a lever in facilitating the extension. The difficulty experienced in applying the forceps on the parietal protube- rances in the transverse positions engaged in the excavation, often becomes (see hereafter) an impossibility, when the head is arrested at the superior strait or above it. To render the biparietal application possible, 31. Baumers, of Lyons, has constructed a new forceps, which I have had occasion to try, and which appears to me to overcome the difficulty mentioned. I am convinced that the biparietal application of the blades, which is impossible with the ordinary forceps, is sometimes easy with that of 31. Baumers, and I think it right to recommend their application in the transverse positions. They differ from Levret's forceps in being curved on the side instead of the edge, so that the general curvature of one of the branches is concave, and that of the other convex. (For further details respecting this instrument and the mode of applying it, see the Gazette Medicate des 14 et 21 juillet, 1849.) This modification of 31. Baumers is altogether similar to that suggested by Uytterheoven. This Belgian surgeon, it is stated by 31. Van Huevel, con- structed, forty years ago, a forceps with the blades curved forwards on their sides, as the others are on the edges. (See the Atlas accompanying the Belgian edition of this work, Fig. 194.) H. Right Transverse Occipito-iliac Position.—In this position, the applica- tion of the forceps scarcely differs from the one just described, excepting that the female branch is introduced first, and the movement of rotation is to be made from right to left, and from behind forwards. When the occiput gets behind the symphysis pubis, the labor is to be terminated as in the preceding case. § 2. Application of the Forceps in the Vertex Positions, where the Head is merely engaged at the Superior Strait: Whenever the head is engaged or locked in the superior strait, and the ver- tex occupies the whole upper part of the excavation, the rules for guiding us in the application of the forceps are the same as those already laid down for its use at the inferior strait. We must remark, however, that its elevated position renders an introduction of the whole hand into the vagina more necessary than ever; that the points of the fingers ought to be carefully placed between the head and the cervix uteri, so as to direct the blade, which is slipped along the palmar surface of the hand, directly into the uterine cavity; that, as it is higher up than usual, the blades are to be pushed further in, in order to grasp it freely; the forceps. 795 and lastly, that, as the head is not yet clear of the superior strait, the first tractions must be made in the direction of the axis of that strait, or in other words, as far backwards and downwards as possible. But, although the theoretical precepts remain unchanged, it must not be sup- posed that the difficulties are no greater here than in the former case; for the elevation of the part renders the application of the forceps more difficult and less certain, as it is not an easy matter to apply the blades on the sides of the head, in the oblique and more especially in the transverse positions. In a word, the higher up it is, the more likely are we to encounter those difficulties and dangers about to be described in applying the instrument on a movable head above the brim of the pelvis. § 3. Application of the Forceps in the Vertex Positions, when the Head is movable above the Superior Strait. There are many circumstances that may require the intervention of art, even while the head is still above the superior strait; and, as the nature of these causes of dystocia may have a bearing on the operative procedure for terminating the labor, we must here take them into consideration. The intervention of our art may be rendered necessary by any accident that endangers the life of the mother or child, such as hemorrhage, convulsions, or a descent of the cord, &c, as also by a contracted pelvis or an excessive volume of the head. In the latter case, a resort to the forceps is proper, provided the dis- proportion between the pelvic dimensions and the size of the head be not very great; since it has elsewhere been shown (see Deformities of the Pelvis) that, whenever the smallest diameter of the pelvis amounts to three inches, there is reason to expect that delivery can be effected by means of the forceps. The question arises, whether version or an application of the forceps is to be resorted to in those cases in which the pelvis is properly formed, but some acci- dent has taken place that requires a speedy termination of the labor ? Under such circumstances, we do not hesitate to recommend pelvic version; but, as this is not the universally received opinion, we extract from Madame Lachapelle the following reasons on which we ground our preference : " An application of the instrument upon a head which is still above the supe- rior strait is both a difficult and a dangerous operation. Difficult, lst, because its elevation renders the diagnosis of the position obscure, and often leaves us operating in the dark; 2d, from its mobility it escapes from the forceps, and, not unfrequently, it is merely held by the points or margin of the blades; so that, as soon as any resistance is met with from the first tractive efforts, it slips out just like a cherry-stone when squeezed between the fingers; and, 2d, because at this height it is impossible to apply the blades on the sides of the head, since the latter is usually found either in an oblique or in a transverse position. Now, to conform to the rule generally laid down, we should apply one blade in front and the other behind, but this is obviously impracticable, for the curvature of the pelvic axis prevents the forceps from passing far enough in, unless the blades are introduced along the sides of the pelvis.1 Dangerous, because the hold on the head, being 1 When an attempt is made to apply them over the parietal regions, the perineum presses the instrument forwards, and gives it such a degree of obliquity with regard to the superior 796 DYSTOCIA. very imperfect, in consequence of the difficulties just enumerated, the instrument may slip; and, should such slipping take place while we are making strong trac- tions on the handles, the edges of the forceps, acting like a cutting instrument, might seriously wound the cervix." We, therefore, prefer version in the case under consideration. However, there is one instance which might demand the use of the forceps; that is, where the uterus is so contracted on the child's body after the discharge of the waters, as to render an introduction of the hand or an evolution of the foetus absolutely impos- sible ; but fortunately, in such a case, the head would be so firmly held at the strait, during the strong contractions of the organ, as to be nearly immovable. On the whole, then, the application of the forceps above the superior strait should be limited to those cases of pelvic deformity in which the shortest dia- meter of the pelvis does not exceed three to three and a quarter inches, and to those in which the uterus is firmly contracted. Mode of Application.—Unless the position is directly antero-posterior, which is extremely rare, no attempt should be made to apply the blades upon the parietal protuberances, but they should be passed along the sides of the pelvis. It is, however, very unusual for this precept to be followed in practice, and for the blades to be really placed upon the two extremities of the transverse diameter; when the head is diagonal, the blades are naturally directed toward the two ex- tremities of one of the oblique diameters. Now in the directly transverse posi- tions, this is what generally happens, even when the surgeon wishes to place them at the sides of the pelvis; for at this elevation, and especially in the sacro- pubic contractions, which are the most common, the head is almost always in a transverse position; now, according to the remark of Ramsbotham and of Simp- son, and notwithstanding the formal precept always to apply the blades to the sides of the pelvis, it is found after delivery that the head has not been seized from the forehead to the occiput. The marks of the blades are almost always to be discovered upon one of the occipital protuberances and the parietal projection opposite. It is natural, in fact, if the head is transverse, for its long diameter to correspond with the transverse diameter of the pelvis. Now, as the latter is narrowed from before backward, the blades can be applied readily, only by direct- ing one of them behind the acetabulum, and the other in front of the sacro-iliac symphysis, which are the only points not occupied by the head. This, there- fore, is the direction which should be given them in all cases. As soon as the forceps are applied, it would in most cases be advisable to tie strait, that there is not room enough between the fenestra? for the reception of the smallest- sized head The latter, being placed above the abdominal strait, has its long diameter situated very nearly in the line of the axis of that strait; but as the long axis of the head ought to correspond with that of the blades, it therefore follows that the forceps must be introduced in the direction of the axis of the upper strait; and, consequently, that the articular part of the instrument is to be depressed beyond the point of the coccyx. But the perineal resistance will evidently prevent this, where one blade is entered behind the pubis and the other in front of the sacrum. Therefore, we are obliged to introduce the blades along the sides of the pelvis; that is, to seize the head by the forehead and occiput in the transverse positions, and by the coronal and occipital protuberances in the oblique positions. M. Baumer's instrument might in some cases overcome these diffi- culties. THE FORCEPS. 797 the handles together before drawing upon them. At first, the tractions should be made as far back as possible, and the instrument ought to be gradually brought forward as the head descends into the excavation. The head, seized by one coronal boss and the opposite occipital protuberance, will soon reach the inferior strait. In thus traversing the whole excavation, the head may possibly turn within the blades and become converted into an antero-posterior position; but it may also happen that this spontaneous version does not take place at all. If, therefore, the obstacle exists at the superior strait alone, and the uterine forces appear adequate to the prompt termination of the labor, we may withdraw the instrument and trust the rest to nature. But in other cases I think it would be proper to endeavor to transfer the blades to the sides of the head, or even to re- apply them in accordance with the precepts before given for their application at the inferior strait. It is evident that, with the assistance of Baumer's forceps, the latter inconvenience would be avoided. § 4. Application of the Forceps in the Face Positions. When the face presents, an application of the forceps may become necessary. either when the head has descended to the inferior strait, when it is engaged at the superior one, or when it is still movable above the brim of the pelvis. 1. When the Head istat the Inferior Strait.—If both the head and the pelvis retain their usual size, the face can only reach the perineal floor by descending with the chin directly forwards, or nearly so. (See Mechanism of Face Posi- tions.) As the application of the forceps in these three different cases does not differ in the least from that described in the corresponding vertex positions, we deem it useless to pass over the same ground. But the face, without having reached the perineal strait, may, nevertheless, be low down in the excavation; and the process of rotation, whereby the chin should be brought under the pubic arch in all cases, may not have commenced at all, or it may either be partially accomplished or fully completed. We might, therefore, have to apply the forceps in a mento-anterior or pubic, in a left or a right anterior mento-iliac, or in a left or a right transverse mento-iliac position. Since it is absolutely necessary, in the face positions, for the chin to come under the pubic arch, the instrument is always to be applied with its concave edges looking towards the chin, taking care to introduce the posterior blade first. By way of example, let us suppose that the face is situated in a left anterior mento-iliac position, and is low down in the excavation. Here, in conformity with the directions before given, the male blade will be placed posteriorly and to the left, near the left sacro-iliac articulation, and the female blade just behind the right anterior arch of the pelvis; when locked, the concave edges of the blades will look forwards and to the left. The rotation is then effected from be- hind forwards, and from left to right, so as to bring the chin behind the sym- physis; and when this is accomplished, we draw directly forwards, and a little downwards, in order to free this part from the pubic arch; and then, after having secured its delivery, the handles are gradually carried up, at the same time drawing moderately, with a view of promoting the flexion and disengage- ment of the head. 2. When the Head is at the Superior Strait.—The face may be found in 798 DYSTOCIA. every possible relation with the different parts of this strait. Should the chin correspond to any portion of its anterior half, the forceps may be applied without i Fig. 118. Fig. 119. Application of the forceps in the left anterior Application of the forceps in the mento- mento-iliac position. (First position of the face ) posterior position. any particular difficulty ; but if the face is in a mento-posterior position, the pelvic or cephalic version, whenever possible, ought to be chosen in preference (see page 647). For when the forceps is once applied, the object would evidently be to bring the chin behind the symphysis pubis; but, as the body is probably held motionless by the contraction of the womb, it will not participate in the rotation of the head produced by the instrument, and hence luxation would occur at the joint between the first and second cervical vertebrae, which does not admit of movement beyond a quarter of a circle. When the face is situated in a mento-posterior position, and has descended so far into the excavation that it is altogether impossible to return it above the superior strait with a view of performing the cephalic or the pelvic version, the use of the forceps becomes a matter of necessity. Under such circumstances, we should therefore apply them for the purpose of relieving the mother from her threatened danger; not, as we observed in the preceding editions, to bring the chin in front, but merely with the intention of flexing the head, and converting the face position into one of the vertex. To accomplish this, the blades are to be placed on the sides of the head, and in operating, the handles should be de- pressed as far backwards as possible, so as to act chiefly on the vertex, until the occiput is brought down under the pubic arch; if the chin were directly pos- terior, such a movement of rotation might be given to the head, prior to any tractive effort, as would carry the former into the great sciatic notch on one side or the other. This appeared to me the most feasible operation some years ago. I observed, however, that, according to 31. 31ascarel (Thesis, page 84), 31. P. THE FORCEPS. 799 Dubois has proposed another; or rather he inquires whether it would not be pos- sible to convert a mento-posterior into a mento-anterior position. It may be objected, he continues, that, if the head is forced to undergo too great a rota- tion, and the body does not turn simultaneously, the child's neck would be twisted; but as the only thing to be done, if this will not answer, is to per- forate the cranium, and consequently to sacrifice the infant, he considers the former measure preferable; more especially as the chin might escape under the ischio-pubic ramus, without the necessity of getting it exactly beneath the pubic arch. I know that this method has sometimes succeeded, and 31. Blot informed me quite recently, that he had delivered three times, by bringing the chin in front. It may be that the shape of the instrument is, in this case, one of the prin- cipal causes of the difficulty met with, and that the use of a straight forceps would render the manoeuvre much easier. This advice, given I believe by M. P. Dubois, deserves to be taken into consideration. In 1850, 31. Danyau read a paper before the Academy, in which he gave preference to this operation; he recommended, however, that, unless the straight forceps are used, the curvature of the edges should be turned toward the chin, as was practised by Campion. He claims to have succeeded several times, and even to have delivered children alive. Still more recently M. Danyau and myself succeeded in bringing the chin in front by the use of the forceps, the child remaining alive. In this case, it is true that the face had begun to rotate, so that when the instrument was ap- plied it was quite near the right extremity of the transverse diameter. Facts of this nature have so accumulated, of late years especially, that they can no longer be regarded as exceptional; and, if the chin corresponds exactly with the sacro-iliac symphysis, especially if it has already undergone a slight move- ment forward, there is reasonable ground to hope that the spontaneous rotation thus begun, will second that impressed by the forceps upon the chin, and the extraction be accomplished with the chin to the pubis, the body, in consequence of the contractions of the womb, having partaken of the motion communicated by the instrument to the head. It must, however, be remembered that, in direct mento-posterior positions, this excessive rotation is likely to kill the child; and such a case I have already quoted. Besides this, it must especially be borne in mind that, however skilful the operator, it has often proved impossible. Messrs. Dubois, Danyau, Cazeaux, and many others have failed ; and Smellie himself, who long since advised bring- ing the chin forward, was often unable to succeed. On consulting the voluminous record of observations published by Smellie, I have found but four cases in v which the face was deeply engaged in the pelvic cavity in a mento-posterior position. In all these cases, he first tried to push up the head, failing in which he applied the forceps. Now in these four cases, he only once succeeded in bringing the chin forward; in one other, he was only able to flex the head with the instrument and disengage the vertex and occiput the first beneath the pubis; in the remaining two cases, he was obliged to use the crotchet. The latter course was also pursued in a case furnished him by one of his old pupils. Thus, of five cases, did but one permit of rotation forward; it being impossible in all the others. 800 DYSTOCIA. Are we prepared to say that after rotation forward has failed, craniotomy alone remains ? I think not, but believe it right first to endeavor to flex the head by means of the forceps. By so doing I extracted a living child. Smellie also succeeded, after vainly trying to bring the chin forward; and similar cases are to be found in the 3Iedical Journals. It ought therefore to be attempted before having recourse to craniotomy. In estimating the value of the various modes of procedure which have been mentioned for effecting delivery in these difficult cases, we must not be too ex- clusive ; for experience shows that the plan which succeeds in one case fails in another, without our being able fully to account for the difference; often, indeed, after having tried them all fruitlessly, it is necessary to have recourse to craniotomy. Especially do I think it necessary to a proper estimate of the utility of each, that great regard should be had at the time of operating to the exact relation of the chin with the posterior plane, to the energy of the contractions, and to the tendency which the head may exhibit to perform its rotatory movement. An almost direct mento-posterior position, immobility of the head, and continuance in that position after a long labor, as also the weakening of the pains so often consequent upon great prolongation of labor, are conditions evidently opposed to artificial rotation. In short, apply the forceps and attempt the rotation, making the efforts coincide with the contractions of the womb; if unsuccessful, try to flex the head ; should this fail, perform craniotomy. 3. When the face is still above the superior strait, an application of the forceps is only to be attempted when the pelvic version is altogether impossible. In fact, it is well known that the face is then usually found in a transverse position. Besides, as previously stated, when the head is so high up, the blades are neces- sarily applied along the sides of the pelvis; consequently, one of them would come into contact with the vertex, the other with the neck, and the pressure made on this latter part would most assuredly compromise the life of the child. We were, therefore, right in saying that the forceps ought only to be used as an extreme measure, and that before using it, unless Baumer's forceps are tried, an attempt should be made to convert the face position into one of the vertex by the cephalic version, and then apply the forceps on the head in this rectified position. § 5. When the Head remains behind after the Body is expelled. WheD the head is retained in the mother's parts, after a natural delivery by the breech, or after the pelvic version, an application of the forceps is rarely indispensable, for the hand alone is usually sufficient to effect the delivery; more particularly in those cases where an extension of the head is the sole cause of difficulty. But when the manual operation has failed, or the base of the crauium is arrested by a contraction of the pelvis, the forceps may certainly be very use- ful, 3Iadaine Lachapelle to the contrary notwithstanding. Whenever an application of the instrument is decided upon, the rules for ope- rating are nearly the same as in the vertex positions; here, also, the blades are placed as nearly as possible on the sides of the head, having their concave edges THE FORCEPS. 801 Fig. 120. always directed towards the part that is to come under the pubic arch, &c. We may further add, that it should be entered along the sternal plane of the child, as also, that the body is to be supported, and carried towards that side where the occiput is situated, /. e. directly forward and upward in the occipito-pubic posi- tions, forward and to the left in the left anterior occipito-iliac positions, &c, &c. The blades having been introduced in the usual manner, we are next, as a general rule, to attempt the disengagement of the head by a movement of flexion, having the nape of the neck as its centre; which is situated at times under the symphysis pubis, and at others at the perineal commissure. In one case only would the accoucheur be warranted in entering the forceps along the dorsal plane of the child, and freeing the head by a process of rota- tion. We mean, where the face is above, the occiput being behind; but this manoeuvre, which was recommended by 3Iadame Lachapelle, does not always succeed; for other practitioners are not as fortunate as that skilful midwife in turning the face into the hollow of the sa- crum. We rather believe, with 31. Velpeau, that, relying on the result of the cases re- ported by Eckard and 3Iichaelis (see page 440), it might be possible, by means of well- directed tractions, to free the occiput at the anterior perineal commissure, after which the delivery of the head would be completed by its extension. But a much more difficult case may be met with in consequence of an arrest of the head above the superior strait; whether arising from an unusual extension, incapable of being remedied by 3Iadame Lachapelle's manoeuvre, or from a contraction of the pelvis, too in- considerable of itself to require the use of the forceps. Both Smellie and Baudelocque, who were as skilful as fortunate, have suc- ceeded in its application under such cir- cumstances; but, notwithstanding the great authority of their names, cases of this kind may well be dreaded when such a man as Dewees has always failed in the operation ! In fact, what a series of difficulties are here met with! Thus, not to speak of the obstacle to the operation caused by the trunk filling up the vulvar orifice, we must remark: "1. That, when the head is lodged transversely with regard to the pelvis, as frequently happens, the forward inclination of the upper strait makes it impossible to apply the blades on the sides of the head; 2. That the vertical diameter of the head will necessarily be placed in the direction of the axis of the blades, and that the latter will consequently be applied upon the two extremities of a long diameter,— a circumstance tending strongly to defeat the operation; 3 That on account of the elevation and position of the head, it is often imperfectly grasped by the instrument, which is liable, upon the first tractions, to slip and wound the parts 51 Application of the forceps where the head is retained after the delivery of the body. 41 802 DYSTOCIA. of the mother. It is, however, the extreme resource, and must be attempted whenever tractions, as strong as are compatible with the life of the child, have proved unavailing. The rules for its accomplishment are very simple; namely, to carry the trunk towards the part corresponding with the occiput; to depress the chin as much as possible, with a view of diminishing the extension of the head; to enter the blades on the side of the pelvis; and, lastly, to operate, as far as practicable, in the direction of the pelvic axes. Should the base of the cranium present after the accidental or designed sepa- ration of the head from the body, it would be proper, provided the pelvis were well formed, to apply the forceps, after having taken the precaution of placing the head in a proper position ; that is, with the smallest diameters corresponding with the plane of the pelvis, and the occipito-mental diameter with the direction of its axis. Should the deformity be too great, the embryotomy forceps will be the only resource. (See Craniotomy.) § 6. General Considerations on the Employment of the Forceps. Although an exceedingly useful instrument when employed by skilful hands in proper cases, the forceps, by being badly directed or improperly applied in those in which it is not indicated, may give rise to the most serious disorders. It is particularly important, therefore, in closing this article, to point out the cases in which it may be advantageously employed. Besides, this short review will serve to illustrate the precepts just given, and render its mode of action more intelligible. The forceps has been recommended : lst, in cases of irregular or inclined ver- tex and face positions, which are neither corrected spontaneously nor can be by the unaided hand. 2. Where a disproportion exists between the pelvic dimen- sions and the size of the head; whether dependent on an excessive volume of the latter or a contraction of the former 3d. Where any accident, serious enough to compromise the life of the mother or child, occurs during the labor, which is not remediable by version. 4th. Lastly, where the head has descended to the pelvic floor, and is there arrested either by the resistance of the soft parts or by shortness of the cord. 1. Inclined Vertex or Face Positions.—As heretofore stated, we consider an application of^he forceps preferable to the use of the vectis (or lever) in these cases, after the inefficiency of the natural powers has been fully determined by a delay of seven or eight hours. The retraction of the uterus would render ver- sion too difficult. In fact, we believe that a prompt delivery is equally demanded for the benefit of the mother and the child, and that the forceps alone can ac- complish this result. Moreover, as the inclined lateral or parietal positions are nearly always transverse, it is unnecessary to add, after what has been elsewhere said, that the blades are to be entered on the sides of the pelvis; and that, as the head descends into the excavation, it will probably undergo rotation, whereby it will be converted into an antero-posterior position.1 By proceeding in this 1 This phenomenon occurred in a lady, in La Rue St. Paul, to whom I was called by Dr Ducros, about seven o'clock iu the evening. The membranes had been ruptured since eight a. m. ; the head was situated in a transverse occipito-iliac position, and was inclined THE FORCEPS. 803 manner, we will avoid, according to Duges, the difficulties of a direct antero-pos- terior introduction as regards the pelvis, and the dangers to the foetus from a bi- parietal application; for it must be obvious that, if the inclination wer*consider- able, one of the blades would bruise the upper part of the neck. 2. Contractions of the Pelvis.—The ultimate limit to which we restricted the use of the forceps, was three inches; because any reduction we could hope to obtain in the diameters of the head beyond that, would not, as a general thing, be great enough to permit it to pass through the contracted diameter of the pelvis. In truth, the enlarged experience of Baudelocque has proved that, when the forceps is applied in the direction of the biparietal diameter, the greatest reduction obtainable, without compromising the child's life, is not more than half an inch. Now, this diameter, on a well-formed head, averages from three and a half to three and three-quarter inches, and even supposing that we can reduce it half an inch, there will still be left three inches at the least. Certain practitioners, having observed that the head became gradually moulded to the shape and dimensions of the pelvic cavity, by the efforts of the womb alone, in some cases in which the pelvis was contracted to less than three inches, have therefore, imagined that the resources of art could accomplish what nature alone sometimes effects; that by the forceps a similar reduction in the diameters of the head might be obtained; and consequently, that the instrument could be use- fully applied when the contracted diameters are even less than three inches. But they have instituted a comparison between two forces that are wholly dis- similar. Indeed there can be no doubt that the expulsory efforts of the womb have succeeded in forcing the head through the pelvis where the smallest diame- ter did not exceed two and three-quarter-inches; but this result was only effected after a tedious labor of thirty, or forty, or even sixty hours ; and where the slow and gradual compression, to which the head was then subjected, has enabled the brain to accommodate itself thereto by degrees. On the contrary, the reduc- tion obtained by the forceps, is produced by a force that does not extend beyond half an hour or an hour at the most. Now, everybody knows that a tumor, whose development extends over a period of several years, may exist within the cranial cavity without giving rise to any serious disturbance, whilst a little drop of blood, suddenly effused, brings on paralysis at once. Consequently, the pressure made by the forceps may kill the child by its sudden action, notwithstanding- the reduction is absolutely less than what nature herself sometimes produces after several hours of suffering. But, when the pelvic diameters exceed three inches, the forceps may prove very useful; though I am induced to believe that the character of its action has been misunderstood, by supposing that it is to serve both as an instrument of on its anterior parietal region ; it had not made the least progress since morning, and was so inconsiderably engaged at the superior-strait, that I was forced to introduce nearly the whole hand for the purpose of ascertaining the position: the waters had escaped, and I attempted in vain to effect a reduction; but an application of the forceps, made in the manner above indicated, was attended by the happiest results. The head descended, and rotated within the blades, and in less than five minutes the child was born living. The lying-in exhibited nothing unusual. 804 DYSTOCIA. traction and as one calculated to reduce the dimensions of the head by its pres- sure. Let it be understood that the forceps merely acts here as an instrument of traction. In fact, the contraction usually exists at the superior strait, where it is parti- cularly apt to affect the sacro-pubic diameter; and, as the head always has a tendency to present its long diameters to those of the pelvis, when retained above, it is generally found in a transverse or an oblique position (more frequently the former). Its biparietal diameter will, therefore, correspond to the smallest one of the strait, and of course the blades of the forceps should be applied in the direction of this diameter; but we have shown that such an application is not possible in any case, and this impossibility is still more evident when contraction exists. For, as Dr. Collins observes, if the sacro-pubic diameter amounts to but three inches, it would be impossible to apply an instrument, the interval between whose blades, when closed, is from three and a half to three and three-quarter inches. The forceps will therefore, have to be applied laterally ; but it is evident that the pressure exerted by it will bear upon the occipito-frontal diameter. Now, although the experiments of Baudelocque may have proved that the head, when flattened in one direction, is not very sensibly enlarged in another, it cannot be supposed that a reduction effected in the occipito-frontal diameter would at the same time diminish the biparietal one, which is perpendicular to it. How, then, does the forceps act? Simply by its tractive power, which, conjoined with the uterine contractions, induces the head to engage in'the excavation; when, of course, as the parietal protuberances correspond with the anterior posterior dia- meter, the biparietal one becomes compressed between the pubis and sacrum; the pelvis itself acting here as the compressory agent, and not the forceps, which latter merely facilitates the process by its tractions. The pressure exerted by the instrument would certainly be more hurtful than useful, by preventing what- ever elongation the occipito-frontal diameter is capable of receiving during the forcible reduction of the biparietal one. This view of the action of the forceps has at least the advantage of demonstrating the uselessness, if not the danger, of the powerful efforts sometimes resorted to by certain accoucheurs for the purpose of compressing the head, and reducing its size; for when the head is well grasped by the instrument, all that is requisite is to tighten the latter enough to prevent it from slipping during the operation. If the forceps can ever be used as a mean of reduction, it is only when the head is arrested by a shortening of the bis- ischiatic diameter. The limits just assigned to the application of the forceps, are the consequence of experiments upon the dead body, and of the most frequently observed cases; but we shall have occasion to prove hereafter that they cannot be regarded as absolute. When the smallest diameter of the contracted pelvis is less than three inches, we are still, almost obliged to try the forceps before having recourse to craniotomy or symphyseotomy (see Symphyseotomy), and it has several times been the means of extracting a living child through a diameter of but two and three-quarter inches, for example. But are the forceps the only resource left before having recourse to a bloody operation in cases of contracted pelvis? We long thought that it was, and, not- THE FORCEPS. 805 withstanding the impression made upon our mind by the perusal of the observa- tions of 31adame Lachapelle, we shared on this important practical point the opinion of the majority of French accoucheurs, and proscribed pelvic version in cases of contracted pelvis, except in the oblique oval variety, in which it was admitted by all to have undoubted advantages. The recent publication of Drs. Simpson and Radfort led us to a fresh exami- nation of the question, and it has already been seen that our opinion was mate- rially changed thereby. " On reading cases of contraction of the pelvis," says Dr. Simpson, " I was struck with the fact, that the labor in certain malformed females, was much easier and more fortunate when the child had presented by the feet than when the head was the first to offer. In several cases even, which would have required craniotomy, the presentation of the feet or pelvic version enabled me to effect the delivery in a succeeding pregnancy. Five observations of this kind are re- corded by Smellie." " According to my tables," says 3Iadame Lachapelle, " of fifteen children deli- vered by the forceps, on account of contracted pelvis, seven lived, and eight perished ; whilst of twenty-five delivered by the feet, fifteen survived." The proportion of success is, therefore, two-thirds for version, and rather less than one-half for the forceps. " These fortunate results of version," adds the illus- trious midwife, " are doubtless due to the greater facility with which we are able, whilst drawing upon the pelvic extremity, so to direct the head of the foetus as to place its transverse diameter in corespondence with the shortened antero-pos- terior one. When, on the contrary, the head presents first, it is, in fact, gene- rally situated transversely; but it may possibly occupy much more unfavorable positions, and those, too, of a kind which the forceps is incapable of altering." Supposing the head to be situated transversely above the shortened sacro-pubic diameter, would it traverse the passage with any more ease if presenting the top of the head, than when, after the extraction or spontaneous expulsion of the body, the base of the cranium is presented to the shortened diameter ? Here, theory seems to be quite in accordance with the above-mentioned facts. The head, regarded as a whole, represents a cone, whose base is the biparietal dia- meter, amounting to from three and a half, to three and three-quarter inches, and the top of the head by the bimastoid diameter, amounting to but from three, to three and a quarter inches. This latter diameter is irreducible, whilst the former is susceptible, under the influence of pressure applied for a longer or shorter time, of being shortened to the extent of three-eighths, or even five- eighths of an inch. Now, when the top of the head presents first, the base of the cone which it represents is brought in relation with a shorter diameter than its own, and all the efforts of the womb, as well as the tractions by the forceps, can have but the single result of flattening the vault of the cranium against the opening of the pelvis, and consequently, of increasing, instead of diminishing the biparietal diameter. If, on the contrary, we suppose the cone represented by the head to engage by its point, that is to say, by its bimastoid diameter, the tractions upon the body of the child might have the following effects : namely, if the shortened pelvic diameter presents at least from two and three-quarters to three and a quarter inches, it will present no serious obstacle to the engagement 806 DYSTOCIA. of the bimastoid diameter, and from that time, the compression upon the sides of the parietal protuberances produced by the resisting symphysis pubis and sacro- vertebral angle, tends to force them nearer together, that is to say, to shorten the biparietal diameter, and the head drawn down by the accoucheur will engage in the contracted part of the pelvis like a wedge, the base of which is compressible. In short, the resistance of the bones of the pelvis in the presentation of the top of the head, tends to lessen the occipito-frontal or occipito-mental diameter, whilst in foot presentations, it tends to diminish the transverse diameter, that is to say, the only one which it is important should be reduced. (Simpson.) A greatly prolonged labor ought, doubtless, be regarded as one of the most dangerous circumstances affecting the welfare of both mother and child, for the lives of both are hazarded in proportion to the lengthening out of the expulsive stage ; now, according to Dr. Simpson, version affords the immense advantage of enabling us to terminate the labor more quickly. What, indeed, is the course generally pursued when it is proposed to apply the forceps in these cases of con- traction ? It is, evidently, to wait before acting, in order to determine the inca- pacity of the uterine efforts, and it is not until after five, six, or eight hours of expectation, that the instrument is used. In the meanwhile, the head is com- pressed powerfully, and the maternal organs are so seriously contused as to expose them to gangrene, or, at least, to those inflammations of the uterus or of the cel- lular tissue of the pelvis, so dangerous during the lying-in. On the contrary, when turning is intended, the most favorable moment can be chosen* in many cases, which is immediately after the membranes are ruptured and the neck com- pletely dilated. The term of expectation would be still longer in presence of a pelvis so contracted as to require embryotomy; for, unless the foetus is found to be dead, the operation is deferred until it shall have perished, or at least until the labor shall have lasted so long as to render its viability exceedingly doubtful. If regard be had only to the interests of the mother, version, as affording op- portunity to act immediately after the membranes are ruptured, should, therefore, be preferred; but is the case the same as respects the fcetus ? If we compare the results of podalic version with those of embryotomy, the reply is ready, for the facts mentioned by 31adame Lachapelle, and some authors, afford us at least the hope of sometimes saving the child by turning, whilst its death is the inevi- table consequence of any other operation. But do not the forceps, within the rational limits which we have fixed for their employment, afford greater chances to the foetus than the extraction by the feet? 3Iadame Lachapelle and Drs. Radfort and Simpson, do not hesitate to declare for the turning. Notwithstand- ing the facts collected by the illustrious midwife, and whilst admitting with the English accoucheurs, that the compression is less dangerous to the foetus when exerted on the sides of the head than when its tendency is to shorten the occipito- frontal diameter, we confess that we cannot share their preference when the top of the head presents in a favorable position. The arrest of the base of the cranium above the contraction, the possible extension of the head, the stretching of the cervical region to which the tractions made on the body necessarily expose it, the possible compression of the umbilical cord during the time occupied in the extraction of the child, are, indeed, very unfavorable circumstances for the latter, and, unfortunately, greatly to be feared during version. But when, with a short- THE FORCEPS. 807 ened diameter of three and a quarter inches, there coincides an unfavorable pre- sentation, as those of the face or of the trunk, and when, before the application of the forceps it is first necessary to perforin the cephalic version; or when, the top of the head presenting, it is so situated that its longitudinal diameter corre- sponds to the contracted one, we are of their opinion, and prefer version to the use of the instrument. When the antero-posterior diameter of the pelvis amounts to but from two and three-quarters to three and a quarter inches, and the child, being still alive, is placed in the conditions just mentioned, we also think that version should be preferred. If, after several fruitless attempts made with the forceps upon a favorably- situated head, the heart is heard to beat distinctly and regularly, we should, if the pelvis has at least two and three-quarter inches, attempt the pelvic version before resorting to craniotomy. We would add, with 3Iadame Lachapelle, that version is also preferable to the use of the instrument, when the inferior strait is contracted transversely, and the pubic arch is narrow and angular. When, in fact, the head is the first to be delivered, the occiput appears first beneath the pubis, and its disengagement under these circumstances is very difficult, and sometimes even imposible. When, on the contrary, the extraction takes place by the feet, the occiput places itself behind the pubis, the forehead is the first to appear in front of the peri- neum, and only the back of the neck engages in the arch of the pubis. To recapitulate, when the pelvis has at least two and three-quarter inches in its sacro-pubic diameter, the forceps should be used if the top of the head pre- sents in a transverse position. The pelvic version should be preferred : 1, in direct antero-posterior positions; 2, in inclined or irregular positions of the top of the head; 3, in face and trunk presentations; 4, in contractions of the infe- rior strait attended with narrowing of the sub-pubic arch. It were useless to recall the important distinction which we have established for the oblique oval pelves. (See page 568.) 3. Accidents.—It is only necessary to recall the conditions in which the version is practicable, to show the part the forceps may play in those accidents that require a speedy termination of the labor. We need not mention the dila- tation or dilatability of the os uteri, for this is indispensable to both operations. Should a completion of the delivery be deemed imperative, when the head has cleared the cervix, or is low down in the excavation, we would apply the forceps; but, on the contrary, if it be but little or not at all engaged at the superior strait, the version would be preferable (see page 757), unless the pelvis was very nar- row, or the womb was so firmly contracted, as to render an introduction of the hand unusually painful, or even impossible. 4. The Resistance of the Perineal Muscles is one of the most common reasons for resorting to the instrument; for nine out of every ten applications of the forceps are made for the purpose of extracting the head, which has been detained at the pelvic floor for four, five, six, or seven hours; indeed, if the measures re- commended on page 573 have proved ineffectual, this is our only resource. But, even here, it is possible that obstetricians have been in error with regard to its modus operandi, since every one, who, like myself, has frequently had occasion 808 DYSTOCIA. to apply it, must have been struck with the fact of how little effort is required, under such circumstances, to effect the delivery of the head. For, where this part has been retained at the same point for seven or eight hours, notwithstand- ing the most energetic contractions of the organ, and all the uterine forces have been expended on an apparently insurmountable obstacle, the young accoucheur, in resorting to his instrument, may anticipate the necessity of using some con- siderable force; and yet, as soon as a few slight tractions are made, this great resistance seems to give way at once, the uterine contractions that were so long ineffectual are henceforth adequate, and the patient soon expels the head and forceps together. Far different would be the result, if the arrest of the head were altogether dependent on an over-resistant perineum; for the exertion re- quisite in those cases, where this part has been rendered less extensible by abnormal bands or cicatrices, is well known. Doubtless, this resistance from the pelvic floor is the first source, but it is far from being the whole cause of the difficulty. In my opinion, the following is the true state of the case; when the head, urged on by the uterine contractions, reaches the floor of the pelvis, it is already in a state of flexion, which must certainly increase as the pains become stronger, and the perineum more resistant; for, being placed between two opposite forces, it will necessarily be flexed on the chest to the greatest possible extent. Now, it is this excessive flexion that constitutes the most serious difficulty, for, in this position, the spinal column abuts directly on the occiput, and every expulsory effort transmitted by it has a tendency to depress the latter, and to flex the head; but here its extension can alone effect a delivery. The question recurs, how then does the forceps operate ? I answer, in a very simple manner ; by the first tractions it extends the head, changing this part to a more favorable position relatively to the spine, and thus restores the efficacy of the uterine contractions, which latter are quite sufficient for the subsequent completion of the delivery. Hence, the reader will understand that, although the perineal resistance is, without any doubt, the original cause of the arrest of the head, yet, in a vast majority of cases, it merely acts by producing an exaggerated flexion; and that. as soon as this is created, it alone constitutes the whole difficulty; a proof of which is satisfactorily afforded by the ease and rapidity of the termination of the labor, after the first moderate tractions made by the instrument have effected a partial extension. 5. Lastly, it has been shown how a shortening of the cord may become a cause of dystocia. AVhere this happens, the forceps is a hazardous resource, that ought to be avoided; but the real source of the delay is generally unknown, and, even if it were not, I know of nothing better to be done, if the head is low down in the excavation. The period of labor for applying the forceps varies with the cause that de- mands its use. When any accident whatever renders it advisable to produce a speedy delivery, and the forceps be deemed appropriate, the time for operating will be judged of by the danger of the accident itself; for we are evidently to interfere as soon as there is reason to fear that the life of either the mother or child is involved. When the head is arrested above the superior strait by a contracted pelvis, we might wait in ordinary cases, as elsewhere stated, for THE FORCEPS. 809 six, seven, or even eight hours after the membranes are ruptured and the os uteri is fully dilated; but a longer delay would expose both mother and child to the most serious hazard. Again, when the arrest of the head is depen- dent on the resistance of the soft parts, the pressure thereby created on the vaginal walls and sometimes even upon the parietes of the womb, might eventu- ally determine a gangrene of those parts, and render the patient liable to the vesical and recto-vaginal fistulas, which often result in consequence. Besides which the fcetus, being subjected for a long time to compression, may suffer from it, and from the disorder thereby created in the omphalo-placental circula- tion ; and the uterus, having exhausted its energy against resistances which it cannot overcome, falls into a state of inertia that continues after the delivery, and becomes then a source of hemorrhage; and, lastly, the inflammation of the womb or vaginal walls that occasionally takes place, may extend to the peri- toneum after, or even during the labor, and speedily prove fatal. All these dangers are easily obviated by the proper application of the forceps; and though, on the one hand, the abuse of the instrument, by employing it too early, as some practitioners are in the habit of doing, is to be avoided, yet, on the other, we must not virtually interdict its use by trusting too long to the powers of nature. We must again allude to what was previously stated in regard to the importance of observing the stage of the labor at which the delay occurs; thus the time that has elapsed prior to the rupture of the membranes, can have but little influence on the mother's condition, and none on that of the child, so that, even where the labor has lasted from thirty to thirty-six hours, there is often nothing to be done; though if the head Avere low down in the excavation, and it had made no progress for seven or eight hours, the forceps ought to be applied. But this rule, which is applicable to most cases, admits of some exceptions; and it would seem useless to add that the state of the patient's health, the strength or feebleness of the uterine contractions, the slowness and intermission, or the regularity of the foetal pulsations, &c, must influence the time of its application. The accoucheur would be justly liable to censure for not acting soon enough, and equally so for vecurring too early to the use of instruments. Statistics, and General View of the Operation.—We fiud the same difficulty in forming an exact idea of the frequency of the cases requiring the application of the forceps, as we did of the cases demanding version, for they vary mnch in different countries, and even in the practice of accoucheurs of the same locality. Thus, on consulting the statistics collected by Churchill, we find for England, 120 forceps cases in 42,196 labors, or about 1 in 351; whilst in France, the in- strument has been used 277 times in 44,776 labors, or about 1 in 162; and in Germany, 1702 times in 261,224 labors, or about 1 in 153. It is still more difficult correctly to estimate the danger of the operation to the mother and child, for the statistics generally represent only the number of mothers and children who perished, without stating the cause requiring the in- tervention of art, and, consequently, leaving us uninformed as to the probable danger of the operation in any given case. Thus, the risks to which the mother and child are subjected when the use of the forceps is demanded only by the resistance of the soft parts, is not comparable to that which threatens them when the head is arrested by a contraction of the pelvis. The length of time which 810 DYSTOCIA. elapses between the discharge of the waters and the intervention of art, neces- sarily influences greatly the result of the operation : now, with the exception of Dr. Collins, whose statistics, though, unfortunately, too limited, prove that the mortality is greater in proportion to the lateness of the operation, very few authors have noted this particular point.1 There can be no doubt that the use of the forceps increases the dangers of the delivery.3 Besides its being always prejudicial to interfere with the operations of nature when they are going on regularly, the application of the forceps, though apparently of the simplest character, may prove dangerous to the mother, and especially to the foetus. The too rapid depletion of the uterus exposes the woman to hemorrhage from inertia. The dilatation of the soft parts takes place with far less regularity when the head is extracted by the forceps, and the perineum is, therefore, much more liable to laceration, however carefully the tractions are performed. Finally, I shall not speak of the lesions of the cervix and of the perforation of the vagina, since it is always possible to avoid them by conforming to the precepts already given. Therefore, the instrument should be had recourse to only when the insuffi- ciency of the powers of nature shall have been well ascertained, and we are con- vinced that a longer expectation would be injurious to the mother or to the child. The posterior position of the head, when the vertex presents, also adds to the difficulties and danger of the operation. Especially when the occiput is directly behind, or behind and to the left, is the operation more laborious. I have men- tioned a case of direct posterior position in which I was obliged to bring the occiput forward (page 802, note). In two other cases of left posterior diagonal position, the head was delivered only by the strongest exertions. The occiput in these cases pressed so strongly upon the sciatic plexus, that both the patients suffered, for a long time after, great pain in the course of the sciatic nerve, and one was unable to walk for more than a year. On the other hand, the compression of the child's head by the instrument may be prejudicial to its health or even to its life, and we have to point out as possible occurrences, cerebral effusions, fractures, and depressions of the bones of the skull, exophthalmia, the contusion, laceration, and separation of the scalp, the compression of the umbilical cord between the head and the blade of the forceps; and lastly, paralysis of the facial nerve, on which we shall make some remarks. Quite recently, M. Landousy has called attention to the facial paralysis of new- born children, that often follows an application of the forceps; and 31. P. Dubois has also alluded to the same fact in his lectures. This palsy, which affects only one side of the face, is caused by the pressure of the blade on the seventh pair of nerves. Owing to the nearly total absence of the mastoid process, and the 1 Dr. Collins gives the following as regards the mothers. When the labor was termi- nated in 24 hours, but one woman died out of 13; between the 23d and 30th hour, there was one death for 6 cases; between the 37th and 48th, one death in 4 ; and beyond 46, one death in 2 cases. 2 In natural labors, the mortality was, for the mothers, 1 in 346, and for the children, 1 in 31; in deliveries by the forceps, it was, for the mothers, 1 in 22, and for the chil- dren, 1 in 4-3. THE VECTIS. 811 defective development of the auditory canal, such a compression of the facial nerve just as it escapes from the stylo-mastoid foramen may occur very easily. The affection is easily recognized immediately after birth, by the following cir- cumstances : the commissure of the lips is drawn out of place; the nostril is neither so dilated nor so movable as its fellow of the opposite side; the eyelids are open, while those on the sound side are closed; the whole side of the face is distorted, and this deformity, heightened by the infant's cries, gives it a very peculiar expression. As soon as the crying is over, the deformity is so slight as scarcely to be noticed, if the eye on the sound side happens to be open; but when the child cries again, the want of symmetry in the features is once more observable. This difference in the phenomena of the disease, dependent on the condition of repose or agitation of the face, is much better marked than it is in the facial hemiplegia of adults. The difference is particularly striking just before it cries, for its face then exhibits alternatives of rest and excitement such as those just described. In the course of a week or ten days these symptoms nearly all disappear, and the equilibrium between the two sides is gradually restored. When the compression of the nerve has been moderate, the hemiplegia does not last so long, and occasionally disappears in a few hours; but in other instances it may persist for a month or two. Hitherto, this affection has never terminated in death, having always passed off, even where no active medication has been employed. The only precautions necessary in such cases, are to protect the eye from the light; and, when the sucking is interfered with by the paralysis, as it occasion- ally is, to find a nurse having a well-formed nipple. CHAPTER III. OF THE VECTIS. The vectis (or lever), which Burns proposed calling the tractor, was formerly much used, though, at the present day, it is scarcely ever resorted to, since, in nearly all the cases in which it has been recommended, the forceps may be ad- vantageously substituted. It was employed to effect the correction of the head in cases of inclined vertex presentations, to depress the occiput in face positions, to force the head to descend, and to free it from the genital organs. One of the Chamberlens appears to have been the inventor of this instrument likewise, but it has undergone numerous modifications since it became public. The one now in use resembles a branch of the forceps; the blade is provided with a fenestra, and is curved on one side so as to adapt itself to the convexity of the child's head; being terminated below by a long flat stem, which becomes narrower and rounded, so as to fit in a wooden handle, which latter is either continued out in the same line, or else is slightly bent in the opposite direction from the blade. Those authors who still recommend the vectis, make use of it in two ways, and to accomplish two different purposes. At times, they merely desire to cor- rect the head, and then abandon the rest of the delivery to nature; at others, by 812 DYSTOCIA. using the vectis as a forceps, they endeavor to extract it. In the latter case, which presupposes, according to the acknowledgment of 31. Velpeau himself, that the head is already down in the excavation, I know of no reason for not using the forceps. When the correction of the head is the only object to be secured, the hand will, most generally, suffice. Nevertheless, if the vectis is employed for this purpose, the following is the proper mode of operating: After having introduced it, according to the rules laid down for the forceps, we next endeavor to slip it over that part of the head on which it is to act—over the occiput, when the object is to flex the head, or upon one of the parietal regions in the lateral in- clined positions. When it is properly placed, the hand, which is already in the vagina, and which has served to guide the instrument up to its place, grasps it near the middle, so as to form a fulcrum, as it were, whilst the other hand having hold of the handle, draws in a direction opposite to the one the head is to take; thus making the instrument act as a lever of the first kind. In some cases, the hand at the exterior serves as the fulcrum by fixing the handle, while the other, acting on the middle of the lever, gives the blade the requisite movement; the instrument then acts as a lever of the third kind. As hitherto stated, the lever might prove very serviceable in some of the posterior posi- tions of the face, when too far engaged to admit of version. When it is used for flexing the head and depressing the occiput, it is passed like a blade of the forceps directly upon the vertex, and as much as possible on the occiput. (Fig. 121 ) Then, by operating in the manner just indicated, we attempt to convert the face presentation into one of the vertex. 31. Boddaert, who has constituted himself the advocate of the vectis in Belgium, states that he has employed it successfully in some cases of deformity of the pelvis, after the for- ceps had failed. When others think of having recourse to craniotomy, he extracts the child alive by means of this instrument. We are of 31. Van Huevel's opinion, that the vectis can never substitute the forceps or version in deformities of the pelvis. Some practitioners are in the habit of attaching a loop near the middle of the instrument, either to give it a point d'appui other than the symphysis pubis, or to convert it into a lever of the third kind; the fillet, drawn by one hand, becoming the active power. The mode of using the lever to pull down the occiput, or to flex the head INDUCTION OF PREMATURE LABOR. 813 CHAPTER IV. INDUCTION OF PREMATURE LABOR. * The title of premature artificial delivery is applied to a labor that is design- edly brought on prior to the ordinary term of pregnancy, but not before the foetus is viable. No obstetrical operation has ever been more warmly or more profoundly criti- cised than this. In fact, it has been supported or condemned by the leading accoucheurs of all countries, and as a consequence of this disagreement among the masters of our art, no part of obstetrical science has ever been studied with greater care. To trace out the first dawning of the induction of premature labor, we should have to go back through the gropings that characterize all human works, to the manoeuvres of Aspasia, to the forced dilatations of the os uteri re- commended by Louis Bourgeois and J. Guillemeau, or to the more gradual pro- cedure of Puzos. But, in all of these methods, the principle differs wholly from the operation under consideration; for, "in & premature delivery, nature accom- plishes nearly everything, art merely contributing a slight, though certain im- pulse ; whilst in the forced labors, art acts almost alone, for all that nature yields must be drawn from her by continuous efforts." (Ritgen.) Under this important distinction, we believe there can no longer be any doubt that the induction of premature labor had its origin in England. According to a few writers, Mary Donally, a midwife of that country, first performed it in 1738; but most of the English authors look upon this as a gratuitous assertion. The judicious Denman states "that, about the year 1756, there was a consul- tation of the most eminent men at that time in London, to consider the moral rectitude of, and advantages which might be expected from, this practice, which met with their general approbation. The first case in which it was deemed necessary and proper, fell under the care of the late Dr. 3Iacaulay, and it termi- nated successfully." His example was soon followed by numerous imitators.1 From Great Britain, this operation shortly passed to Germany, where it was proposed by A. 31ai, of Heidelberg, in 1799, but Wenzel first put it in practice in 1804. Owing to his success, and the publication of Reisinger's remarkable work, it has since been supported by numerous and zealous partisans. It has been performed a number of times in Holland by Salomon, Weleubergh, and Schow; Lovati has been equally fortunate in Italy; and the periodical works of Denmark, of America, Switzerland, and Poland, have severally reported interest- ing cases of delivery before term. In France, the reception of this operation into practice is quite modern ; indeed, for a long time prior to its admission as a valuable resource, it was i The first idea of the induction of premature labor is found in Raphael Moxius (Liv. II, chap 16 P 495) ; he recommends the provocation of labor with the object of saving the mother, at two different periods of pregnancy. In the first months, before the fcetus be- comes animated, and' in the last two months; because then « fcetus etiam si per vim ab utero extrudatur, vivere tamen potest, aut saltern non defraudatur vita amime, quia vivus nascitur et baptizari potest." 814 DYSTOCIA. rejected as a crime. Roussel de Vauzesme proposed it as early as 1779, though it then received but little attention. It was imperfectly understood for a very long period, and we may doubtless attribute the blind and passionate opposition of Baudelocque and his pupils to their want of a clear and definite idea of what mio-ht be expected from its employment. Fodere, however, persisted iu recom- mending the premature delivery, on several occasions, notwithstanding the ana- themas of this celebrated school. In 1830, 31. Burchardt, in a remarkable thesis on this subject, sustained its propriety at Strasbourg, and, finally, in 1831, Professor Stoltz performed this operation for the first time in France, and with the most perfect success. Since then all doubts have gradually vanished, and most of the French accoucheurs have at length adopted a practice, which has now, for nearly a century, rendered such important services to humanity.1 Being once rid of the question of its morality, which for so long a period deterred some practitioners, who did not hesitate about the Caesarean operation or symphyseotomy,3 we have only to resolve, at the present day, the two following questions : In what cases is premature labor to be induced ? And which is the best method of effecting this object? ARTICLE I. CASES REQUIRING A PREMATURE DELIVERY. A. When summing up the indications presented by the pelvic deformities, it was stated that a premature labor might be brought on where the smallest dia- meter of the pelvis did not exceed three and three-quarter inches, and where it was not less than two and a half inches; but we must now explain this proposi- tion more fully. It should be remembered that this operation is always resorted to for the double purpose of saving the child's life, and of preserving the mother from a danger which very frequently threatens her own existence. In other words, it is not to be attempted until the pregnancy is so far advanced that the viability of the fcetus is fully established, and only in those cases where the contraction 1 The French works on this subject are as yet quite few in number; but their authors, Burchardt, Dezeimeris, P. Dubois, Stoltz, Ferniot, and Lacour, have scrupulously examined the objections raised at various periods against the induction of premature labor, and have endeavored to ascertain the precise indications for its performance ; but neither of them has thought of imitating certain accoucheurs of neighboring countries, who make no scruple of trespassing on the domain of other obstetrical operations. They have attempted to prove that each of these operations has its own special indications, which cannot be substituted for any other; and hence, in our country, the induction of premature labor has always been governed by these rigorous data. For fuller details, the reader is referred to the cases, now quite numerous, performed by the French accoucheurs. We have had occasion to perform it ourselves six times. Three of the children were born living, but only one still survives. 2 It is really wonderful that the consequences of this operation have been so long dreaded ; since, in two hundred and fifty cases collected by M. Lacour, in the commencement of 1844, more than one half of the children survived, and scarcely one woman in sixteen died. Let any one compare these results with those furnished either by symphyseotomy or by the Caesarean operation. INDUCTION OF PREMATURE LABOR. 815 of the pelvis is such that a delivery at term is wholly impossible without perform- ing either a bloody operation on the patient or mutilating her child. The French law, which has been constructed with a view of meeting all pos- sible anomalies, has decided that the end of the sixth month is the period at which a fcetus might be considered viable; but, laying aside some rare excep- tions, which ought not to be brought in question, every practitioner well knows that the fcetus seldom lives if born before the end of the seventh month. Con- sequently, we should not think of determining its premature expulsion before the full term of seven months. Although this point is easily decided so far as the interests of the new being are concerned, yet with regard to the mother such is not the case ; for the mere assertion that this operation is to be performed when- ever it is known that a natural delivery at term will be impossible, is altogether too vague and uncertain for a question of such importance; and therefore the two following points are to be established with the greatest possible precision; namely, lst, the degree of contraction beyond which the provoked delivery is no longer practicable ; and, 2d, within what limits its employment is justifiable. As the operation is only admissible after the seventh month of gestation, we must of course ascertain what is the length of the various diameters of the head at that period ; because the extent of the biparietal diameter, which in most in- stances corresponds to the contracted one of the pelvis (the antero-posterior), will evidently show to what ultimate degree of pelvic contraction a delivery.is still possible. Now, it appears from the researches of Dubois, of Stoltz, and Madame Lachapelle, that the biparietal diameter at the end of the seventh month averages from two and a half to two and three-quarter inches; in addition to which, we may hope for a further reduction of one-fourth of an inch, on account of the compressibility of the head. Therefore, the smallest pelvic diameter must be two and three-quarter inches at the least. This, then, is the extreme limit, beyond which the induction of premature delivery is no longer to be thought of. But practitioners are not equally unanimous with regard to the highest limit. From the fact of the biparietal diameter being three and a half inches in a foetus at term, some have supposed that the labor ought to be induced whenever the least diameter of the pelvis does not equal this length; and making allowance for the reducibility of the head, they have fixed upon three and a quarter inches as the highest limit. No doubt, when the woman in a former pregnancy could only be delivered by a resort to embryotomy, the practitioner would clearly be warranted in bringing on labor, even though the sacro-pubic diameter was not less than three and a quarter inches; yet in primiparae this would not be justi- fiable, for a spontaneous delivery is generally possible under such conditions. On the whole, therefore, the induction of premature labor is admissible only when the smallest pelvic diameter measures at least two and a half inches. In multipara, where former experience has shown the necessity of a resort to em- bryotomy, it may be practised as high as three and one quarter inches, but in primiparae never beyond three inches. As regards the child, it is the more likely to live as its sojourn in the uterine cavity has been the more prolonged; and this proposition, the truth of which is universally acknowledged, should induce the operator to delay the induction ot premature labor as long as possible. The degree of contraction, therefore, must 816 DYSTOCIA. guide us in selecting the most suitable period; but, in order to draw any positive conclusion from an examination of the pelvis, it is absolutely requisite to kuow the child's successive growth during every week that elapses between the end of the seventh month and the close of pregnancy. This has been determined ap- proximatively by 31. Stoltz, as follows : From the 32d to the 33d week, the biparietal diameter measures 2| inches. From the 34th to the 35th week it measures 3£ inches. From the 36th to the 37th week it measures 3i inches. Thus, if the labor were to be induced in consequence of a contraction to two and a half inches, it would be necessary to operate at the end of the seventh month, making an allowance for the reducibility of the head, which at that period is quite considerable. But where it is clearly ascertained that the case under care is a twin pregnancy, the operation might be put off for some time, or either abandoned altogether to nature, if the pelvic contraction be not very great; because, on the one hand, twins usually attain a less degree of develop- ment, and on the other, if born before term, their organization is generally too imperfect to admit of ahealthly extra-uterine existence. Perhaps it would be proper here to give our opinion with regard to certain circumstances that have been stated by some accoucheurs as contra-indicatious to the induction of labor; we allude to the influence of first labors, of twin pregnancies, and malpresentations. Merriman has been the most prominent in urging circumspection in the cases of primiparous females; but the fears on this head are evidently exagger- ated, as numberless observations, among others the successful result quite re- cently obtained by 31. Nichet, in the case of a rachitic patient who was pregnant for the first time, clearly prove. For myself, I would not hesitate to follow the example of Stoltz and Velpeau, and bring on the uterine contractions in a primi- para, if I had fully ascertained the degree of contraction of the pelvis; in fact, I have already done so. The obliteration of the cervix, which we all know re- mains closed almost till term, is certainly one difficulty the more to overcome in first pregnancies, but still this is not insurmountable. Busch's dilator, a species of three bladed forceps, which is dilated after being introduced into the neck and thus distends the orifice, will, in my opinion, rarely be found useful. With regard to a malpresentation of the fcetus, were we to pay any attention to it, we should often lose the advantages of the operation, since this is an obstacle of very frequent occurrence. And as a delay of a few days only may compromise the success of the attempt, it would be better to change the pre- sentation by external manipulations, as performed by Stoltz. When this measure proves unsuccessful in modifying the presentation, we should still endeavor to excite the uterine contraction, so as to perform version as soon as the os uteri shall be sufficiently dilatable. The mere detection of a vertex presentation is not a sufficient reason for feel- ing secure as respects an unfavorable position. In one of the six operations which I have had occasion to perform, although the contraction affected the antero-posterior diameter, the head presented in an occipito-pubic position after the membranes were ruptured: and as this circumstance required the application of the forceps and considerable traction, the child was born dead. INDUCTION OF PREMATURE LABOR. 817 b. The cases in which there is a contraction of the pelvis do not constitute the only ones in which the premature labor has been recommended. For the many serious diseases to which females are subject during the latter months of gestation are evidently connected with that condition; and a depletion of the womb is the best and often the only means of removing them. This is also advised by some writers in certain affections that endanger the patient's life; among others, 31. Ferniot has endeavored to prove, in a recent thesis, that under such circumstances the premature labor is quite as justifiable as in the pelvic contraction. The forced delivery was long since recommended in cases of pro- fuse flooding, particularly in those dependent on the insertion of, the placenta over the os uteri; and the artificial rupture of the membranes, resorted to in our day, is merely another method of bringing on the uterine contractions. Further, many skilful physicians have not hesistated to bring on labor when an attack of convulsions has resisted the ordinary remedies, or which, after being checked, returned every few days with a constantly increasing severity. And why should not the same course be pursued, when any serious disease, that existed before pregnancy, is so highly aggravated by this condition as to threaten an early ter- mination in death, if its course be not speedily arrested by emptying the womb ? In 1827, 31. Costa submitted the question to the Academie de 3Iedecine, whether or not it is proper to bring on labor whenever the pregnancy is compli- cated by any disease that seriously threatens the mother's life, supposing the fcetus is viable. We think the Academie erred in treating this proposition as inexpedient; for although Costa's question was too general, and, doubtless, ought to have been better matured before making a final decision, yet restricted within certain limits, determined by observation, it already has received and will still receive numerous applications in practice. For instance, an aggravated disease of the heart, general serous infiltration of the tissues, accompanied by effusions into the great cavities, a threatened suffocation, and the existence of a large aneurismal tumor, which is liable to be ruptured from the obstruction to the general circulation caused by the developed uterus, are certainly quite as danger- ous as flooding or an attack of convulsions; and a premature delivery appears to me advisable, after all the therapeutical resources usually resorted to in such cases have been tried without benefit. It is important, however, that a determi- nation of this kind should be come to very carefully, and, as often as possible, after consulting with enlightened practitioners. In describing the disorders to which the pregnant condition exposes the female, it was seated, that whenever they became so serious as to threaten the life of the patient, we thought that the induction of premature labor was thereby sufficiently justified. Thus, vomiting which resists all therapeutic measures, ex- treme dropsy of the amnios, ascites connected with amniotic dropsy and threat- ening the patient with suffocation, and the recurrence of convulsions at short internals and with increasing severity, are all of them, we have said, sufficient reasons for performing the operation. But these are not the only cases in which the operation has been proposed, and we have yet some other indications to settle. 1 Abdominal Tumors.—In treating of the various tumors that so often com- plicate pregnancy and parturition, Dr. Ashwell suggests premature delivery as 52 818 DYSTOCIA. the most certain method of preventing those serious consequences, to which the patient is then exposed during the labor, or lyiDg-in. But this opinion, in our estimation, is only admissible in the following cases: lst. When any voluminous tumor whatever exists in the belly and incommodes the enlargenienUof the womb; or is itself exposed to such a compression, as almost necessarily to lead to consecutive inflammation. 2d. When a tumor developed in the excavation is so fixed and adherent to the pelvic walls that it can neither be pushed above the superior strait nor drawn down beyond the vulva; provided its bulk is sufficient to prevent the expulsion of a fcetus at term. 2. Smallness of the Abdominal Cavity.—The capacity of the abdominal cavity in some individuals of very small stature, is so inconsiderable as to be in- sufficient for the normal development of the uterus, which after attaining a cer- tain bulk might render the regular performance of the great functions impossible. Thus, M. Depaul mentions a case of asphyxia occurring in a rachitic female who was affected with a deformity of this kind. Hence, it is evident that under similar circumstances, a premature delivery might and ought to be thought of. Still, it is rarely necessary to have recourse to the operation, for* the elasticity of the soft walls of the abdomen of these individuals permits the development of the uterus to take place outside, as it were, of the abdominal enclosure; and if the walls should prove too resisting, it is infinitely probable that in consequence of its violent compression, the uterus would enter spontaneously into action. 3. Nervous Disorders.—The nervous disorders which come on during gesta- tion may sometimes become so serious as to suggest the question, whether it be not advisable to terminate the pregnancy which gave rise to them. 31. Dubois was consulted in the case of a young lady in the third month of gestation, who had been affected for six weeks with symptoms resembling chorea. The spasms were first limited to the voluntary muscles, but finally invaded those of organic life, so that deglutition and speaking had become difficult. All the antispasmo- dics had been employed without success. 31. Dubois replied, that he approved of the means that had been used, but that, whenever the convulsions invaded important organs, he anticipated the necessity of inducing premature labor. We have in charge a young lady who, when in her ordinary health, has, very rarely, some short paroxysms of asthma, and then almost always in consequence of an emotion or physical pain, but which become much more frequent and dis- tressing when pregnant. Having reached the fourth month of a fifth pregnancy, she has just had a slight attack of varicella, preceded by six days of intense fever. During these six days, the suffocative paroxysms became so serious, that MM. Andral and Dubois, who were called in consultation, delivered the most unfavorable prognosis. All these symptoms vanished upon the appearance of a dozen very small pustules, only two of which presented the umbilical depression. The idea of premature delivery might certainly present itself, should such acci- dents reappear and continue at a later period of the gestation ; but it should not be forgotten that, as 31. Laborie remarks, too much haste should not be made, inasmuch as these nervous phenomena often cease instantaneously; and the operation should be carried into effect only when the condition of the patient demands it imperiously. INDUCTION OF PREMATURE LABOR. 819 4. Intercurrent Acute Diseases.—Most of the acute affections which occur during pregnancy, seem to be affected unfavorably by abortion and spontaneous delivery. We have already stated that in cholera, in which the induction of premature labor and abortion have been recommended as a therapeutic measure, there was nothing to prove conclusively that the expulsion of the fcetus was at- tended with any favorable result. We think therefore that, as yet, it were wisest to abstain. 5. Death of the Fcetus in preceding Pregnancies.—There are certain women who, after reaching the eighth or ninth month of gestation without the slightest disorder, suddenly find the active motions of the foetus to diminish, and the child dies. This unfortunate event occurs with some again and again, for several consecutive pregnancies, so that certain females have been known to be delivered thus prematurely, and always of a dead child, five and six times in succession. Denman, and several others, thought that by bringing on labor before the period at which the fcetus had perished in the preceding pregnancies, there would be a chance of obtaining living children. In two cases mentioned by the English author, the operation proved successful. The indication should not, therefore, be entirely rejected. However, it is well to observe with M. P. Dubois, that, notwithstanding the fatal termination in preceding pregnancies, there is always cause to hope for a happier issue as respects the one in charge, so that it is impossible to establish a general rule in reference to the matter. It is one of the cases in which the responsibility of the physician is deeply implicated. 6. Finally, the induction of premature labor has also been recommended in cases in which the fcetus is dead, and in pregnancies which overrun the usual time. At present, and especially in France, the supposed disorders attributed by Mai and Fodere to the death of the foetus in the womb, are no longer believed in. Expectation is adopted, because it is well known that the mother incurs no danger, and that nature will rid herself of the dead fcetus without requiring the intervention of art. Nor are the dangers of the delayed pregnancies less illusory. ARTICLE II. OPERATIONS FOR THE INDUCTION OF PREMATURE LABOR. The methods proposed for effecting the premature expulsion of the child are quite numerous; though, with reference to their mode of action, we may, like Professor Stoltz, divide them into two classes: including in the first, all those which, by primarily influencing the general organization, have the secondary effect of exciting the uterine contractions; and, in the second, all those that operate directly and mechanically upon the womb, for the purpose of arousing its action. The operation of the means appertaining to the first division is too uncertain to be relied upon in a case where it is necessary to act promptly and surely; and although tepid bathing, venesection, &c, have occasionally been followed by a premature delivery, yet no one would ever think of employing them with this view. Even the partisans of the ergot are few in number; for though its influ- ence in rendering the slow and feeble contractions of the organ more energetic 820 DYSTOCIA. is undoubted, there is no positive evidence that it is capable of arousing them where none have previously existed. Wherefore, the accoucheur can only expect to bring on the uterine contrac- tions with certainty, by resorting to those measures that act directly on the womb; these are, lst. Frictions made over the fundus, and titillations of the os uteri; 2d. The detachment of the inferior segment of the ovum from the uterine wall; 3d. Perforation of the membranes; 4th. The introduction of a foreign body into the cervix; 5th. Plugging up the vagina; 6th. Uterine douches. The repeated frictions over the anterior part of the belly, and the fundus of the womb, originally recommended by Professor D'Outrepont, to which Ritgen added direct excitation of the os uteri by one or more fingers introduced into the vagina, are now generally rejected. In truth, the irritation thereby pro- duced is too feeble and transitory to bring on a genuine labor. The same remark applies to the plan proposed by Dr. Hamilton; which was to introduce the finger, or a gum-elastic catheter, beyond the internal orifice, and push it up as far as possible between the membranes and the internal surface of the womb, so as to destroy their feeble adhesions. But, even supposing that it were always feasible to enter the finger, or a sound, in this manner above the internal orifice, it is not at all apparent how such a separation of the lower part of the ovum could prove sufficient to determine the expulsive pains; and it is highly probable that, in those cases where this plan appeared to answer, the success was rather owing to the irritation at the neck, caused by the introduction of a foreign body, than to the detachment itself. Ought we to attribute any greater value to the uterine injection, recently pro- posed by Dr. Cohen, of Hamburg, for the artificial induction of premature labor? Experience can alone determine the question. His process is, however, so simple, and, according to the author, is attended with such prompt effects, and is so devoid of danger, that we think it right to notice it. He says, " I perform the injection as follows: I use a small syringe, usually of pewter, containing from two to two and a half ounces of tar water, and whose canula, from eight to nine inches in length, and about the eighth of an inch in diameter, has a curvature similar to that of a female catheter. I lay the woman flat on her back with the hips raised, then, inserting two fingers up to the posterior lip of the os tincae, I use them as a guide to the canula, which I pass between the anterior wall of the uterus and the ovum to the distance of two inches within the uterus. It is then only that I commence the injection. I force it gently and slowly, taking care to raise the syringe a little to avoid applying the opening against the wall of the uterus, and changing the direction of the instrument whenever any obstacle pre- sents to the passage of the fluid. The syringe is withdrawn very gradually; ten minutes afterward, the woman may rise and walk, and if at the expiration of six hours there is no appearance of labor, the injection is renewed." .... As M. Cohen has succeeded once, and the process is so harmless, it is very desi- rable that he should try again. Perforation of the membranes would naturally suggest itself as the most cer- tain method of accomplishing the object; and this was the mode adopted by Macaulay, in 1756, when he first put the recommendation of the most celebrated London physicians into practice. 31ost of the accoucheurs who have performed INDUCTION OF PREMATURE LABOR. 821 this operation since his day have likewise punctured the ovum; the various modi- fications suggested at different times merely refer to the shape, the length, or the curve of the instrument used, and scarcely merit a notice. For it must be evident that any canula whatever, that is sufficiently curved to correspond with the line of the pelvic axis, and is long enough to reach the os uteri without diffi- culty (that is, about eight to eight and a half inches), and furnished with a trocar, having its poinjfc concealed within, or only projecting a few lines beyond the end of the canula, will be all that is requisite. The only precautions to be observed consist in guiding the instrument along in such a way as not to injure the mother's parts, and so as not to wound the fcetus by the point of the trocar. As elsewhere stated, this is the most certain plan, because a discharge of the waters necessarily occasions a retraction of the uterine walls, and sooner or later a manifestation of the pains; we may further add, that it is quite as easily accom- plished, and is less painful to the mother than those about to be described; but we must acknowledge that the child's existence is much more endangered, because a partial or even a total escape of the amniotic liquid is not always followed at once by the occurrence of the first pains. Sometimes forty or even sixty hours elapse before the uterus, irritated by the prolonged contact of the foetal inequalities, begins to contract; and even when the labor has actually commenced, the dilatation of the os uteri progresses very slowly, for at the seventh or eighth month the fibres in the neck have not as yet undergone those modifications which, at the ordinary term of gestation, render the dilatation easy; and thus a further period of twenty-four or thirty-six hours often passes away before the os uteri is sufficiently dilated. Now, during all this time, the foetus, being no longer protected by the amniotic liquid, is subjected to the direct pressure of the contracted uterine walls; the umbilical cord might very easily be involved, and, from its compression, an interruption of the cir- culatory relations, which are indispensable to the support of the child's life, would inevitably result; besides which, the placenta itself might be partially detached in consequence of the retraction of the womb. 3Iany accoucheurs, influenced by these palpable dangers, had altogether re- jected the perforation of the membranes, when a modification was proposed by Meissner, of Leipsic, which, fortunately, prevents the accidents just indicated, and, therefore, merits a further investigation into the propriety of puncturing the ovum. Various plans were suggested for moderating, as it were, the dis- charge of the amniotic liquid, and of only permitting the escape of a sufficient quantity of it to secure the induction of the pains; but no one had hitherto suc- ceeded in accomplishing what 3Ieissner has so happily effected. His process is as follows: Instead of puncturing the bag of waters at its lowest part, he perforates it high up close to the fundus of the womb, by using an instrument consisting of a canula and two stilets. The canula, which is made of silver, is nearly thirteen inches long, aud about two lines in diameter; and it is curved so as to correspond to a segment of a circle which has a radius of eight inches. A ring is attached to it, near the lower extremity on the convex side, by which the instrument is managed, and which serves to indicate the direction of the curvature after the introduction. The two stilets (one beifTg terminated above by an olive-shaped button, and the 822 DYSTOCIA. other by a trocar) are adapted to the canula; their lower end is flattened out so as to keep them from slipping in too far; the olive-shaped extremity of the first stilet ought not to project more than two or three lines beyond the canula; but the trocar point of the second should advance at least half an inch. The first stilet is intended to facilitate the introduction of the canula, and the second to make the puncture. 31. 3Ieissner performs the operation in the following manner: The patient is placed in an erect posture, and the operator, stooping down on one knee before her, first ascertains the exact position of the cervix; if this is high up, and at the same time is directed so far backwards as scarcely to be reached, the patient will have to sit down on the edge of a chair, or else lie on a settee. The accou- cheur then introduces the canula armed with the blunt stilet, along the palmar surface of the index finger into the cavity of the cervix, and presses it on until it has passed the internal orifice; of course, always having the convexity of the instrument directed towards the hollow of the sacrum. When the point of the canula has once got beyond the internal orifice, it is easily slipped up between the membranes and the uterine walls, to the extent of eight or ten inches above the os uteri. After having ascertained that the point of the instrument does not rest on any portion of the foetus, the accoucheur withdraws the olive-shaped stilet, and substitutes the trocar, with which he then punctures the membranes. The trocar is next withdrawn, a small quantity of liquid is allowed to escape through the canula, and then the latter itself is removed. After the ope- ration is over, the woman may be permitted to sit down or walk about at plea- sure. The waters gradually escape, thus lubricating and preparing the passages, and the pains make their appearance in the course of twenty-four or forty-eight hours; and, in most cases, the dilatation is soon effected, the contractions are strong, and the labor is completed in thirty-six or forty-eight hours. When the labor does not advance regularly, and the resistance from the contracted pelvis is very considerable, M. 31eissner resorts to the measures usually employed under similar circumstances at term. He has tried this mode of operating fourteen times, and he avers that both mother and child were saved in every instance ; such a result, as compared with those obtained by other plans, certainly demands attention, and must encourage other practitioners to attempt it. Let us hope that the principals of large lying- in hospitals will shortly confirm, by fresh success, the favorable accounts given by 3Ieissner. The introduction of 31eissner's canula is liable to occasion a partial separation of the placenta, and consequently endangers the lesion of some of its vessels. This, indeed, happened in a case observed by Kivisch, of Wurzbourg : the canula would ascend no higher than five inches, and after the puncture, nothing escaped but a little blood and serum. Not having obtained a discharge of water, it was decided two hours afterwards to puncture the ovum in the usual way. . . Why not have directed the canula toward another point ? Dismayed by the dangers to which the child is exposed by the old plan of tapping the membranes, many obstetricians have suggested an induction of the uterine contractions, by introducing a foreign body into the neck of the womb, which is designed to act both as an irritant and as a mechanical dilator. Kluge INDUCTION OF PREMATURE LABOR. 823 may-be considered as the author of this method of dilatation, and his process is the one still generally preferred. As well known, this is performed by intro- ducing a conical piece of prepared sponge into the cervix uteri, and keeping it there by plugging up the vagina, until the pains are fully developed. The mode of operating is as follows : After having obtained the patient's consent, and, whenever possible, the ad- vice of some professional brethren, the accoucheur has the woman prepared, by directing her to use warm emollient and narcotic injections into the vagina, for a few days previous to the operation ; before commencing, the bladder and rec- tum are to be emptied, and a fresh examination is to be made for the purpose of ascertaining the degree of the pelvic contraction, as well as the child's position. The female being placed in nearly the' same position as if the forceps were to be applied, the operator first draws the cervix towards the median line, whenever it is found deviated; or, he might endeavor to get the neck within the uterine extremity of a speculum (Dubois). But this is not always practicable. especially if the part be directed a little forward; in general, the finger answers every purpose as a conductor; then a conical plug of prepared sponge, about two inches long, and half an inch in diameter at its base, and having a piece of tape ten inches long attached to it, is held by its large extremity, in a pair of long curved forceps, and is carried up towards the uterine orifice where it is gradually made to enter. After holding it there for five or six minutes, the forceps and speculum (if used) are withdrawn, and the vagina is next filled up with a large sponge, or bits of charpie, so as to keep the first sponge in its place; the whole is to be retained by a proper bandage, and the patient replaced in bed. The mode in which the foreign body acts here, is obvious ; the prepared sponge becoming saturated with the fluids from the neighboring Fie. 122. parts, swells up, and irritates the cervix by its bulk; this determines a dilatation of the latter, and the irritation thus caused, by reacting on the fibres of the uterus, often brings on the contractions in five or six hours. Should it happen that the pains are not fully established, or the-dila- tation of the os uteri is not completed in the course of twenty-four hours, the opera- tion ought to be performed again, taking care this time to introduce a larger piece of sponge (the first having been extracted by the tape) ; this second operation is nearly always successful. If, however, the labor pains be still too slow and feeble, local irritants, such as frictions over the abdomen, and Kluge's method of dilating the os uteri. 824 DYSTOCIA. titillations of the Cervix, or still better, the general stimulants, ergot particu- larly, might be resorted to. This process, which has now come into general use, has the great advantage of retaining the amniotic liquid nearly as long as in natural labor at term ; its results, however, are far from being so satisfactory as those obtained by M. Meissuer's plan, which certainly constitutes a sufficient reason for not persisting in its employment, in all cases, and for giving a trial to the modification pro- posed by the Leipsic accoucheur. The necessity of plugging the vagina, and keeping the tampon applied for two or three days, and sometimes even longer, occasions great suffering to the woman. From having witnessed this suffering, I had an instrument constructed, in 1845, by means of which the prepared sponge is kept in its place wdthin the cervix. It is composed : 1. Of a hypogastric belt, to the middle and front part of which is secured a metallic stem eight inches long, and curved at its free extremity, which carries a canula one and a half inches in length : 2. Of a stem of whale- bone, six or seven inches long, and about a quarter of an inch in diameter, bear- ing at its extremity a forceps with claws capable of being closed at will, by means of a sliding ring, like those of a porte-crayon. The prepared sponge is first fixed in the forceps, and then introduced as usual within the cervix : the whalebone stem is next introduced into the canula and held fast by the pressure of a screw. In this way, the use of the tampon, which is always painful, is avoided; the sponge cannot be displaced and escape from the cervix, as often happens in Kluge's process, nor are the functions of the bladder and rectum in any degree interfered with. The patient is not condemned to the absolute repose usually directed, but can move in bed without inconvenience. I therefore regard it as a plan which does away with most of the inconveniences justly complained of in the performance of the operation. Quite recently, Dr. Schceller, of Berlin, has suggested a measure which is new as to its proposed object, though one of long standing in obstetrical science. Every practitioner is aware of the principal objection to the use of the tampon, so highly extolled by Leroux, of Dijon, as a remedy for uterine hemorrhage; now M. Schceller has conceived the idea of employing the irritation it produces as a means for the induction of premature delivery; for it is well known that its application is most generally followed by uterine contractions. He first made use of it in 1839, and was entirely successful; since that time he has performed five similar operations, and the child was born living in four of them. The mode of operating, according to Stoltz's translation, is as follows (Gaz. Med. de Stras- bourg, Jan. 1843): Before commencing, the bladder and rectum are to be emptied; then several little rolls of charpie, steeped in oil, or smeared with cerate, are successively pushed towards the upper part of the vagina, the first of them having a piece of tape attached, to facilitate its subsequent extraction. Prepared sponge might be used for the same purpose, but it would then be requisite to retain it in situ by another common sponge. It is not necessary to fill the whole vagina; in fact, this would be attended with some inconvenience, for the excretion of the urine and fecal matters would be thereby impeded. It is advisable to introduce the tampon in the evening, when the patient is recumbent, because she will be more likely to remain quiet during the early periods of its operation. INDUCTION OF PREMATURE LABOR. 825 The effects of this measure are shortly manifested by pains in the abdomen and loins, and by a feeling of tension in the womb itself; repeated frictions are then made over the fundus uteri, with a view of aiding its operation. As the tampon soon becomes saturated with the mucus from the vagina, and exhales a disagreeable odor, it ought to be renewed at least once in the course of the day, or even twice, if the sensibility of the parts permits; but, before introducing the second one, the vagina is washed out by an injection. As soon as the tampon has roused the uterine contractility, and the orifice dilates, it may be withdrawn ; though, should the labor be lingering, and the contractions become slow and feeble, it must be reapplied, and ten grains of the secale cornutum be admi- nistered by the mouth every half hour. The pains may also be restored by dilating the orifice with the index finger, carefully avoiding a rupture of the membranes, until the dilatation is nearly completed. The number of instances in which Schceller's process has been tried, is as yet too limited to warrant us in recommending it for general adoption. But the perusal of his cases has induced us to believe that the tampon will not always succeed; and at least, has convinced us of the slowness of its operation. For instance, in one of the five cases reported, it was first applied on the 23d of November, and the delivery did not take place until the 29th; in another, it was introduced on the 27th of January, and the labor was accomplished on the 5th of February. The process must be a very painful one, besides which, as 31. Stoltz observes, the abortive action of the tampon has only been noticed in those cases where the labor had already commenced, or where some marked disorder in the functions of the womb bad occurred; but there is a vast difference be- tween these latter and that of a woman in whom the uterine contractility still lies dormant. Lastly, there is a still more recent process possessing undoubted advantages over all the others, namely, that which consists in directing a stream of warm water upon the neck of the uterus. The honor of introduding it into obstetrical practice is due to Professor Kiwisch. His apparatus was a simple tin box, pro- vided with a long tube furnished with a stopcock. The extremity of the tube is introduced by the vagina to the neck of the uterus. The temperature of the water should be about 76° or 78° of Fahrenheit, and the jet should be large and powerful. The injections should last from 10 to 15 minutes without inter- ruption. Instead of Kiwisch's apparatus, M. P. Dubois uses Dr. Eguisier's instrument for irrigation and steady injection. The latter containing six quarts of fluid, is sufficient for a douche of a quarter of an hour in duration, and there is no occa- sion to renew the water as in Kiwisch's contrivance. Besides, there is no neces- sity for its being very elevated like the other, which renders it much more con- venient to manipulate. I made use of Eguisier's pump in the three cases in which I employed the uterine douches. Unfortunately, it is quite expensive, and not readily procured out of the city. Therefore, it is well to remember that any vessel, capable of containing eight or ten quarts of water, placed at an eleva- tion of seven or eight feet, and provided with a flexible tube of sufficient length, will serve the same purpose. The tube is furnished with a stopcock about a foot from its free extremity. To this extremity is adapted a gum-elastic canula with 826 DYSTOCIA. a single orifice the sixteenth of an inch in diameter. The power of the jet may be increased or diminished at will by varying the calibre of the canula. The woman's seat is brought to the edge of the bed, which is previously covered with oil cloth, so that the water may fall into the vessel placed between the legs without wetting the clothes or the bed. The forefinger of the left hand is introduced to the cervix for the purpose of guiding the canula which the accoucheur holds in the right hand. In ordinary cases, three or four injections a day are sufficient, though, if the case were urgent, they should be repeated more frequently. The number of douches required varies greatly. Sometimes, the contractions appear upon the third or fourth application; in one of my own cases, the first pains were perceived after the second douche, though generally a much greater number are required. In the ten observations of Kiwisch, he was obliged to repeat them four times at the least, and eighteen times at the most; the mean for the ten cases being ten douches. The mean length of time between the commencement of the operation and the moment of delivery, was about three days and a half. In one case, but twenty- four hours elapsed, whilst in two others, it was delayed seven days. We thus see that, in this respect, the cases differ greatly, though the same variations are observed in all the other processes. Still, as that of Kiwisch is not painful to the woman, nor of itself exposes the foetus to any danger, I accord it the preference. There can be no doubt as to its possessing the following advantages claimed for it by its author: 1. The uterine douche prepares the way for the act of premature delivery in the best manner possible, by effecting the softening and necessary dilatation of the inferior segment of the uterus. 2. It requires no preparatory treatment. 3. It is easily employed, and is not disagreeable to the patients, inasmuch as the injection of warm water occasions no uncomfortable sensations. 4. It occupies but a short time. 5. Its action can be regulated at will by the accoucheur, who may increase or diminish, according to circumstances, the strength of the jet and the temperature of the water, or change the point of the uterine neck or inferior segment of the womb upon which it'is directed. 6. It can never injure either the genital organs, the membranes of the ovum, or the foetus; besides, it imitates nature chiefly in this, that it hastens the prepa- ration of the genital passages by occasioning an afflux thither of a greater amount of fluid. The use of uterine injections was not restricted by Kiwisch to the induction of premature labor. He also recommends them as a means of increasing the energy of the contractions in cases of inertia of the uterus, and of making them regular when spasmodic or irregular. He asserts having used them with advantage in a case of spasmodic contraction of the cervix. I have not had occasion to test the value of these last assertions; but M. Campbell states that 31. Dubois restored the contractions by douches, in a case of inertia, or, rather, of extreme sluggishness of the womb. It is, therefore, a means which should not be ne- glected in cases of the kind, especially if there should be any difficulty in regard to the use of ergot. PRODUCTION OF ABORTION. 827 I have also used the douches with the object of procuring the expulsion of a placenta which was retained for several days after the expulsion of the foetus, and whose presence within the uterus kept up a hemorrhage, which was a source of uneasiness. The miscarriage had taken place at the end of the fourth month. Although the happy effect of the douche was not rigorously demonstrated, I am convinced that it was useful, and would advise it to be used in a similar case. Until of latter time, I had practised exclusively the method of Kluge; giving preference to the prepared sponge, kept within the cervix by means of a little instrument hitherto described, whenever I had occasion to bring on premature labor; but for two years past I have found such great advantage in the use of Kiwisch's injections, that I do not hesitate to recommend them almost exclu- sively, and am persuaded that ere long they will be generally adopted. Whatever may be the process employed, when once the pains become quite regular, the remainder of the labor presents nothing peculiar. Whatever may be said to the contrary, the delivery of the after-birth is not more difficult than usual. Children born before term, being on that account more feeble, require much greater care. They should be enveloped in warm wadding, and for the first days especially, their nourishment should be less substantial. CHAPTER V. PRODUCTION OF ABORTION. The premature artificial delivery requires, as just seen, certain dimensions in the diameters of the pelvis; but when the contraction is so great that the smallest diameter is less than two inches and a half, a question of the highest interest presents itself, namely, that of the production of abortion. When a woman, three to four months pregnant, has so contracted a pelvis as to preclude all hope of a possible expulsion or extraction of a viable fcetus, may we think of inducing abortion ? This question, put to Dr. Hunter, in 1768, by W. Cooper, was shortly afterward decided in the affirmative by most English practitioners. The propriety of the operation was also acknowledged in France. by Fodere (1813), 3Iarc (1821), Velpeau (1829), and by ourselves (in 1840), in the first edition of this work. In 1843, 31. P. Dubois published an article in the Gazette Medicate,—an article which foreshadowed his opinion, although it did not positively express it. About the same time, M. Simonard, of Brussels, published a dissertation, in which, after showing the morality of the operation, he points out the indications. Finally, 31M. Stoltz, Jacquemier, and Chailly, have adopted the views of the English accoucheurs. Too many imposing authorities have pronounced in favor of producing abor- tion to make it necessary for us to stop in order to discuss the moral, religious, and medico-legal questions which this operation has raised.1 Like premature 1 For further details, see M. Cazeaux's report to the Academy of Medicine, and the dis- cussion which followed it. (Bulletin de V Acadimie etV Union Midicale, 1852.) 828 DYSTOCIA. delivery, it is now received as an obstetrical operation, and it only remains for us to determine the indications, and the most expeditious and least dangerous means of accomplishing the object. 1. The extreme contractions of the pelvis, those whieh afford the woman at the term of her gestation only the sad choice between embryotomy and the Cesa- rean operation, and for a still stronger reason, those which, by affording less than two inches to two inches and a half, allow of the extraction of a dead or living foetus only by incision of the abdomen, constitute the most positive indication for producing abortion. If, indeed, as we shall endeavor to prove in the following chapters, the sacrifice of the child is fully justifiable when the choice only lies between hysterotomy and embryotomy, this sacrifice would be still more rational at a period of gestation in which the operations necessary to the production of abortion are much less dangerous than those which the mutilation and extrac- tion of a fcetus at term would require. For our own part, therefore, we think that the accoucheur is warranted in producing abortion, whenever a woman, who is five or six months pregnant at the most, shall have less than two and a half inches in the smallest diameter of the pelvis. 2. Contractions of the pelvis are not the only cases in which it has been pro- posed to produce abortion. A host of accidents connected with the pregnant condition, and a multitude of coexisting morbid phenomena, all becoming very dangerous to the mother in consequence of this coincidence, have appeared to some physicians to be quite as rigorous indications as the pelvic contractions. We cannot partake of this view, at least as respects the majority of cases. The precepts laid down by us in treating of premature delivery, require to be greatly modified when abortion is concerned. In a grave case, indeed, but one in which the issue is only probably favorable, we may conclude to induce labor after the seventh month : the danger to which the mother is probably exposed certainly legitimizes an operation which affords considerable chance of saving the child's life. The same is by no means the case as respects the production of abortion ; here it is no longer sufficient that the mother's life is probably compromised, it should be almost certain that death is imminent. Under this head, hemorrhages that have resisted all kinds of treatment, irreducible displacements of the womb, extreme dropsy of the amnion, tumors of the soft parts which caunot be dis- placed, punctured, incised, or extirpated, seem to me to be the only admissible indications for the production of abortion. The reasoning by which we endea- vored (page 257, et seq.) to oppose the provocation of abortion in cases of obsti- nate vomiting, appear to me to be entirely sound as applied to serious nervous disorders, and chronic or acute diseases complicating gestation. As regards eclampsia, it is rare in the first half of pregnancy, and the slowness with which the abortive measures act at a very early period, seem to me to be a formal contra- indication. To recapitulate, extreme contractions of the pelvis, voluminous, immovable, and non-operable tumors of the excavation, extreme dropsy of the amnion, irre- ducible displacements of the womb, and hemorrhages which have resisted the employment of the most rational measures, we consider to be the only indications for abortion. Some authors have admitted a greater number, but only for want of distinguishing clearly between abortion and premature labor. PRODUCTION OF ABORTION. 829 The only contra-indication is the formal refusal of the mother; for with her alone, after all, remains the right to decide the question. Whilst respecting the scruples of certain minds as respects a deformed woman upon whom abortion has been once practised, I confess that it would not deter me for an instant in a succeeding pregnancy. We have no right to constitute ourselves judges of the morality and of the antecedents of the patient who de- mands our assistance. Even supposing that we have to do with one of those unfortunate creatures who will trample under foot the most sacred feelings, and give way all the more to their passions, because they think they can find impu- nity for their bad conduct in the humanity of the surgeon, we owe her none the less our care; for us, the only question to resolve in the second, or third, as in the first pregnancy, is, whether the conformation of that woman allows us to hope for the extraction of a viable child. It, therefore, only remains for us to determine the period at which it is proper to operate, and the most advantageous methods. None but the contractions or obstructions of the pelvis, permit the accoucheur to choose the most favorable moment, and then, the only precaution to be ob- served, is to wait until the pregnancy can be certainly determined, that is to say, between the fourth and fifth months. In all other cases, it is necessary to act as soon as the gravity of the accidents have left no other alternative. Modes of Operating.—In,the first half of gestation, the womb is far from having acquired the muscular properties which it possesses in so high a degree at a later period ; its contractility is very feeble, and the irritability also is much less acute than towards the ninth month. Therefore, most of the external or internal excitants, by whose assistance premature labor can be induced, would probably have no effect within the first four or five months of gestation. Even electricity, which several physicians have employed successfully in cases of inertia during or after labor, appears to have been ineffectual whenever it was attempted to excite contractions which had no previous existence.1 I therefore 1 Electricity, proposed by several physicians as a means of producing premature labor, but hitherto without success, was employed by M. Dubois in a case of a rachitic woman three months and a half gone in her second pregnancy. The electric shocks were not, per- haps, continued long enough on account, of the indocility of the patient, still, the result was, that he was obliged to relinquish the attempt after two trials, without having ob- tained a single contraction. The professor made use of the ingenious machine of the Lebreton brothers ; the two conducting plates were applied on the fundus of the uterus, depressing at the same time the anterior wall of the abdomen, and then the machine was put in action. The patient immediately experienced violent shocks in the hypogastric region, and the pain was so se- vere that she refused to submit to the operation. It was with great difficulty that she could be prevailed upon to make another trial after an interval of a few days, and then it was relinquished. The pregnancy was not in the least affected by these attempts, and the ute- rus continued to increase in size. The uselessness of efforts, made to bring on premature labor by means of electricity, rendered its efficiency very doubtful as applied to the production of abortion ; for, as we have already said, the muscular organization of the womb is yet too imperfect to allow us to hope for its having the same action upon that organ as upon the other muscles of the economy. Still, the process is so simple, and so innocent as respects the mother, that I see no impropriety in repeating the attempts. Besides, the irritability of the womb differs so 830 DYSTOCIA. think, that whenever it is desired to produce abortion, the use of ergot, frictions upon the abdomen, frequent excitation of the cervix, and even the separation of the inferior segment of the membranes,1 should be set aside, and that the choice lies between the puncture of the ovum, the introduction of the prepared sponge, and the uterine douches. A. The 'puncture of the membranes is a sure method of terminating the preg- nancy, but when performed within the first four or five months, it appears to ine to expose the woman to too much danger. We have already pointed out in the article on Abortion, how greatly the integrity of the ovum facilitated the dilata- tion of the cervix and the action of the expulsive pains, and on the other hand, how difficult the expulsion of the membranes and placenta is, after the waters are discharged, and to what dangers their expulsion exposes the woman. There- fore, we shall not insist upon them further. b. Kluge's process we regard as the best means for producing abortion. It is the one which I used to effect this result in the case of the woman on whom 31. Dubois the next year performed the operation, the details of which I have given in the two preceding notes. It is true that, as the length, density, and resistance of the neck of the uterus at the fourth month of gestation would have led us to suppose, the action of the prepared sponge was much slower than at the eighth month; still, by the expi- ration of five days, it had produced a dilatation ajid softening, which greatly facilitated the puncture which was afterwards necessary, and the expulsion of the ovum. 'The long time for which I was obliged to leave the sponge applied, is not an objection to the employment of the method; for, during all this time the apparatus which I have described, enabled the woman to support it without pain, and almost without inconvenience, which certainly would not have been the case had I introduced the tampon as is usually done. much in different individuals, that past failures ought not to make us renounce the effort in another case. 1 The separation of the membranes, now generally abandoned as a means of inducing pre- mature labor on account of its uncertainty, appears to me to be liable to the same objection as applied to the production of abortion. Nevertheless, it was practised successfully by M. Dubois, in the case of the woman mentioned in the preceding note. He first made use of a gum-elastic catheter supported by a stylet. It was easily introduced into the neck of the uterus, but as he found it too yielding, he substituted for it a large silver catheter, which enabled him to effect the separation extensively. The instrument encoun- tered the placenta and destroyed its attachments to a certain extent, giving rise to a slight effusion of blood (Laborie). The membranes were not ruptured. Some abdominal and lumbar pains came on almost immediately after the operation. Until three o'clock in the morning of the next day they were quite feeble; but from that time the labor went on regularly and was accompanied with but a very moderate loss of blood. The membranes gave way spontaneously at four and a half p.m., and at five o'clock the expulsion was completed. We would remark, 1. That the placenta was partially detached, which is very different from the mere separation of the inferior segment of the membranes; 2. That this detach- ment might give rise to flooding; 3. That if, as the non-existence of previous pains and the undilated state of the cervix might have led to anticipate, the labor had continued for several days, the hemorrhage might have become serious and have deprived the operation of the innocency which is the principal advantage of the detachment of the membranes.. EFFECTS OF BLEEDING. 831 It will often be necessary to puncture the ovum after a commencement of dila- tation and softening has been brought about by the use of the sponge; but in consequence of the contractions which will have taken place on the preceding days, the detachment of the ovum will have taken place to a great extent, and its expulsion be rendered much more easy. I do not think that Kiwisch's injections have ever been tried for the purpose of producing abortion, though there is every reason for supposing that they might prove efficient. CHAPTER VI. OF THE EFFECT OF BLEEDING AND A DEBILITATING REGIMEN UPON THE DEVELOPMENT OF THE CHILD. As the foetus, during its intra-uterine existence, necessarily derives from its mother the means of nutrition, it was natural to suppose that her emaciation, brought about by restricted diet and frequent evacuations by bloodletting or purgation, might have the effect to retard the development of the child. This supposition has not, however, always been confirmed by experience; for women, exhausted by disease, or the severest diet, have been known to have very large and robust children, whilst others who had become stout and strong during pregnancy, and who had gained thirty pounds in weight, gave birth to very medium-sized children (Baudelocque). This observation of Baudelocque's, the truth of which has been many times proved, has dispelled the idea of using purgation, bleeding, and diet, as an ob- stetric means in cases of contracted pelvis. With the exception of 31. Moreau, no one in France thought of having recourse to this method, when M. Depaul published, quite recently, two very interesting observations tending to prove its efficiency. Fortunate results had indeed been mentioned by others. Thus Dewees, who states that he had often seen mothers in consumption give birth to very robust children, and who was not, therefore, a priori, favorably inclined towards the method, nevertheless, quotes a letter addressed to him by Dr. Hol- comb, in which five cases are reported. Four of these five women had never been able to have living children, and one of the four had lost eleven. These five were very early subjected to the daily use of purgatives, and were all deli- vered of living children. Dr. Ritter relates the case of a woman with a contracted pelvis, who was several times delivered of dead children, with great difficulty. From the fourth month of her fourth and fifth pregnancies, she was subjected to repeated bleedings, to the use of a slightly purgative mineral water, and se- vere diet, composed chiefly of a small quantity of vegetables, milk, bread, and fruits, without meat, eggs, or dried vegetables. The children, which were much smaller than usual, were extracted quite easily, but were still-born. One, which presented by the feet, died whilst the head was retained by the contraction, and was expelled spontaneously. The other presented the arm, and had to be turned; it was necessary to extract the head by the forceps. 832 DYSTOCIA. These cases, though certainly encouraging, are not sufficiently numerous to establish the value of this method. Admitting, for an instant, that a severe regimen, assisted by bleeding and repeated purgation, would always have the effect upon the development of the child, which it appears to have had in the preceding observations, should this method be preferred to the induction of premature labor ? The latter operation, though almost always innocent as regards the mother, is frequently fatal to the child: thus, of 225 cases, mentioned by 31. Lacour, 37 of the children perished. According to 31. Stoltz, but half of the children are saved; and judging by my own cases, and those which I have witnessed, the mortality of the children is even greater. Unfortunately, we have not yet enough cases in which the regimen has been employed, to establish a comparison. However, out of the ten cases mentioned, we have only two dead children, and this may be partly accounted for by the mode of presentation. Therefore, this method appears to afford greater chances to the children. It is greatly to be feared that the same cannot be said as respects the mothers. It is, indeed, very difficult to suppose that a pregnant woman, who often has much greater appetite during, than before her pregnancy, can be deprived for five or six months of three-fourths of her usual allowance, with impunity, besides being subjected to more or less frequent bleeding or purgation. Is it not to be feared lest debility, and the alteration of the solids and fluids resulting from such a course, so long continued, should predispose strongly to post-puerperal disor- ders, and even have an unfavorable effect upon her future health ? I am well aware that nothing of the kind is mentioned in the cases referred to; but these are yet very few, and on that account no rule for the future. In giving preference to any method, we should also take into account the suffering to which it subjects the patient. That occasioned by the induction of premature labor is almost nothing, and lasts but a short time. That such is not the case as regards the prolonged diet, even its partisans admit. In speak- ing of his first patient, 31. Depaul says, we may conceive what she had to suffer, especially at the outset. For the first two months, he says, alluding to the second, she suffered much from epigastric pains, and a feeling of extreme hunger; her strength gave way, so as to make her unable to walk any consider- able distance, or use an}7 violent exercise. All these sufferings would be readily endured, and, as 31. Depaul remarks, the woman would derive, from the ardent desire of maternity which controls her, strength sufficient to brave everything, could we only assure her as to the result. But, as most authors have regarded this method as very uncertain, as a large number of well-observed facts, though under other circumstances, tend to excite doubts as "to its efficiency, and especially, as besides it, is found an operation which in no degree endangers the life and health of the mother, and saves the life of the children in nearly half of the cases, I acknowledge that, had I to decide for my wife or sister, I would prefer the latter. Again, to what cases of contracted pelvis is this method particularly adapted? I have no doubt, says M. Depaul, that it would be entirely successful whenever the diameters were shortened to the extent of an inch and a quarter; but I would EFFECTS OF BLEEDING. 833 not venture to affirm it, if the antero-posterior diameter was only from two and three quarters to three and a quarter inches in length. It is, therefore, to such pelves as present diameters of at least from three and a quarter to three and a half inches in length, that 31. Depaul restricts the use of the debilitating regimen. But, when placed on this ground, the question changes its aspect, and the results of the method are no longer comparable to those of the premature delivery; for the latter operation is never practised but for contractions of a far more aggravated character. Accoucheurs are unani- mous in considering the spontaneous delivery or extraction of a child as possible when the sacro-pubic diameter is at least three and a half inches in length; and even though embryotomy had been required in previous labors, they rely upon the frequent variations in size of the children of the same woman, and discard the provocation of premature labor. But if, alarmed by the recollection of antecedent deliveries, you fear lest the child should have a large head like its predecessors, and conclude to interpose, do not subject a poor mother to the martyrdom of the prolonged regimen. Should the pelvis present three and a half, four, or four and a quarter inches, you might defer much longer the period at which premature delivery is effected; and instead of bringing on pains at seven months, or seven months and a half of gestation, you might wait for eight months, or even eight months and one or two weeks. The operation would then very probably afford a living child; for it is likely to support an independent existence in proportion as its intra-uterine life has been prolonged. The mortality of the children, which has been justly objected to the induction of premature labor, diminishes greatly as we approach the term of gestation. By this operation, you spare the mother the long sufferings of the regimen, and probably afford equal security to the child. Below from two and three quarters to three and a quarter inches, there is nothing which shows any advantage in the plan of dieting, &c, over the induc- tion of premature labor. But would the latter operation afford more favorable results if the mother were subjected to a severe regimen for a long time before practising it ? It is enough to remember that the extreme weakness of children born before term is the usual cause of their death, in order to set aside a method the effect of which is to weaken them still further. I think, therefore, that in the present state of our science, new facts are required before adopting the die- tetic regimen and bleedings. However, in order to enable the practitioner to judge this question for himself, I think it proper briefly to state the rules laid down by 31. Depaul for carrying out the plan. 1. The greater the obstacle the more necessary is it to diminish the amount of food, and to bleed more frequently. Thus, when the pelvis is contracted by from three quarters of an inch to an inch and a quarter, the method should be put in full force. (31. Depaul's first patient had her food regulated as follows: Soups formed its basis; vegetables once a day; meat once a week, and in very small quantity; half a pound of bread daily, including that in the soups. The first bleeding at three months, a second at six, a third at eight, and the last one at eight and a half months. Fourteen ounces of blood to be taken at each time.) 2. It should be commenced toward the third or fourth month. 3. It would be 53 834 DYSTOCIA. well to diminish the amount of food progressively. 4. She should abstain from dark and very nutritious meats. 5. The bleeding must be regulated by the con- stitution and state of the circulation; it will be more useful in proportion as practised in the latter months. It is hardly necessary to add, that if the obstacle were less considerable, it would be proper to act with less rigor, to begin the treatment later, and to in- crease the amount of food in proportion to the object to be attained. For the same purpose, 31. Delfraysse, of Cahors, recommends the administra- tion of iodine during the last two months of gestation. Beside experiments made upon animals, the results of which seem favorable to his proposition, he mentions the cases of two women. One of them, whose pelvis was rather less than three and a quarter inches in extent, had been delivered three times, and very painfully, of dead children. In the two subsequent pregnancies, and during the last two months, she took, every morning, six, and afterwards eight drops, of the following mixture: Iodine, pure, . . . . . . .15 grs. Iodide of potassium, ...... 30 grs. Distilled water, ....... f§j. She was delivered spontaneously of living children, one of ttfem weighing twenty-two ounces, and the other twenty-three less than their predecessors. Experience only can decide the merits of this new method, which does not appear to have been injurious to the mothers. CHAPTER VIII. OF SYMPHYSEOTOMY. The relaxation of the pelvic symphyses, and the consequent separation of the articular surfaces, which often occur during pregnancy, have so long been known to the profession, that it is somewhat surprising the operation in question was not sooner suggested. It should be stated, however, that certain reflections, and even some facts well worthy of attention, are scattered here and there through- out the annals of our science. For instance, Severin Pineau, when treating of the relaxation of the pelvic ligaments, quotes the text of Oalen, and seems to anticipate the Sigaultian operation; since, in speaking of the pelvic articulations, he says, Non tantum dilatare, sed etiam secari tuto possunt. In a work pub- lished by Delacourvee, a French physician, in 1655, we find that, being sum- moned to a pregnant woman, who died near full term, he divided the pubic symphysis with a razor, in order to extract the child more readily. In 1766, Plenck, under very similar circumstances, first performed the Csesarean opera- tion; but, being unable to extract the head, which was low down in the excava- tion, he divided the symphysis, and was successful in delivering the child. But SYMPHYSEOTOMY. 835 this early attempt, instead of leading to the performance of this operation on the living female, seemed to have the opposite effect. In fact, it was only towards the end of the last century (in 1768), that Sigault, then a student of medicine, suggested it to the Academy of Surgery, by whom it was rejected as a rash proposal. Not disconcerted by this reception, young Sigault supported his invention in a thesis at Angers in 1773 ; that is, five years after the presentation of his original memoir; and, finally, in 1777, he performed his first operation, assisted by Alphonse Leroy, who declared himself its zealous partisan. The mother and child were both saved; and, on account of his suc- cess, Sigault, who had been almost reviled by the Academy of Surgery, was thenceforth covered with honors, and regarded as a benefactor of humanity. The Faculty of Medicine at Paris even resolved to celebrate this wonderful dis- covery by having a medal struck in honor of its author. But, notwithstanding its early success soon gained him numerous followers, it also stirred up new and bitter adversaries; and the medical world was for a long time divided into two sets of enthusiasts, the Symphyseans and the Ccesareans; but, after their first. ardor had abated, both parties finally settled down in a common opinion, as soon as they discovered that there had been exaggerations on each side. Since that time, the Caesarean operation and symphyseotomy have been alike regarded as useful operations, applicable to certain particular cases ; and, so far from attempt- ing to exclude either, the more modern writers have rather endeavored to desig- nate the conditions requiring their respective employment; which, indeed, would have been the wiser course at the time of its first discovery. § 1. Effects of Symphyseotomy. Supposing the propriety of the section of the symphysis pubis to be admitted for the moment, let us ascertain what advantages could be derived from it. From the best works published on this subject, it would appear that we cannot hope to gain more than four to six lines in the length of the antero-posterior dia- meters of the superior strait and excavation. After a division of the inter-pubic cartilage, the bones of the pubis separate spontaneously from four lines to an inch; which separation is produced by the retraction of the ligamentous fibres, known as the posterior sacro-iliac ligaments. While this is being effected, the coxal bone may be considered as a lever of the first kind, having its long anterior arm bent near the middle; the centre of movement, or fulcrum, is found at the posterior part of the articular surface of the sacrum. During the separation, the ligaments situated on the front part of the sacro-iliac articulation become tense and stretched, or even lacerated, when this is carried to a high degree; conse- quently, the amount of their resistance greatly influences the degree of separa- tion. Again, if the accoucheur, by taking hold of the iliac crests, attempts to draw them asunder, he may considerably increase the interval already existing be- tween the pubic bones; but it would be imprudent to carry this artificial separation too far; because, if carried beyond two inches, the anterior sacro-iliac ligaments would probably be ruptured, and the mother be subjected to very serious conse- cutive inflammations. The antero-posterior diameter of the strait is increased from two to three lines for every inch of separation between the pubes ; and, since this interval may amount to two inches, four to five lines are therefore added to 836 DYSTOCIA. the length of the sacro-pubic diameter. In addition to which, the anterior pari- etal protuberance, by engaging in the space left between the pubic bones, dimi- nishes the biparietal diameter to a corresponding extent; and it has been calcu- lated that two to three lines are gained in this way; which would give a sum total in the increased length of the sacro-pubic diameter of six to eight lines. But the sacro-pubic is not the only diameter augmented by symphyseotomy ; for the oblique, and more particularly the transverse, ones are thereby greatly enlarged. In fact, the researches of Desgranges would seem to prove that the increase in the transverse direction, throughout the whole pelvis, amounts nearly to one-half of the separation at the pubis; and that the transverse enlargement of the pubic arch is almost equal to the whole of this interval. Whence it fol- lows that the operation, which would appear to be applicable to those cases only in which the contraction affects the sacro-pubic interval, is in reality especially advantageous when the transverse diameters of the excavation, or of the inferior strait, are shortened. § 2. Indications for Symphyseotomy. The results furnished by experiments made on the dead body, naturally lead to the conclusion that this operation is practicable whenever five to eight lines, added to the contracted diameters, would prove sufficient to admit of a sponta- neous delivery, or, at least, of an extraction of the foetus by the forceps. Such is the view adopted by most practitioners since the days of Sigault, and the ex- tremes of the operation have been limited to two and a half inches for the lowest, and three and a quarter inches for the highest. But, at the present day, sym- physeotomy is seldom resorted to, and it will be even less so hereafter, when accoucheurs generally shall have learned to appreciate the advantages derivable from the induction of premature labor. The circumstances that have led to the performance of the Sigaultian operation, are equally strong iu favor of the induction of premature labor; and the results deduced from experience, the only impartial judge in such cases, have already decided in behalf of the latter operation. For, whenever a patient comes under care during the last two months of her pregnancy, whose pelvis ranges from two and a half to three inches in its smallest diameter, we ought to bring on the labor before term; more particularly if a mutilation of the foetus has been deemed necessary in a former confinement; and, on the other hand, we have elsewhere shown (page 569) that, whenever there is reason to believe that the child's life is more or less compromised by the previous duration of the labor, and the un- successful attempts resorted to for its extraction, the accoucheur should act as if it were really dead. Hence symphyseotomy should only be performed, even though the pelvis measures from two and a half to three inches in its smallest diameter, when the operator ascertains the existence of the deformity before the membranes are ruptured. For, even admitting that it were not better to sacrifice the infant's life than to perform an operation which so often endangers the existence and commonly the health of the mother, is it always possible, in practice, to conform strictly with theoretical principles ? The cases in which a similar degree of retraction has permitted the spontaneous expulsion of the foetus naturally suggest themselves to SYMPHYSEOTOMY. 837 the mind ;'and although these exceptions to the rule are certainly rare, yet they may reoccur. Consequently, is it not prudent, before alarming the patient to ascertain, by a proper delay, the inefficiency of the uterine efforts ? Is not such a delay indispensable for proving the necessity of the operation ? In most in- stances, would it not require several hours to induce the patient to yield to the entreaties of her family ? Would the relatives themselves consent, before the lapse of time had convinced them of the absolute impossibility of a natural de- livery ? And would they not demand a trial of all other means, before a resort to such an extreme measure ? Could the accoucheur object to an application of the forceps, which has so many times, under like circumstances, been followed with success ? Or could he refuse, had he, like ourselves, seen a living fcetus expelled at term through a pelvis whose antero-posterior diameter measured but three inches? These uncertainties, hesitations, and forced delays, which a firm and resolute physician having charge of an hospital may escape, are inevitable in private practice, where we have the fears of the family, the resistance on the part of the patient herself, and oftentimes the anxiety caused by the jealousy of some of our own brethren, to contend with; during all which, time runs away, the labor is progressing, the membranes are ruptured, and the favorable chances for performing the operation are lost. It will be said, perhaps the slowness of the labor is more dependent on the feeble contractions than on the disproportion between the diameters of the head and those of the pelvis; or, perhaps a little artificial aid joined to the powers of nature will succeed in accomplishing her work. Bnt while thus wavering from hope to hope, from perhaps to perhaps, the labor reaches that stage where we begin to doubt the viability of the fcetus ; and, when such a doubt arises, can we any longer think of resorting to symphy- seotomy ? This operation has been proposed in other cases, besides those dependent on a contraction of the pelvis; as, for instance, for tumors in the excavation, for a very large head, or a retroversion of the womb, occurring during the early months of gestation. Thus, it was resorted to by Duret, in order to overcome an ob- stacle to the engagement of the head, created by the development of an exostosis, about the size of a nut, on the first false vertebra; as also in the following case, published by Dr. Damman, in Casper's journal: A woman had been three days in labor, but the head was so voluminous that it could not engage in the excava- tion, notwithstanding the perfect conformation of the pelvis; and, having become wedged in the superior strait, an application of the forceps was impossible. Al- though the long duration of the labor ought naturally to have created some doubt with regard to the child's condition, yet M. Damman resorted to symphyseotomy; the infant was born dead, but he was fortunate enough to save the mother. The remarks before made with regard to this operation in cases of deformed pelvis, equally apply to those of tumors in the excavation, and to those in which the excessive size of the child's head constitutes the only obstacle to a sponta- neous delivery. As to its utility or disadvantages when resorted to for the pur- pose of facilitating the reduction and correction of a retroverted uterus, expe- rience is still wanting. In our estimate of the indications for this operation, we cannot conform, as the reader will see, to the rules laid down by its partisans; because, so far from being 838 DYSTOCIA. precise and positive, as they suppose, these rules only leave the practitioner in doubt and uncertainty. Laying aside for a moment all theoretical discussions, and looking at the question only in its practical point of view, we are led almost irresistibly to the conclusion that, in the present state of our science, symphyse- otomy is no longer practicable. For, independently of the difficulties in deter- mining- its indications precisely, it must not be supposed that the operation is attended with as little danger as Sigault and Alphonse Leroy endeavored to prove; and we only need refer to the numerous accidents thereby produced to sustain the justice of our conclusions. In fact, these dangers are so sreat that, according to Baudelocque, of forty-one females operated upon, fourteen died, and thirteen children only were born living! Not to allude to the numberless infirmities that embittered the existence of nearly all the patients who survived the operation. Operation.—This is very simple. The woman, being placed in the same posi- tion as if the forceps were to be applied, is properly supported by assistants ; the bladder is emptied, and the catheter left in the urethra for the purpose of pro- tecting this canal from the edge of the knife, by pressing it towards the right side. The operator depresses the skin covering the pubis, so as to find the pre- cise spot for cutting down on the symphysis. This being done, an assistant stretches the skin upward as much as possible, and the surgeon then makes an incision through the soft parts, commencing about half an inch above the sym- physis, and prolonging it downwards over the centre of the articulation, nearly to the clitoris, and terminating a little to the left; the inter-pubic ligament is then carefully incised, and, when it is nearly cut through, great precaution is requisite not to wound the bladder. As soon as the section is effected, a separa- tion of the pubes follows; when, if the patient's strength is not exhausted, and the uterine pains are still strong and frequent, the further delivery is abandoned to nature; but in the opposite case the forceps is applied, or the labor termi- nated by the pelvic version and by tractions on the lower extremities. After the delivery is completed, the patient is cleansed, and the vessels tied, if any were divided; the pubic bones are drawn together, and the lips of the wound sustained by adhesive strips, charpie, and a compress, and the whole retained in situ by a bandage around the body. The symptoms subsequently manifested are to be carefully combated as they rise. The perfect consolidation of the sym- physis is seldom completed under three or four months, even in the most favor- able cases, and instances have been known where this never occurred, though the patients were ultimately enabled to walk, by the formation of a cellulo- fibrous tissue; which, says Alphonse Leroy, by filling up the space in the sym- physis, restores the solidity of the articulation. ' This process is the one generally followed; but numerous modifications of it have been suggested, most of which are intended for the better protection of the urethra; though none of them, however, are of much value. Attributing the consequences that follow in the train of symphyseotomy to the exposure of the articular surfaces and the lips of the womb to the external air, M. Imbert, of Lyons, has proposed the division of the interpubic cartilage, without involving the skin. This procedure is feasible enough; but, in our estimation, it can only obviate the smallest part of the consecutive accidents; for the various CESAREAN OPERATION. 839 dangers to which the patient is then exposed, are far less dependent on an in- flammation of the pubic symphysis than on the disorders created by the separa- tion of the sacro-iliac articulations. These remarks apply with equal force to the division of the pubis, which Pro- fessor Stoltz advises to be performed by the subcutaneous method. But, after the opinion I have advanced with regard to the operation itself, it seems un- necessary to dilate on the different ways of performing it; I must, however, describe that of the Strasbourg professor, for, although experience has not decided on its relative merits, yet it seems to offer the most favorable chances. It consists in the division of one of the public bones near the symphysis, by means of a chain-saw, without incising the integuments. The skin having been previously shaved, a small opening is made on the mons veneris at the point corresponding with the crest of the pubis, either on the right or left side of the symphysis; a long and slightly curved needle, having the saw attached, is then entered at this opening, and slipped along the inner face of the pubis, grazing the bone, and its point is brought out at the side of the clitoris, between the cavernous body and the descending branch of the pubis from which the latter arises. The handle is next fitted on, and, taking the saw by both extremities, it is moderately stretched between the two hands, and the pubis is cut through by a few strokes. The divided portions of the bone immediately separate, and this separation can be increased almost at will, or it may be effected by the direct pressure of the child's head or trunk. The pubis being divided, one of the handles is removed, the instrument is withdrawn, and the small opening which is left behind heals up without difficulty. But I repeat, that the modifications suggested by Stoltz and Imbert still re- quire the sanction of a more extended experience. CHAPTER VIII. OF THE CESAREAN OPERATION. Hysterotomy, or the Caesarean operation, consists of an incision through the abdominal and uterine walls, for the purpose of extracting the child. This section had been recommended in cases where a pregnant woman died undelivered, long before it was resorted to on the living female; and it can readily be traced back to remote sources worthy of credit, without confounding it with the mysteries of the poets, or with the marvels of antiquity. Thus, Valerius Maximus speaks of the posthumous birth of the philosopher G-orgias; and Pliny states that the celebrated Scipio Africanus and Manilius were saved under Numa's law, which interdicted the interment of a woman, big with child, until her belly was opened. This wise and prudent law was received and adopted throughout Christendom, and it still flourishes vigorously in the Roman Church. The precise period at which the operation was first performed on the living 840 DYSTOCIA. patient remains undetermined. 3Iansfield, of Brunswick, endeavored to discover indubitable traces of it in the Talmud; but one of his cotemporaries has wholly refuted such an opinion. According to 31. C. Lage, the first authentic case was reported by Nicolas de Falcon, in 1491; J. Nufer performed it in 1500, as de- tailed by Gaspard Bauhin; and F. Rousset published a work in 1581, which has since acquired considerable celebrity from the great number of cases it con- tains, all of which were successful. The surgeons were so emboldened by Rousset's monograph, that the Caesarean operation was often resorted to without any indication whatever, and its popu- larity became so great at one time, that a cotemporary Dominican friar, Scipio Merunia, affirms that it was as common in France as bloodletting in Italy. However, a reaction soon took place; for Gruillemeau, Pare, Viard, and some other prominent surgeons having failed in their attempts, 31archant succeeded in stirring up his countrymen against Rousset, by founding some virulent attacks on these reverses; and the Caesarean section would have fallen into oblivion, if Gaspard Bauhin had not come to its aid with fresh proofs in its favor. The interesting and delicate question of hysterotomy was again contested during the whole of the seventeenth century, and then, as in the preceding one, its advantages and disadvantages were grossly exaggerated; so that the following century arrived without any clear idea having been formed respecting the opera- tion or its value, owing to the total want of probity and justice in the examina- tion of the facts of the case. In 1749, Simon read a remarkable memoir on this subject before the Royal xVcademy of Surgery ; but it is characterized by credu- lity rather than accuracy. Since that period, most of the works on the Caesarean operation have merely discussed the indications for its performance ; but not one of them, unless it is Sacombe's passionate and scandalous dissertation, has at- tempted to prove the impossibility of its proving successful. Although the favorable cases are not very numerous, yet there are a few that may clearly be considered as incontestable. In our day, the field for the Caesarean, as well as for all other obstetrical operations, has been limited; but this is rather to be attributed to the advance of science, and to the eminently practical spirit of the present age. This operation may be practised on the living female whenever the natural passages through which the child has to pass are so narrow, or so obstructed, that a delivery by the application of the forceps, or by symphyseotomy, is wholly impossible; and when the mutilation of the child itself would not permit its ex- traction without exposing the mother to the greatest dangers. It may likewise be resorted to for the purpose of saving the infant when the patient dies in the advanced stages of gestation. Whenever a phvsician is summoned to a pregnant woman soon after her death, he ought to perform it, after having carefully ascertained that the death is real; because, the child's decease does not always precede that of the mother, and nu- merous instances are recorded where living children have been extracted ten or fifteen minutes, and even half an hour, after the woman died. Although the operation will generally prove ineffectual after the lapse of a longer period, still it ought to be tried; since some few cases, whose authenticity I do not vouch for, would seem to prove that the fcetus has continued to live in the womb during ten, fifteen, and even twenty-four hours ! CESAREAN OPERATION. 841 We can only expect to extract a living infant after the seventh month; never- theless, the desire of the relatives in Catholic families to have the child baptized, often constrains the medical attendant to open the patient, even where death occurs before the sixth month of gestation. The incision through the abdominal and uterine walls, under such circumstances, should be made with the same pre- cautions as during life; because, the necessity of acting as promptly as possible, may not afford the operator a sufficient length of time to ascertain that the death is real. Should the female die during the parturition, he ought to examine the condition of the genital organs immediately; for, notwithstanding the fact that the labor may have but recently commenced, these parts, from their diminished resistance after death, have occasionally permitted the delivery of the foetus to be effected by the version or the forceps. In fact, this latter operation would be positively indicated if the child's head were low down in the excavation; be- cause, in such cases, its extraction by the Caesarean section would be rendered extremely difficult, if not impossible ; for numerous recorded instances have fully tested the inefficiency of tractions made on the foetal trunk through the abdomi- nal incision. . When practised on the living female, the Caesarean section constitutes one ot the most serious operations in surgery; for three-fourths of its unfortunate vic- tims have perished. This result, which would probably be still more unfavorable if the same pains had been taken to bring before the public the unsuccessful, as have been used to circulate the more fortunate cases, is, indeed, calculated to alarm the surgeon who is obliged to contemplate performing such an operation. All accoucheurs agree in the opinion that, when the smallest diameter ot the pelvis does not amount to two and a half inches, a delivery by the natural pas- sages is absolutely impossible; and that we have then only to choose between hysterotomy and a mutilation of the foetus. Now,, with a view of explaining more clearly the indications presented by this degree of contraction, we shall adopt the subdivision made by 31. Paul Dubois; that is, into pelves presenting at least two and one-eighth inches in the smallest diameter, and into those below that point. . , , .. Supposing the smallest diameter measures two and one-eighth inches, and it has been positively determined that the child is still alive (for the question is no lon-er doubtful when there is the least uncertainty on this point), two different measures are presented for our serious consideration, namely, embryotomy and the Cesarean operation. All the French accoucheurs, including Dubois himself, are in favor of the latter, for he says, "the Caesarean operation is our only resource, and, therefore, it must be resorted to. (These, p. 71.) We are not ignorant of the importance of this question; and it requires a set- tled and positive conviction, on our part, to warrant us in deciding it differently from other French authors; but we are sustained by the almost unanimous opinion of the English practitioners, who believe that the child ought to be sacrificed whenever the delivery can be effected by embryotomy. Nineteen_yea«^ago we strongly expressed a desire (in the first edition of this work, page 766) to ee the views of our neighbors more generally disseminated in France, in the following words: -And, as to ourselves, our voice will be against the Caesarean operation in all cases where it is not absolutely indispensable to the mother s safety. And 842 DYSTOCIA. we do not hesitate now to advance the same doctrine. In fact, it cannot be for- gotten that this operation is nearly always fatal to the female, even admitting that the statistical tables exhibit the exact truth. For instance, laying aside the details contributed by the surgeons of Great Britain, who are charged with the non-performance of the operation at the opportune moment, and supposing that the unsuccessful cases have been as honestly reported as the successful ones, an impartial examination of all the facts leads to the melancholy conclusion, that nearly four-fifths of the mothers have perished (according to Keyser, the precise ratio of mortality is seventy-nine per cent.). The question then recurs, does this frightful operation save the child? Or is it at all certain that we can present to the mother, as a compensation for all her sufferings, something more than a life- less corpse? Unfortunately, this is not the case, and the partisans of the Caesa- rean section are constrained to acknowledge that they are not always fortunate enough to extract a living child, even when the operation is performed at the most favorable moment. But admitting for an instant that, if resorted to imme- diately after the membranes are ruptured, the section will always save the child, still this, in my opinion, does not compensate for the dangers to the mother. You confess that more than one-half of the females die, but can you aver that more than a moiety of the children you save by gastrotomy will live long enough to dry the tears shed over their birth ? Read the tables hitherto published on the average of human life, and then tell me whether fifty, out of a hundred living infants, attain their thirtieth year.1 Wherefore, it is not only the immediate effect of gastrotomy, but also its remote consequences that are to be taken into consideration. This at least is certain, that you sacrifice more than half of the women immediately; and, even supposing that every child was alive at the time of its birth, the experience of ages has proved, that you will not find one-half of them attain the age at which their mothers died. The advantage is, therefore, in favor of embryotomy, when considered with regard to the mere question of figures. But the feeble and uncertain life of an infant, who is connected with the external world only through its mother, who as yet has neither thought nor affection, hope nor fear, can it be compared to that of a young woman associated with those around her by a thousand social and religious ties? Or will the survival of this poor child fill up the void left by the death of its mother? And, lastly, can society at large ever hope to receive from a new-born infant the duties it had a right to expect from the adult woman ? Hence, family ties and social interests all militate in favor of the mother. In a political, if not in a moral point of view, we are clearly justified, says Ramsbotham, in preferring the strong to the feeble, the sound man to a diseased one, and, consequently, the mother of a family to the still unborn infant, when- 1 From the investigations of Villerme, it appears that in France 20-100 of the inhabitants in the wealthy departments die atone year of age, and 22-100 in the poor ones; 31-100 in the wealthy departments and 33-100 in the poor ones die at four years of age; 38-100 in the former and 42-100 in the latter die at ten years ; and, finally, at twenty years, rather more than 42-100 die in the wealthy departments, and 49-100, that is to say nearly one- half, in the poor ones. Yet these figures do not include children abandoned by their parents, of whom, notwithstanding the zeal of public charity, at least 60 out of every 100 die in Paris within the year. M. Villerme's researches are confirmed by those of M. Benoiston, of Chateauneuf. CESAREAN OPERATION. 843 ever we are placed under the cruel necessity of sacrificing the one or the other. One more argument yet remains in favor of the view I adopt—the most ancient of all the principles of morality, the foundation of all medical law—is, that we should treat our patients as we would treat ourselves or our dearest relatives; now, where is the physician who, if forced to decide under such circumstances between the life of his wife and that of the child she still bears in her womb, would hesitate to authorize the sacrifice of the latter ? We are therefore justified in the conclusion that, whenever the pelvis exhibits but two inches and one-eighth in its smallest diameter, embryotomy ought to be resorted to. This rigorous exclusion seems to us warranted by the facts we have witnessed and the record of results of operations performed in large cities, and especially in great hospitals. It is thus shown that the immense majority of patients have perished; we have, however, to repeat, that for some years past quite a number of cases have been published by honorable physicians practising in the country or small towns, and that their aggregate results would make the operation much less serious than when performed in large cities. This fact ought evidently to be taken into consideration, and render less warrantable the preference we accord to embryotomy in the case of women out of the great centres of population. If, indeed, it be true, and we think it is so because our confreres affirm it, that in the country three-fourths and even four-fifths of the women who suffered the Caesarean operation recovered, we have no hesitation in giving it the preference in country practice, whilst maintaining our first conclusion in reference to its performance in large cities. But, unhappily, the Csesarean operation is the only practicable resource when the smallest diameter of the pelvis does not exceed two inches; for the extrac- tion of a mutilated fcetus is then so slow, difficult, and painful, that, while necessarily killing the child, the danger to the mother is as great as from the performance of hvsterotomy. The almost constant failure of the operation in large cities, such as London and Paris, as compared with the successes obtained in smaller localities, has suggested to some individuals the propriety of erecting a hospital in the country, or at least of sending out of town such patients as it is supposed will require the Caesarean operation. This precaution is especially insisted upon by M. Guisard, who has just published three new cases of success. The idea could not be carried into execution very easily, yet I think it deserves to be considered, and suggested to the proper authorities. All who have had long experience of the diseases of lying-in women, are convinced that most of them originate in the assemblage of a large number of newly-delivered patients in the same place; and this is espe- cially true as regards those whose labors were difficult, and required a bloody operation. To increase the number of lying-in institutions, and to separate the patients as much as possible, I regard as the surest means of obtaining an early POT1 VfLlPSOPUCG It must not, however, be supposed that by sending to some leagues' distance from Paris such deformed women as will require our care at term, they will be placed in as favorable conditions as women who have always lived in the country. The gravity of the operation is certainly influenced by the locality in which it 844 DYSTOCIA. is performed, but so is it also by the health of the patient; now wc know that in this respect, there is great difference between the women of cities and those who have always resided in the country. To afford them the best chance, there- fore, these unfortunate persons ought to be placed in the best hygienic condi- tions for several months before the end of gestation. Supposing the necessity for the operation has been fully determined, numer- ous important questions arise for consideration, namely, what is the most favor- able stage of the labor for its performance ? Has the previous duration of the labor any positive influence over the result? And is it better to operate before or after the membranes are ruptured ? An answer to all these questions will be found in the careful examination of the published cases. A. Duration of Labor.—The whole duration of the labor has been noted in one hundred and sixty-four cases; in sixty-two of which the woman recovered, and in one hundred and two she was lost. With a view of showing the influence of duration as regards the mother, we divide these cases into three classes, namely : Where the operation was performed after the labor had lasted twenty-four hours, there were.....20 successful and 40 unsuccessful cases. From 25 to 72 hours, there were . 34 " 41 " " More than 72 " " .8 " 21 " " 62 102 From this table, which is taken from Keyser's excellent work, we may con- clude that the duration of the labor would appear to have an unfavorable in- fluence only when it has continued beyond seventy-two hours. But the same remark does not apply to the child; 'for, taking the same one hundred and sixty-four cases, in a hundred and fifty-eight of which the infant's condition is reported, we find that fifty-seven were still born, and a hundred and one survived; and, adopting the same division, we have : After a duration of 24 hours, . . 42 successful and 16 unsuccessful cases. From 25 to 72 " . . 48 " 24 " " More than 72 " . . 11 " 17 « « 101 57 Whence it follows that the chances are less for a living child as the labor is the more prolonged. B. Rupture of the Membranes.—The time that elapsed after the membranes were ruptured has been stated in one hundred and twelve cases. We shall like- wise classify these under three heads, according to whether the operation was performed: As regards the Mother. . Cases. Successful. Unsuccessful. 1st. Before or within 6 hours after the membranes were ruptured,......= 39 20 19 2d. From 7 to 24 hours after the rupture, . = 35 14 21 3d. More than 24 hours after the rupture, . . z= 38 13 25 112 47 65 CESAREAN OPERATION. 845 From which it appears that the operation is so much the more unfavorable for the mother as a greater time has elapsed after the rupture of the membranes. The fate of the child is known in only one hundred and six cases; still using the same classification, we have : lessful. Stillborn. 34 3 25 7 19 18 lst. Before or within 6 hours after the rupture, . = 37 2d. From 7 to 24 hours after the rupture, . . = 32 3d. More than 24 hours after the rupture, . . = 37 106 78 28 c. It is unnecessary to add that, with regard to the foetus, the prognosis is much more unfavorable when an artificial extraction has been attempted before resorting to the Caesarean section. Indeed, it must be evident, from the fore- going facts, that the most favorable time for operating is either before or imme- diately after the rupture of the membranes. Whenever we have an opportunity of attending the patient during the last few days of her pregnancy, it is advisable to prepare her for the operation by a suitable regimen, such as tepid bathing, moderate bloodletting, &c. But when the labor has actually commenced, the operation is to be proceeded with as soon as the os uteri is sufficiently dilated to permit the subsequent discharge of the lochia. It has been recommended to puncture the membranes, lest the waters be effused into the peritoneal cavity; but as this accident can very easily be pre- vented, and as the distension of the womb is favorable to the retraction of the organ after the operation, this ought not to be done. Just before commencing, the bladder and rectum are to be emptied. Two bistouries, the one convex, the other having a straight probe-pointed blade, forceps, ligatures, cold and tepid water, a little vinegar, sponges, needles armed with thread, quill-barrels, strips of adhesive plaster, some charpie, and compresses, and a bandage for the body, constitute tbe necessary apparatus. The patient is then laid on a bed of the proper height, and is held quiet by the attendants; an intelligent assistant is charged with the duty of keeping the womb on the median line by placing his hands over it; and another presses one hand over the fundus uteri with a view of keeping up the intestines, which are apt to become insinuated between the uterine and the abdominal walls. The surgeon then makes an incision along the median line, through the skin and sub- cutaneous fatty tissue, extending from a little below the umbilicus, downwards to within an inch and a half or two inches of the pubis; this incision ought to be at least five or six inches long, and provided this extent is not obtained within the indicated points, in consequence of the woman's low stature, it should be prolonged a little upwards and to the left of the umbilicus. The operator next divides the aponeurotic fibres of the linea alba, layer by layer, and thus gets to the peritoneum, into which he then makes a small opening; having inserted the index finger of the left hand into this, he directs the probe-pointed bistoury along its palmar face and enlarges the incision. The tissue of the uterus is now carefully incised, layer by layer, until the surface of the membranes or the pla- centa is brought into view; the bag of waters is then opened by a simple punc- ture and the probe-pointed bistoury is entered at this orifice, and the incision 846 DYSTOCIA. enlarged to the extent of five or six inches, directing it rather toward the supe- rior than the inferior angle of the external wound. The assistant, who is charged with the duty of keeping the lips of the wound apart, must be very careful to hold the abdominal and uterine walls in contact with each other at the time when the membranes are ruptured. The extraction of the foetus is afterwards accomplished by seizing hold of the first extremity that presents. The uterua retracts immediately and effects the detachment of the placenta, which is pushed towards the wound; it is then extracted together with the membranes, which have been carefully twisted into a cord. If any blood has escaped into the uterine cavity, it is removed, as well as any other foreign body that may obstruct the cervix. The wound in the uterus requires no other attention than that of being well cleansed. The lips of the one made through the abdominal walls are brought together at two or three points by the twisted suture, taking care to leave a free space towards its inferior part for the discharge of the fluids that escape from the abdomen ; strips of adhesive plaster are used between the points of the suture, over which the uniting bandage is then applied ; some modern surgeons use no sutures, relying wholly upon uniting bandages for keeping the edges of the wound in apposition. Thus 31. Lebleu (of Dunkirk) first places beneath the patient, and opposite the last dorsal and lumbar vertebrae, two narrow body bandages with digitated extremities. Upon these, so as to come next the skin, are laid two strips of adhesive plaster, each four inches wide, but long enough to cross each other in front of the incision. Each strip is cut into three from its extremities for three-fourths of its length. After the operation, the ends of the adhesive strips are applied first to the skin, and then, as they come near the wound, upon two thick graduated compresses placed on each side. They are made to cross each other opposite the incision, leaving only a small open space below. Charpie, compresses, and the two body bandages complete the dressing. This arrange- ment seems to me well adapted to the case. The wound is next covered with charpie smeared with cerate, and common compresses, and the whole retained in situ by a moderately drawn body-bandage. The subsequent treatment is re- stricted to combating the inflammatory and other symptoms as they may arise. As one of the means best adapted to prevent undue inflammation, Dr. 31etz (of Aix-la-Chapelle) insists strongly upon the use of cold. As soon as the patient is placed in bed, compresses saturated in cold water are applied to the abdomen, and followed in a few hours by ice inclosed in bladders. Injections of cold water are also administered, and the patient caused to swallow small frag- ments of ice. She is, herself, conscious, says 31. Metz, of a degree of comfort, resulting from the action of the cold, which is a sure guide to indicate the point to which it is best to carry it. The final effect of the cold is the production of discomfort, and should the use of it be continued, an unfavorable reaction might result. Should the cold injections or swallowing of ice bring on diarrhoea, they must be stopped and replaced by enemata of starch and laudanum. If, on the contrary, the injections do not soon produce stools, calomel or castor oil ought to be adminis- tered. The use of cold has never seemed to interfere with the regular accomplish- ment of the puerperal functions. CESAREAN OPERATION. 847 M. Metz relates eight cases of his own, showing but one death. Five others, two being furnished by Dr. Vossen, one by Dr. Kesselkaul, and two by Drs. Kilian and Gentz, also exhibit a favorable result. We have therefore twelve cases of success out of thirteen operations. For our own part, we are quite in favor of adopting the plan of 31. 3fetz, in- asmuch as we have twice seen newly delivered ladies apply in spite of us, and without the least inconvenience, cold compresses upon the abdomen and breasts. We are not therefore alarmed for the consequences which, a priori, we should have feared from the continued action of cold, yet we are unable to think the results obtained by 31. 31etz as encouraging as he believes them to be. Very probably the future will undeceive him sadly. Still, we have been impressed by the memoir of the Aixla-Chapelle physician, and do not hesitate to recom- mend a method which gave him such results, convinced as we are that no serious objection applies to it. Several modifications of the operation have been proposed, all of which we think it useless to mention, inasmuch as the success attributed to them was, I believe, owing much more to the special conditions under which they were per- formed, than to the more or less ingenious plans suggested by their authors. There is one, however, which deserves mention, if only on account of the hopes which it at first awakened; it consists in performing the operation without wounding the peritoneum. If the incision of the latter could be avoided, effu- sions of blood or of sanious or purulent matter in its cavity would not take place, and the patient be protected from the most efficient cause of death. This ad- vantage is, unfortunately, so fully balanced by the difficulties of the operation, by the number of vessels wounded, and by the inflammations liable to follow the extensive separation of the peritoneum, that the method is now entirely aban- doned. Vaginal Ccesarean Operation.—This name is applied to the incisions which are sometimes made on the neck or' other portion of the uterus that projects into the vagina. It may be resorted to in cases of partial obliteration of the cervix, where a scirrhous, or carcinomatous degeneration of the lips prevents its dilata- tion ; or when any accident occurs necessitating a prompt delivery and the os uteri is not sufficiently dilated. This therefore is a mere division of the neck, having no resemblance whatever to the Caesarean operation properly so called. But in some instances no opening at all is to be found, and then the uterine wall has to be divided for the purpose of creating an artificial passage for the child. This latter operation has been practised a number of times by different persons, among others by my friend, Dr. Caffe, in 1833, with entire success. The mode of performing it is very simple : a sharp-pointed bistoury is carefully guided up along the left forefinger directly upon the anterior inferior portion of the uterine wall, which it incises; but the instrument must not be pushed in too deep, lest the presenting part of the child be wounded; and equal care is requi- site to avoid prolonging the incision too far, either forwards or backwards, for fear of injuring the bladder or rectum. Of course, the lateral incisions are the least dano-erous. A crucial form is the best one for the opening, and, the latter being effected, the delivery is generally abandoned to nature. 848 DYSTOCIA. CHAPTER IX OF EMBRYOTOMY. Fig. 123. Fig. 124. This name is applied to the operation by which the parts of the child are divided so as to admit of their successive extraction, when it is impossible to ter- minate the delivery in any other way. In some cases, it consists of simple punc- tures or incisions made on the head, chest, or abdomen, with a view of diminish- ing its size, while in others the body of the child is divided into several parts. It was elsewhere stated that, whenever a considerable quantity of water had accumulated in the head, chest, or belly, the fluid could easily be evacuated by a simple puncture with a straight bistoury, or still better by a trocar; and, there- fore, we need not recur to the subject. (See Hydrocephalus.) Embryotomy is indicated whenever there is any insurmountable obstacle to the spontaneous expulsion of the child, and where an application of the forceps proves insufficient to effect the delivery; always supposing that the foetus is dead, or there are good reasons for believing that its viability is destroyed by the length of the labor. This operation is resorted to in England much oftener than in France; for most of the accoucheurs of that country pro- scribe the Caesarean section and symphyse- otomy, except in cases of absolute necessity, but they do not hesitate to mutilate the infant, even when it is still living; and the reader will have seen, from the foregoing chapters, that we fully .embrace the same opinion. Of course, when the pelvis is thus contracted, the child may present cither by its pelvic or its cephalic extremity, or by some intermediate portion of the body, at the superior strait; and therefore, we have to describe the operation re- sorted to in these different cases. A. Presentation of the Head.—Embryotomy having been decided upon, the surgeon should proceed to the operation as early as possible, with a view of sparing the patient useless and often dangerous exertions. The artificial dimi- nution of the head is compounded of several successive operations, the whole of which constitute craniotomy, or cephalotomy; these are the perforation of the cranium, the removal of the cerebral matters, and the crushing of the base of the skull. Numerous instruments have been devised for each of these purposes, but we shall only enumerate those which appear preferable. Craniotomy.—The perforation of the cranium can be accomplished by a straight, sharp-pointed bistoury; but the best instrument by far for this purpose is Smellie's scissors, which is very strong, and has its cutting edges externally; and, being terminated by a sharp point, is admirably calculated for penetrating through the osseous vault; when, by opening the handles, the original orifice Fig. 123. Fig. 124. Smellie's scis.-ors closed. The same opened. EMBRYOTOMY. 849 is easily enlarged. The patient being placed in a proper position, the instrument is held in the right hand, and its point, covered by a little pellet of wax, is carefully guided along the palmar sur- face of the left one, previously introduced into the vagina (see Fig. 125) directly upon the head, on a fontanelle, or suture, if possible ; but if, as generally happens, this is not feasible, the point of the scissors is applied against one of the cranial bones, being careful to place it perpen- dicularly on the part, to pre- vent its slipping. It pene- trates easily through the scalp which is often quite thick, and as soon as it is felt to have reached the bone, the in- strument is rotated in opposite directions, until the want of resistance shows that it has entered the cranium. The opening is next enlarged, either by pressing the handles of the scissors apart, or, if deemed more advisable, by making a second incision at right angles to the first. The instrument is now pushed deeper, and moved about, so as to break up the cerebral mass. 31. Hippolyte Blot has latterly had a perforator constructed by M. Charriere, which, I think, is destined to supersede Smellie's scissors, generally made use of hitherto. It possesses all the advantages of the latter without its incon- veniences. This craniotome is composed of two blades, which cover each other, so that when the instrument is closed, the blunt edge of one extends slightly beyond the cutting edge of the other, and reciprocally. Each free surface bears at its extremity A, a projection, which gives to the point of the instrument a quadrangular form (these projections are borrowed from the perforator of 31. Marchand, of Charenton) ; a screw fixed on the inter- nal surface of the movable branch D, enters a notch in the opposite branch, and limits its motion in one direction, whilst the spring c, limits it in the opposite one. The two branches are articulated in a manner peculiar to M. Charriere (d tenon), which admits of their being readily dismounted. The patient being placed in a suitable position, the operator grasps the instru- ment by its handle, with his right hand, and introduces it to the head of the fcetus by passing it along the palmar surface of the fore and middle fingers of the left hand, which also serve to keep it in its place; it is then rotated on its axis like a punch, until it penetrates the cranium, which is indicated by the cessation of 54 Fig. 125. Mode of introducing and using Smellie's scissors. 850 DYSTOCIA. resistance. Then, and not before, the instrument is opened for the purpose of enlarging the aperture. To effect this, the left hand retains its position, and holds the instrument, whilst the extremities of the four fingers of the right hand press upon the lever D, the handle resting upon the thenar eminence. Figs. 126 and 127. Fig. 128. Fig. 126. Cephalotome closed. Fig. 127. Cephalotome opened. Fig. 128. Cephalotome incising the cranium. The brain is afterwards broken up by inserting the instrument still deeper, and moving it in all directions. Before withdrawing the craniotome, it is allowed to close itself, after which its extraction from the genital parts is unattended with danger either to the vaginal mucous membrane, or to the fingers of the operator. The principal advantages of this instrument may be summed up as follows : 1. Great solidity and simplicity. 2. Introduction and withdrawal entirely safe, rendering it capable of being used by the least experienced operators. 3. Capability of acting by pressure, and that with a single hand, the other remaining at liberty to guide the instrument, keep it in its place, and know what becomes of it during the operation. EMBRYOTOMY. 851 4. Power of perforating the bones with the least effort, and, consequently, with the least chance of slipping. 5. It is easily dismounted and cleaned. 6. Finally, simplicity of structure, rendering it a cheaper instrument than Smellie's scissors, provided with their sheath. Whatever instrumlnt is used for perforating the cranium, the second stage of the operation, or evacuation of the cerebral substance, should be immediately performed. This is done by injections through the opening which has been made, by means of a syringe, provided with a long canula. But such injections are generally superfluous when the embryotomy forceps is to be used, for the pressure made by it is quite sufficient to produce the evacuation. If the woman is not much exhausted, and the pelvic contraction is not such as to preclude the passage of the base of the skull, the operation might be sus- pended for a time, and the subsequent delivery be left to the powers of nature; but, under other circumstances, the common forceps, or even the embryotomy forceps, where the narrowed pelvis is less than three inches, ought to be ap- plied. This latter instrument is advantageously substituted for the serrated pincers, the sharp crotchets, and all the other murderous implements that were formerly used in these difficult cases. The honor of its invention, notwithstanding several rival claims, is due to 31. A. Baudelocque, nephew of the celebrated accoucheur of that name. It is composed of two long branches, the blades of which are de- void of fenestra, and, besides, are far less curved than those of the ordinary forceps, so that, when closed, they can pass through a diameter not exceeding two inches. The two branches articulate with each other near the middle, and when they are joined, the blades can be tightened at pleasure, by means of a screw passing through the ends of the handles, and worked by a powerful lever. Even as it is now constructed, Baudelocque's embryotomy forceps is certainly f a very useful instrument; but as I have elsewhere proved (Revue Medicate, May, 1843), it presents some disadvantages which render its application difficult and often even dangerous. For instance : 1. It is too straight to accommodate itself to the curvature of the pelvis, and it is therefore applied with difficulty to the sides of the head ; 2. As the clams are nearly plane they open like a pair of scissors, and do not encase the head, as the concave blades of the ordinary for- ceps do; consequently, they are liable to slip, and thus give rise to serious acci- dents ; 3. Tractions made by it are very often ineffectual, even when well applied to the head; because it necessarily draws in a direction different from the axis of the superior strait, owing to the absence of curvature in the edges of its blades. As the difficulties and dangers attending its use are not imaginary, I have endeavored to prevent them, by suggesting a modification in the embryotomy forceps generally employed, although well convinced that the failure of an opera- tion is very frequently more dependent on the operator himself than on his in- strument. With this view, I had an instrument made by 31. Charriere, which differs in two important particulars from those hitherto constructed, and which seems to obviate the various disadvantages I have just enumerated. 852 DYSTOCIA. We stated above that the absence of curvature in the edges interfered very seriously with the seizure of the head, which is found more anteriorly than in well-formed pelves, both in consequence of the pelvic contraction and its own elevation; hence, we have given a curvature to our forceps slightly exceeding that of Levret's. This, however, did not require a great effort of the imagination, for we have only impressed the same modification of the*embryotomy forceps that Smellie and Levret long since gave to the one invented by the Chamberlens. This curvature is intended to fulfil the indication of accommodating the shape of the instrument to that of the curved canal it has to traverse. The slipping of the head during the tractions is principally owing to the fact, as averred above, that the blades, from being nearly plane on their internal sur- Fig. 129. Fig. 130. The embryotomy or cephalotribe forceps. A comparison of these two figures will furnish an idea of the amount of separation obtained at the base of the blades (Fig. 130), by means of the regulating screw. face, do not properly embrace this part, and that, opening like a pair of scissors, their widest separation is found at the points. Here the difficulty was consider- ably greater, because the internal surface of the clams could not be hollowed out without greatly increasing the interval at their middle part, and, consequently, without rendering the instrument inapplicable to a host of cases where Baude- locque's might be successfully used. After mature reflection, we propose the following as its second and most important modification : namely, to make a much wider entablature at the joint; while, in other respects, the length and width of our forceps correspond with Baudelocque's. This increased width at the articular part permits the base of the blades to be removed from each other laterally by means of a regulating screw, that can be turned at will; the point of which, by working on the pivot, will permit a greater separation at the base than at the points of the blades. Hence, it is evident that when the head is once embraced by the instrument it cannot slip from the extremity of the clams during the tractions, because the interval is much less here than at the base or even than EMBRYOTOMY. 853 at their middle part. In a word, the embryotomy forceps hitherto employed resembles a cone when half opened, the base of which is at the points of the blades, and the apex at the articulation ; but ours, on the contrary, may, under the same conditions, be compared to a cone having its base at the articular part, and its summit at the extremity of the blades. 31. Baudelocque has erred in endeavoring to extend the employment of the embryotomy or cephalotribe forceps beyond its sphere. But when restricted within proper limits, it certainly con- stitutes one of the most powerful instruments in obstetric surgery; for experience has already shown that it may render invaluable service whenever the smallest diameter of the strait amounts to two inches ; but, less than that, it cannot re- duce the size of the head sufficiently to enable it to pass through the contracted part. Hence (as already stated, when treating of the indications presented by the pelvic deformities), the Caesarean operation is our only resource where the contracted strait does not afford two inches of space. The application of the cephalotribe is regulated by the same rules as that of the ordinary forceps, being always introduced on the sides of the pelvis. The Fig. 131. The embryotomy forceps applied and locked. greatest precaution is requisite to ascertain positively that the instrument has really entered the uterine cavity, and that none of the mother's parts are pinched by its clams. After the blades are articulated, a strong pressure is made on the head by means of the winch attached to the end of the handles ; and, when the reduction is supposed to be sufficient, the operator takes hold of the instrument with both hands, and endeavors to make the head engage, by resorting to tractions in the proper direction. Of course, as this descends, he must accommodate the line of traction to the axis of the part through which it is passing. In case of necessity, and if there was no embryotomy forceps at hand, the practitioner should resort to the crotchet, and carefully fix it on one of the most solid parts of the cranium. But the greatest possible care must be taken to pre- vent its slipping, and to protect the soft parts of the mother from its point. However, it is out of the question to lay down positive rules for the regulation of its use in all cases; the operator must be governed by circumstances. It would certainly be much better to use strong-toothed or hooked pincers, articulated in the usual style or like the forceps. One of the jaws should be in- troduced in the opening made in the cranium, while the other is applied to some 854 DYSTOCIA. part of the external surface. These instruments are far less likely to wound the mother's parts than the sharp crotchet. There are pelves so exceedingly contracted, that it is impossible to extract the head even when crushed by the embryotomy forceps, and by too long-continued efforts, the patient's risks may be greatly enhanced. M. Van Huevel has devised a very ingenious instrument which he called the saw forceps, which enables him, after seizing the head, to divide it transversely from above downward, be- tween the blades of the instrument. The portions can then be extracted separately, and as they flatten of themselves, and yield to the slightest traction, they neither wound nor bruise the patient. I borrow the description and mode of operation from the Belgian edition of this work, to which they are added in a note by 31. Van Huevel himself.1 1 It is composed : 1. Of an ordinary forceps, each blade of which bears internally two tubes flattened in opposite directions, and soldered together, the side of one against the surface of the other, so that their horizontal section represents an overturned H. They are bent from without inward, like the forceps itself, but are set in a straight line from below upwards, and from behind forward in one, or curved on the anterior edge in the other. The internal of the tubes encloses a steel blade which conducts the saw: the external, which is directed across the instrument, lodges the prolongation of the chain. They communicate by a large slit, which divides the internal and external walls of the former throughout its length, and the internal side only of the latter. The forceps articulates by entablature, with a movable pivot; upou the base of the latter turns a support perforated with a hole, in which is in- serted a grooved key. 2. Of a clock chain, toothed as a saw in the middle of its length for the space of eight and a half inches, and provided with transverse handles, one of which can be unhooked. This chain passes by the upper opening of two steel blades, which are flexible above, and thicker and toothed below, and which, by entering the internal tubes, conduct the saw between the blades of the forceps. 3. Of a long key, with grooves and collar, like that of Heurteloup's instrument for crush- ing calculi, entering into the hole of the support upon the base of the articular pivot, and fitting into the teeth of the conducting blades. The extremity of the handle is split, and serves to turn the pivot of the forceps, as also for drawing out separately, with one of the two points, the blades from their sheaths. The instrument should only be applied when the woman cannot be delivered either natu- rally, or with the assistance of the vectis, forceps, or by turning; the neck of the womb should also be dilated, and the membranes ruptured. Before operating, a bed should be prepared with a straw mattress, and a mattress folded double ; bolsters, pillows, napkins, and bedclothes, make up this part of the provision The woman lies upon her back, with the hips brought down to the edge of the mattress; the legs and thighs are flexed, and held apart by two aids, one on either side. The forceps are warmed slightly, and greased externally. Suppose the head presents, no matter in what position. The operator takes his place before the woman, and inserts first on the left side of the pelvis, the male branch, if he uses the straightest forceps, or the female branch, if he uses the one with the greatest cur- vature. He introduces it as far as possible into the uterus, and one of the assistants holds it, whilst the other is passed in on the right side. When the forceps is articulated, a few tractions are made, in order to be certain that the head is well seized. The surgeon gives the handle of the instrument to the assistant on his right, whilst he surrounds it with a ligature. Then immersing the ends of the conducting blades, armed with the saw, in oil, he introduces both of them into their respective sheaths until they touch the head of the fcetus. He next passes the key beneath the left thigh of the patient, and engages the EMBRYOTOMY. 855 Further trials are evidently required to confirm the advantages claimed by M. Van Huevel for his instrument. We know that it has been used but a few times in France, and that it has failed in skilful hands. Still, this is no reason for passing over the successes attributed to it by the Brussels accoucheur, and we recommend that it be afforded a fair trial. B. Presentation of the Pelvic Extremity.—Should the head be arrested by a contraction of the pelvis, after the delivery of the breech, and the attempts made for its removal prove ineffectual, a resort to craniotomy appears to us the only resource, whether the child be living or dead. But in these cases the base of the cranium presents, a perforation of which is attended with much more diffi- culty than any other part; and, therefore, the point of the perforating instru- ment ought to be entered at the posterior part of the occipital bone. The application of the embryotomy forceps will also require greater precaution, and will be attended with more difficulty, from the presence of the trunk in the excavation; and, should this obstacle prove insurmountable, the child may be decapitated, and the head alone be left in the parts. But this is not the only case in which the separated head is left behind in the uterus, for it will presently appear that a similar course is adopted in certain trunk presentations; or, the same thing may happen from ignorance or stupidity. In all cases the head has to be delivered, and its extraction is exceedingly pain- ful when the pelvis is much deformed; for it then presents by its base, thereby rendering a perforation more difficult". Under such circumstances, it has been grooved end in the opening of the support; the assistant takes its handle in his right hand, and turns the key slowly on its axis, whilst the operator puts the saw in motion. Care should be taken to prevent the chain from twisting, and, as far as possible, to make the tractions in the direction of the guiding tubes. Unless the key is turned very slowly, the saw will be arrested by pressing too strongly upon the bones of the head. Should this occur, the assistant must reverse the motion of the key slightly, and afterward continue the manoeuvre until the operation is completed. When the section is finished, the key is taken out, and the handle of the chain unhooked, that it may be withdrawn; the conducting blades are also removed, and, finally, the branches of the instrument itself, after their disarticulation. At this stage of the operation, if the woman is not exhausted, and expulsive pains make their appearance, the rest is left to nature, being careful to ascertain the disposition of the segments by the touch. A part of the brain escapes, the sawn edges override each other, the two portions of the cranium, especially the posterior one, become flattened, in conse- quence of their being traversed by flexible sutures, and the foetus is eventually expelled. When, on the contrary, the woman's strength is exhausted, the detached portion of the head is seized with the abortion forceps or a pair of pincers, and therewith extracted. Should it happen that, in consequence of the blades of the forceps not having been intro- duced far enough into the pelvis, the division was not thoroughly effected, the adhesions should be broken up by means of twisting and other motions communicated by the pincers; as soon as the segment is detached, both it and the remaining parts will pass without difficulty. However, should any trouble be experienced in extracting the fragments, there is no reason why another section, different from the first, should not be made, by giving another direction to the forceps. The already divided cranium can be depressed without difficulty, and therefore cannot prevent the diagonal application of the branches. This second ope- ration leaves the skull divided into four unequal portions capable of being compressed in any direction, and extracted without difficulty. 856 DYSTOCIA. recommended to attempt to turn the head, so as to bring some portion of the cranial vault to the superior strait, which of course should be done whenever possible. The excessive mobility of the head singularly favors the slipping of the perforator, and exposes the mother's parts to laceration. The best way of preventing this accident, is to direct an assistant to place both hands over the hypogastric region, and fix the head there by making considerable pressure at that point. But the difficulty is not brought to an end by the perforation of the cranium, for even then the embryotomy forceps will often become necessary if the con- traction is excessive ; and, owing to the mobility of the part, its application is very imperfect, and it is likely to slip at the first tractive effort. The trouble in getting hold of the head is not merely dependent on its mobility, because, when the inclination of the superior strait is very great, it is situated above the pubis, and therefore cannot be reached by the instrument, which is necessarily directed posteriorly, in consequence of its moderate curvature. It was to this, that I attributed the failure of the attempts made on one occa- sion by 31. Paul Dubois, at la 31aternite. The Professor, being worn out by several hours of fruitless manipulations, had the kindness to permit my assistance. I introduced the right hand, and got hold of the lower jaw, which I attempted to draw down, but without any better success, as the base of the cranium was arrested by the symphysis; I found that the failure of my tractions was owing to the fact of their being directed too far downwards and forwards ; I then sub- stituted a blunt hook for the finger, and fixed it on the lower jaw, when, by depressing the handle of the instrument posteriorly, so as to make it operate downwards and backwards, I was soon fortunate enough to get the head into the excavation, from which it was readily delivered afterwards. 3Iost of the difficulties met with in this case might certainly have been pre- vented, by using the instrument just described, invented by myself. (For further details, see the before-mentioned article in the Revue Medicale.) c. Presentation of the Trunk.—Version is not always practicable in the trunk presentations; for instance, where the membranes have been ruptured, and the waters discharged for some time, and the shoulder is low down in the excava- tion, the forcible contraction of the uterus may render an introduction of the hand and version of the fcetus absolutely impossible. In such a case, we have nothing to do but to wait for spontaneous evolution, if the child is living; but, as soon as it is dead, we must promptly relieve the mother from the dangerous consequences of a prolonged labor. To amputate the arm under such circumstances is altogether useless, because its presence cannot incommode the operator; and, besides, it may afterwards prove very serviceable by favoring the tractions; it is on the body we have to act. Various plans have been suggested for this purpose, but those described by Celsus and Dr. Lee are the only ones that appear practicable. In cases of this kind, Celsus had recourse to decapitation; and I have known this plan to be employed by M. Dubois on several different occasions. He acts in the following manner: Having ascertained the exact situation of the child's neck, he introduces the whole hand into the uterus (the left one when the head is at the right side, and the right one when it is at the left), and, hooking the index EMBRYOTOMY. 857 finger over the cervical region, he endeavors to draw it downwards, so as to make this part more accessible; should the finger not prove sufficient, the blunt hook is advantageously substituted for the same purpose (see Fig. 132). A pair of long scissors, having thick and very sharp blades, and moderately curved on the side, so as to correspond with the axis of the pelvis, is then guided up to the infant's neck along the palmar surface of the hand previously introduced; then the blades are opened a little, and a small portion of the neck is cut, then a second, and thus, by repeated small incisions, its whole extent is gradually divided. When the decapitation is com- pleted, he draws on the arm which is usually found in the vagina, in this way extracting the trunk without much difficulty; and afterwards he delivers the head in the man- ner above stated. Ramsbotham, Sr., devised an instrument resembling the blunt hook, and having a cutting blade concealed within its curved part; when the neck is properly secured, this blade is detached from the principal stem, so as to operate like the guillotine on the child's neck. 31. Van der Ecken has recently proposed, for the same purpose, to embrace the child's neck with a blunt hook containing a chain saw. The decapitation is not always feasible, at least we could not succeed in effecting the section, in a case to which we were called by Doctor Leveille. The head and neck were so high, and the uterus so strongly contracted, that it was not possible to get the hand and scissors far enough up to embrace the neck properly • after several fruitless attempts, we determined to perform the opera- tion recommended by Doctor Lee, but, before doing so, concluded to try the pelvic-version The right hand was passed in as far as the breech, but it could not reach the feet; the forefinger, curved like a hook, grasped the buttocks and whilst this hand was pulling on the breech, the side of the foetus, which had already engaged in the excavation, was pushed upwards and to the right by the fingers of the other hand. By operating in this manner for five or six minutes we were fortunate enough to bring down the pelvic extremity, and thus terminate the labor favorably as regards the mother. The lying-m presented nothing unusual. , , , Doctor Lee's method consists in separating the arm from he body as also in perforating the thorax and abdomen; then, by fixing the blunt hook on the pelvis or lower part of the spine, he makes use of sufficient force to bring the child down double, and thus effects its delivery by a mechanism very similar to the spontaneous evolution. Perhaps it would be better to follow Davis s plan, Mode of using the blunt hook in the trunk presentations, to bring down the neck. 858 DYSTOCIA. and divide the trunk in two, and afterwards extract the parts separately.1 This method should never be resorted to except when the section of the neck is im- possible. In a case in which version could not be effected, M. Parmat resorted to a pro- cess somewhat resembling that of Dr. Lee's, except that he did not first amputate the arm, this very properly seeming to him an altogether useless preliminary. Making use of the blunt hook which terminates the handle of the forceps, he passed it beyond the false ribs, and then turning it forcibly, so as to bring its extremity in contact with the integuments of the foetus, he perforated with it the walls of the abdomen, if unable to reach the ribs, so that in withdrawing it, it hooked into the lower border of the thoracic parietes. Then, by means of tractions with the branch of the forceps, he succeeded in communicating to the trunk a motion similar to that which it performs in spon- taneous evolution. The head and shoulder ascended gradually, whilst the pelvis approached the vulva and was finally delivered. This quite simple method is certainly preferable to Dr. Lee's, and in many cases might be substituted for the decapitation of the fcetus. 1 M. Payan, of Aix, resorted to Davis's operation in one instance, where the trunk was low down in the excavation: but the plan certainly did not originate with him. (Gaz, Med. 521, 1840.) PART Y. OF THE DELIVERY OF THE AFTER-BIRTH. This comprises the natural or artificial expulsion of the fcetal appendages from the mother's womb, and is the complement of the labor. Like the latter, it is generally accomplished by the unaided powers of nature, though in certain cases, which are fortunately very rare (about one in two hundred), it is attended by difficulties or complicated by accidents that may'require the intervention of art. We shall, therefore, have to treat of the natural and the artificial delivery of the after-birth. ARTICLE I. OF THE NATURAL DELIVERY OF THE AFTER-BIRTH. Whilst the expulsion of the fcetus is being completed by the spontaneous exit of the breech and lower extremities, or immediately after the expulsion, the walls of the uterus retract in virtue of their inherent contractility of tissue, and its cavity diminishes; but the placenta, being a spongy and non-contractile mass, does not follow this action of the organ. Consequently, it becomes puckered up, and the cellular and vascular tissues, that connect it to the internal uterine sur- face, are rendered tense and then torn, as the difference in the respective size of the two bodies becomes greater under the force of the repeated contractions. A rupture of all these bonds of union is soon effected, the placenta is completely detached, and descends by its own weight to the os uteri; the latter, being irri- tated by its presence, reacts on the body of the organ which is immediately thrown into contraction; the internal orifice, which was closed after the delivery of the child, again dilates, and the placenta, being driven from the uterine cavity, passes into the vagina, whence it is forced outwards by the contraction of the vaginal walls aided by the abdominal muscles. Hence there are three distinct stages in the delivery of the after-birth; which we may divide, like Desormeaux, into the detachment of the placenta, its expul- sion from the uterus, and its expulsion from the vagina. fhe detachment of the placenta is not always accomplished in the same way; the process varying with the part of the uterus to which it is united. For in- stance, when attached to the fundus, the separation first begins near the centre of the mass, because this is the thickest part, and can least accommodate itself to the retraction of the uterine walls; whilst its thinner margins, being more 860 DELIVERY OF THE AFTER-BIRTH. easily wrinkled, are less liable to rupture the tissue connecting them with the womb; a lenticular cavity is thereby created, which is bounded externally by the still adherent borders of the placenta. A quantity of blood is gradually effused into this cavity, which contributes, with the uterine contractions, to effect the separation; thus, in this case, the detachment is effected from the centre towards the circumference. The placenta, being wholly detached, then descends to the orifice, its fcetal surface corresponding to the latter, and becoming the ex- ternal face, whilst the uterine surface is the internal face, which, together with the inverted membranes, constitutes a pouch, wherein such a quantity of fluid or coagulated blood is occasionally collected, as to seriously impede its delivery. When it is attached to the anterior, the posterior, or the lateral portion of the womb, the separation commences at one of the margins; or, if at the centre, it is soon propagated towards one border, generally the superior, though, in some instances, the inferior one. In the former case, the process advances in the way just described, and the placenta again presents, by its fcetal surface, at the cervix uteri; but, in the latter, being suspended on the uterine wall until the detachment is completed, it presents at the neck by its inferior margin. It is then generally folded upon itself, and engages in the orifice rolled up in a conical form. When the placenta presents its fcetal surface at the os uteri, it plugs up the orifice by its bulk, and prevents the blood from escaping; wherefore, its delivery in such cases is usually followed by the expulsion of numerous large coagula. But where only one border engages, there is no obstacle to the issue of the blood, and hence the discharge of this fluid commences with the detachment of the after-birth, is increased at every pain, and persists throughout the whole process. From the description just given, the reader would naturally suppose that the detachment of the placenta only begins after the child is born; this, however, is not always the case. In fact, the following phenomena are more usually ob- served to take place: as soon as the labor pains are developed and the dilatation of the os uteri has commenced, the separation of the ovum begins in the neigh- borhood of the uterine orifice, and then gradually progresses over all parts of its surface, although not in a perfect and complete manner. After the membranes are ruptured, and the waters are partially discharged, the uterine cavity dimi- nishes; the ovum becomes wrinkled, and its detachment is carried to a still greater extent; even involving the after-birth, as proved by the fact that the fluid or coagulated blood is frequently expelled simultaneously with the foetus, in cases of protracted labor; which blood must evidently come from that portion of the uterine surface in contact with the placenta. A separation of the greater part of the placental mass is particularly apt to occur in the breech presentations, in consequence of the gradual contraction of the womb, as the lower parts of the fcetus are delivered. « The interval between the child's birth and the delivery of the secundines is very variable. Dr. Clarke, from a great number of observations, established its mean duration at twenty-five minutes; but if by this a perfectly spontaneous delivery is to be understood, one in which no traction is made on the cord, we believe he is in error, for this interval is generally much longer. At the in- NATURAL DELIVERY. 861 stance of M. P. Dubois, we made some experiments, in 1836, with a view of de- termining this question ; and those researches proved that, when the delivery was left entirely to nature, the final expulsion of the placenta did not usually occur under an hour or an hour and a half after the birth of the child. It is true, the detachment of the after-birth, and its removal from the uterine cavity, is effected, as Clarke states, in the course of fifteen, twenty, or twenty-five minutes; but, having passed into the vagina, it sometimes remains there for several hours with- out causing the least irritation by its presence, the least tenesmus, or bearing- down effort. This circumstance is easily explained by the fact that the sensi- bility of the vaginal walls is blunted, as it were, by the long pressure they were subjected to from the head and other parts of the child. Besides which, as Levret long since remarked, the after-birth will be the sooner expelled in pro- portion as the patient is stronger, and the contractions more energetic; as the quantity of water in the womb was smaller, and as the period between the rup- ture of the membranes and the delivery of the child was the longer. Although its delivery may generally be left to the powers of nature without any serious inconvenience, yet it is equally true that it will be delayed a long time in a large number of cases. Now, such a delay would force the patient to remain on a bed, which is poorly adapted for repose after all the fatigues of labor; and besides, so long as the delivery is not completed, she still considers herself exposed to numerous dangers, and her fears may have an unfavorable in- fluence over her condition. On this account, most of the accoucheurs of the present day believe it advisable to accelerate the extraction a little, for the purpose of relieving the woman from her anxiety, and of sparing her unnecessary pain; without, however, attempting to deliver the secundines immediately after the child's birth. But, before making any traction on the umbilical cord, it is necessary to ascertain the situation of the placenta, and especially the condition of the uterus. If the latter is small, hard, and contracted, and situated in the lowest part of the abdomen, it is infinitely probable that the placenta is, in great part at least, expelled from the cavity of the womb into the vagina. This, how- ever may be easily ascertained, for the fiuger introduced into the vagina readily detects the mass, and even distinguishes the insertions of the cord. Tbere is then, generally, nothing to prevent its being extracted at once, and simple trac- tions upon the external end of the cord are all that are required for this pur- pose. When, on the contrary, the uterine tumor continues on a level with, or even above the umbilicus, and has a soft doughy feel, due to its imperfect contraction, the placenta is very probably still within the womb, and the first object should be to ascertain whether or not it is detached. Now we know that the separation is usually accomplished by the fresh contractions that reappear after the apathy which follows the expulsion of the child; and hence, there is every reason to suppose it is completed when these contractions have repeatedly occurred. A little blood usually escapes from the vulva during the process. Finally, if one or several fingers be passed up to the uterine orifice, the after-birth is found present- ing there, °and, if it should not be met with, the accoucheur may rest satisfied that the separation is not yet completed, and therefore he ought to wait. Should the detachment be delayed too long, frictions over the fundus uteri are resorted to, 862 DELIVERY OF THE AFTER-BIRTH. for the purpose of rousing the pains, or the same object is produced by titillating the cervix uteri with one or two fingers. Great care should be taken not to make frequent tractions upon the cord, for unpleasant consequences might result. Thus, if the placenta is completely adherent, the tractions are liable to detach a part, and give rise to hemorrhage, or they might tear away a portion of the after- birth and leave the remainder in the womb; again, the organ might be inverted or the cord ruptured thereby. Certain writers recommend a ligature on the placental extremity of the cord after the child's birth, for the sole purpose of facilitating the detachment of the after-birth. The easy separation when this has been done, says 31. Stoltz, is caused by the weight and turgescence of this organ, which, when expelled, is found to be engorged with blood; this practice is attended with no inconve- nience, and is at least beneficial by preventing the patient's bed from being soiled with the blood that ordinarily escapes from the cord. After its entire separation, the after-birth constitutes a foreign body in the uterine cavity, which the organ endeavors to dislodge by contracting. These contractions, which are recognizable by the hardness of the uterine globe, and which are usually perceptible to the patient, indicate the time for operating; the accoucheur then takes hold of the umbilical cord, after having enveloped it with a cloth so as to prevent it from slipping, and winds its end around one or two fingers; he next makes a moderate traction with a view of extracting it, but, as Fig. 133. The mode of extracting the placenta. soon as any resistance is felt, he ought to slip up two or even three fingers of the other hand along the upper surface of the cord as far as the os uteri; the points of these fingers, which are intended to press the cord backwards, are brought together so as to receive the latter in the entering angle thereby formed, around which it plays like a pulley. To understand the advantage of this manoeuvre, it is only necessary to bear in mind that the tractions made by one hand alone would correspond to the axis of the vagina, which forms an angle with that of the uterus; whence it happens that the placenta, instead of being drawn to- wards the centre of the orifice it has to traverse, would abut against its anterior border, and the corresponding parts of the cervix, upon which all the tractive efforts are spent. The patient should be directed to bear down while the trac- tions are made. As the placenta clears the orifice, and gets into the excavation, NATURAL DELIVERY. 863 the operator changes the line of action, and gradually carries the cord forward, so as to make it always correspond with the axis of the pelvic canal. Under the joint influence of the tractions and the patient's bearing-down efforts, the placenta soon reaches the vulva, where it is seized by the thumb and fingers and twisted round several times, so as to complete the detachment of the membranes and form them into a solid cord, for the double purpose of preventing their laceration and of securing their entire removal.1 It is impossible to state precisely the amount of force which may be used in these tractions upon the cord, and it must be left to the intelligence of the practitioner to discover what is proper to be done. When, however, the tractions have no effect, and the placenta seems to rise up and draw the cord after it, as soon as they have ceased, all efforts should be suspended for the time being. " When the placenta is partially engaged in the orifice by a portion of its periphery, this plan," says M. Guillemot, "ought to be somewhat modified; for, in this presentation, the root of the umbilical cord, instead of correspond- ing to the cervix, is higher up in the uterine cavity; and hence, if the operator resorts to traction, the centre of the placenta will have a tendency to enter the orifice, and thus add its bulk to the disk already engaged there. Such a dispo- sition sometimes constitutes an obstacle to the further delivery of this mass; but it is surmounted by making some moderate tractions, not on the cord itself, but rather upon the part previously engaged, by applying two fingers on its sur- faces." We have had numerous opportunities of testing the practical utility of M. Guillemot's advice. " This seems," says Merriman, "all that it is right to do, for a full hour after the child is born ; but that time being elapsed, and there being no reason to expect that uterine contractions will spontaneously arise, the accoucheur is to consider whether it is prudent to wait longer, before he proceeds to extract the placenta, by introducing his hand into the uterus. " If no bad symptoms are present, there can be no danger in allowing more time to elapse before we proceed to this operation; especially, if there be reason to think that the retention arises principally from the exhausted state of the patient; because it is possible that a little more delay will recruit her strength, and that afterwards sufficient power may be imparted to the uterus to expel the placenta. "Yet, generally speaking, we can have but little expectation that the pla- centa will be expelled by the natural powers, after it has been retained much i There certainly would be no very great danger in leaving a portion of the membranes in the uterine cavity ; although, in addition to the accidents that may ar^e pre sence of a foreign body there, the following phenomenon might possibly occur. The membranes may inclose'some Coagula, and thus form a mass .hose expuls.on Mi often difficu t. In the course of a few days, the uterus, being irritated by the presence of tins fncTv nient lodger, begins to contract, and the woman experiences some col.cky pains, Tryuig in intensity with the strength of the contractions ; a little blood escapes from the vu va and, after the pains have lasted for a longer or shorter period the patient is finally delivered of the foreign body, or, according to her expression, of a large piece of flesh, the appearance of which causes great alarm. 8(34 DELIVERY OF THE AFTER-BIRTH. more than an hour; we may, therefore, consider ourselves justified in interfering to extract it, at the end of an hour or two after the child is born. "It appears, then, to be a question of prudence or discretion, which every accoucheur must judge of in the individual case he is attending, whether to proceed to delivery at the end of the hour, or to wait another hour or two be- fore he undertakes this operation. But, of course, this only applies to cases where there is no apparent danger." (Synopsis, page 153.) "The time for interference of the accoucheur for the delivery of the pla- centa, should always be regulated by the condition of the uterus itself," says Dewees, " and that condition is whenever it is firmly contracted. Time, simply considered, can never form a safe rule for the delivery of the placenta; the degree of contraction of the uterus alone can point out the proper moment to operate, or teach us when it would be improper to attempt it. This rule, I be- lieve, will never deceive, or at least, I have uniformly acted upon this principle; and, so far, I think I am safe in saying, I have not had cause to believe it wrong." (System of Midwifery, page 447.) As soon as the placenta is delivered, we must ascertain whether any portion of it, or of the membranes, has been left behind in the womb; but this is easily done by carefully examining the secundines. Should it happen that the membranes or after-birth are not extracted entire, it would be proper to pass the hand into the uterus, for the purpose of removing the remnants. If a large quantity of the coagula that usually accompany the placenta re- mains in the womb, they may subsequently become a source of the after-pains before described. Consequently, if there is reason to suspect the presence of large clots in the womb, the latter ought to be stimulated to contraction by re- peated frictions over the hypogastrium. Some authors have even recommended the introduction of the hand into the uterine cavity, so as to rid it completely of all foreign bodies; but this advice ought not to be followed, because, on the one part, the uterus would be unnecessarily irritated, and on the other, it would not prevent the subsequent formation of fresh coagula. We stated above, that usually in the course of fifteen, twenty, or twenty-five minutes after the birth of the child, the uterus, by contracting, notifies the accoucheur, as it were, of the proper moment for his intervention. It should always be remembered, however, that moderate tractions are all-sufficient for the delivery of the after-birth; and, if much resistance is met with, it would be far better to wait, and not make any new attempts, until the contractions shall have partly or completely overcome the obstacle. Where there is the least reason to suspect the existence of a second child, after the birth of the first, the physician ought to satisfy himself on that point, both by an external and an internal exploration, before attempting to remove the placenta; and should a twin pregnancy be recognized by the great size of the womb, and more particularly by the vaginal examination, a ligature is to be ap- plied immediately on the placental extremity of the cord belonging to the first infant; and the secundines are only to be extracted after the expulsion of both children. If, however, the placenta were detached, and presented at the orifice, he should attempt to extract it, more especially when it seems to obstruct the passage of the second foetus. Nevertheless, such tractions ought to be exceed- ARTIFICIAL DELIVERY. 865 ingly reserved ; because, in compound pregnancies, there are frequent adhesions between the two placentas; and, if this were the case, it is evident that any forcible traction might detach the after-birth of the second child long before its expulsion; and this premature separation would render the mother liable to severe hemorrhage, and the child to fatal asphyxia. After the birth of both children, so far from pulling on the two cords simul- taneously, and moderately twisting them into one, it is more prudent to bring down the placentas, one after the other, giving the priority to the one which offers the least resistance. The mass of these conjoined bodies is made to en- gage in this way by one extremity; and it is thus enabled to clear the uterine orifice more readily. In most cases of compound pregnancy the womb is excessively distended, and this distension, as we are all aware, is one of the circumstances that is most likely to enfeeble the contractility of its tissue; therefore the removal of the after-birth, after the labor is over, should not be accelerated too much, and the womb must be allowed a longer time than usual for its retraction; while mode- rate frictions are to be made over the fundus of the organ for the purpose of stimulating its action. As regards the removal of the secundines after a miscarriage, we have no- thing to add further than what was stated in the article on Abortion. (See p.. 338.) ARTICLE II. OF THE ARTIFICIAL DELIVERY OF THE AFTER-BIRTH. The difficulties that may require an artificial delivery of the after-birth are caused either by inertia of the womb, excessive volume of the placenta, weakness of the umbilical cord, irregular contraction of the uterus, or by intimate adhe- sions of the placenta itself. Whenever repeated attempts to effect its delivery, made in the usual way, prove ineffectual, the attendant ought to search for the cause of the delay, both by abdominal palpation and by a vaginal exploration. One of two things will then occur : either the placenta will be found lying over the internal orifice, or it will be so high up that the finger cannot reach it. Supposing the previous tractions had been made in the proper direction, an obstacle to the delivery in the former case could only depend on the unusual size of the after-birth, on the fragility of the umbilical cord, or on a contraction of the uterine orifice; in the latter, the placenta must evidently be retained at the fundus, either by abnormal adhesions, or by the irregular contraction of some part of the uterine walls. This first diagnosis being once established, the operator only has to decide upon which of those circumstances the delay is dependent. § 1. Inertia of the Womb. We have hitherto stated that the contracted uterus forms a large, hard, and resistant tumor in the sub-umbilical region after the child is born. Now, it may happen, either from the general debility of the patient, or from the feebleness or atony of the womb itself, that its organic contractility is not aroused, and the 55 866 DELIVERY OF THE AFTER-BIRTH. organ still remains after the birth of the child in a state of partial or complete inertia. This inertia of the womb (which will claim our special attention when treat- ing of the hemorrhage that so frequently accompanies it after the delivery) may be simple, or complicated with flooding; but we have only to speak of the first variety at the present time. This condition is indicated by the large, soft, and insensible tumor, which is detected by applying the hand upon the abdomen. If the inertia of the womb is not attended with flooding, it is probable that the placenta still remains undetached; and therefore no imprudent tractions should be made on the cord, lest a separation occur before the inertia is remedied. This would inevitably produce a frightful hemorrhage, which might cost the patient her life in a few minutes; or, should the placental adhesions resist the tractive efforts, the womb would be drawn down along with the after-birth, thus producing a partial or complete inversion of the organ. It is, therefore, a truly fortunate circumstance when the inertia is manifested before the separation of the after-birth is commenced. A further source of hemorrhage is found in the umbilical vessels; but this accident is exceedingly rare, and besides it can easily be remedied by applying a ligature on the cord. The best course to be pursued in cases of simple inertia, is to wait until the uterus regains its powers; the return of the contractions might be accelerated, however, by moderate frictions over the lower part of the belly, or by titillating the os uteri with one or two fingers in the vagina, and by the application of cold compresses over the hypogastric region, and on the upper part of the thighs. In cases of partial inertia, some English practitioners, Dr. Murphy in particular (London Med. Gaz.), have recommended a tight bandage around the abdomen; or, preferably, a resort to immediate pressure over the uterus, by applying both hands on the sides of the organ. 31. Guillemot asserts that he has often suc- ceeded in arousing and keeping up the contractions by plunging the end of the cord in a glass of cold water; but we can scarcely comprehend how this singular result can occur. The patient's strength is to be kept up at the same time, by some broth, or, possibly, by a little good wine; but the use of this latter article, as well as of the cordial stimulants recommended by the older accoucheurs, which frequently gave rise to the most dangerous hemorrhages, requires the exercise of a sound discretion. § 2. Excessive Volume of the Placenta. This may be either real, or due to the collection of large coagula in the pouch of the membranes, created by the inversion of the placenta in falling upon the os uteri, after its detachment. This source of difficulty is easily recognized by observing the unusual volume of the uterus above the pubis, and by detecting the detached mass at the os uteri by the finger. In most instances, the natural contractions of the womb, assisted by a mode- rate traction upon the cord, are all-sufficient for the delivery of the after-birth; though it is occasionally necessary to pass the hand into the vagina and to carry one or two fingers up into the uterine cavity for the purpose of hooking it down. When the increased size is owing to the accumulation of coagula in the pouch, ARTIFICIAL DELIVERY. 867 the membranes, if within reach of the finger, or the placenta itself, should be perforated so as to afford an outlet to the fluid part of the blood, whereby the total mass is diminished, and its subsequent expulsion or extraction facilitated. § 3. Weakness of the Cord. This weakness, whether owing to deficient development of the cord itself, as happens in cases of premature labor, or to the particular mode of distribution of the umbilical vessels, so well described by Benckiser in his inaugural thesis (see Umbilical Cord), may facilitate its rupture; and hence the operator ought to be very careful in pulling on this part. Again, a rupture of the cord during the delivery may be dependent on its oblique attachment to the placenta. Therefore, as a general rule, whenever the hand feels it giving way during the traction (for it produces a peculiar yielding sensation), the attempt should be discontinued ; and, unless there are some special reasons to the contrary, the further delivery must be left to the powers of nature, or else the placenta itself should be laid hold of, if it be deemed proper to extract it immediately. In conclusion, if, notwithstanding all proper precautions, the cord does become ruptured, the accoucheur has only to introduce the band into the vagina, and pass up two or three fingers into the uterine cavity, so as to seize and extract the placenta. It is then sometimes difficult to distinguish the placenta from the wall of the uterus itself, thus exposing the operator to make dangerous tractions upon the latter. The following signs may enable us to avoid committing an error of this kind : 1. The fingers applied to the foetal surface of the placenta can distinguish the1 projections formed by the vessels which are distributed upon it. 2. Pressure upon the placenta would hardly be perceived by the patient, whilst it would be painful if applied to the wall of the uterus. 3. Lastly, the other hand applied upon the hypogastric region, is sensible of a greater thickness of parts intervening between it and the hand within the organ than could be due simply to the united thickness of the walls of the abdomen and of the uterus. § 4. Irregular or Spasmodic Contraction of the Uterus. The causes of uterine spasm are very obscure; though, according to Stoltz, the predisposition exists in the organ itself. If any exterior causes can contribute to its production, they certainly must be those which have a special action on the womb • such as, improper frictions or manipulations, pulling on the cord, and the abuse of stimulating remedies, the ergot, particularly. Again, the irregular contractions of the uterus are more frequently remarked after a twin labor than others The modern authors, who have made this a subject of special study, do not fully agree with each other, in regard to the sequel* of these irregular con- tractions. The different forms exhibited by the uterus in such cases have been reduced, by M. Guillemot, to two principal varieties : the one depending on the conformation of the womb; and the other developed as a consequence of the presence of some foreign body in this viscus. The former is designated by him L the hour-glass, or spasmodic contraction of the neck at its interna orifice; the latter by the term encystment, or the irregular contraction of the body of the womb. 868 DELIVERY OF THE AFTER-BIRTH. We shall follow the example of 31. Stoltz, by admitting four distinct varieties of uterine spasm, namely : lst, a spasmodic contraction of the external orifice of the neck; 2d, that of its internal orifice ; 3d, that of one or more portions of the body of the uterus; and, 4th, a spasmodic contraction of the whole womb. A. Spasmodic Contraction of the External Orifice.—A person who has had many opportunities of observing the softness and flaccidity of the cervix uteri at its lower part after the child is born, can scarcely comprehend the possibility of spasm at its outer orifice ; and hence many authors have altogether denied its existence. Besides, it must be evident that, even if such a condition were to occur, it would constitute but a momentary obstacle to the delivery of the after- birth ; and therefore we would only have to wait until the spasm of the orifice had yielded to the force of the contractions. Or, if any accident should occur requiring a prompt delivery, the resistance might be surmounted without diffi- culty. B. Spasmodic Contraction of the Internal Orifice.—This is what M. Guille- mot understands by the term hour-glass contraction of the womb; and we quote a considerable part of his excellent description of it. When the hand is intro- duced, the cervix is found projecting into the vagina, and so disfigured that it resembles a section of the large intestine ; but about five or six inches above this, the finger is arrested by a kind of stricture, which is the wrinkled and contracted internal orifice. According to Madame Boivin, the uterine neck sometimes mea- sures five or six inches in length and four to five in diameter, in this state of flaccidity; the cavity of the womb containing the placenta is found above the retracted part. In some instances, the uterine walls are firmly contracted around this mass, whilst at others they are in a state of partial or complete inertia. The cavity of the womb is thus divided into two portions. When the upper one is contracted on the placenta, as most generally happens, its volume does not ex- ceed the moiety of the whole organ; and hence the retraction, although seated at the internal orifice, seems to exist very near the middle of the uterus; which circumstance has induced many practitioners to suppose that they had encoun- tered an irregular contraction of the body of the womb. In most cases, the after-birth is retained entirely within the superior cavity; but this is not always the case, for, in some instances, this vascular mass has been found strangulated, to a certain extent, by the stricture of the neck, one part being retained in the upper portion and one in the lower. Whence it may happen : lst, that a very small portion of the placenta projects into the vagina; or, 2d, that it is strangulated near its central part; or, 3d, that more than one. half of the placenta hangs down below the strictured orifice; which different circumstances, as we shall have occasion to show, modify the treatment. The hour-glass contraction is recognizable by the shape of the uterus, and by the resistance presented at the internal orifice, both to the placenta, and to the accoucheur's finger. The organ is found hard and contracted, when felt through the abdominal walls, and all tractions on the cord prove ineffectual; besides, the operator, by resorting to the touch, will find the placenta above the internal orifice, which is contracted, whilst the walls of the neck below are soft, flabby, and pendent in the vagina; and. lastly, there is no discharge of coagula, and sometimes even no blood of any consequence escapes. ARTIFICIAL DELIVERY. 869 When the stricture is not accompanied by any pressing symptoms, we should wait, for the spasm generally gives way in the course of a few hours ; the uterus then regains its normal form, and the after-birth is expelled. Should it persist longer than four or five hours, the opiate preparations might first be resorted to, followed by venesection, if indicated by the general phenomena of plethora; bathing might, likewise, prove very useful. But the difficulty of watching the state of the uterus during its administration must restrict its use greatly. But if, notwithstanding the employment of all these measures, the spasm does not yield, or if it is complicated by an alarming hemorrhage, we must forthwith attempt the dilatation of the strictured part. This is effected by first introduc- ing one finger, then two, and then three, with a view of enlarging the orifice by degrees until it will admit the whole hand. The advice of M. Stoltz, to smear the fingers with belladonna ointment, might prove serviceable. Should a portion of the placenta be engaged in the retracted part, our course would evidently vary under the different circumstances alluded to above. For instance, if a very small portion only of the after-birth is engaged, the operator ought to push it up, and then penetrate into the uterine cavity, in the way just described; but if strangulated near its central part, the fingers are to be slipped up between it and the neck, and then the part that is still above the stricture is to be gradually drawn down. Again, if most of the placental mass is already clear, we must get hold of this free portion, and by compressing it forcibly in the hand, endeavor to reduce the size of the strangulated part, and thereby effect the delivery of the whole. C. Irregular Contractions of the Body of the Womb.— The womb in contract- ing, becomes accurately applied on the body contained within its cavity ; and, of course, where the placenta still remains undelivered, the womb retracts upon it. As the contractions operate at all parts, the walls of this organ, being opposed to the circumference of the placenta, and, consequently, meeting with little or no resistance, gradually approach each other, and shut it up within their cavity; this constitutes the inclusion of the placenta; and it may assume two very dis- tinct forms, to which different names have been applied, i. e., the encystment and the encasement. Encystment is that variety in which the placenta is so surrounded on all sides, excepting at the opening of the cell for the entrance of the umbilical cord, that it is absolutely imprisoned. Encasement is that in which the uterine walls m contracting upon the circumference of the placenta, constitute around its margin a kind of collar, or frame, which encases it, just as the turgid conjunctiva sur- rounds the cornea in chemosis. These two species may either be partial or complete: the encystment is said to be complete, when the placenta is altogether shut up in the cell or cyst formed by the retracted uterine walls; and incomplete, where some portion of it breaks out of the door of the cell. In the latter case, the cell is perfect, being lined throughout by the centre of the placenta, whilst the other parts of the latter, that have escaped from the cyst, are attached to the neighboring portions of the uterine walls. The encasement is complete, when the collar formed by the retracted uterine fibres surrounds or encases the whole circumference of the placenta; and in- complete, where it only exists on a part of the periphery of this vascular mass. 870 DELIVERY OF THE AFTER-BIRTH. The hour-glass contrac tion of the womb. In some instances, the womb is not moulded on the circumference alone of the placenta. " For if," says M. Velpeau, " the after-birth were solid and even. like the head, the womb in contracting would necessarily retain the form of a pouch; but the cotyledons, in the process of the detachment, may separate from each other, and the placenta would then offer more resistance in some parts than in others; so that the uterus soon divides into seve- ral compartments, or divisions, more or less distinct from each other, and each of which embraces some portion of the after-birth." In these cases, the hand, in effecting the artificial delivery, would necessarily have to penetrate through four, five, or occasionally even six circular stric- tures, after having dilated them. The encystment may be complicated by a retraction of the internal orifice (see Fig. 134); but, in most of the re- corded cases of this kind, the resistance has easily been surmounted. It may take place at any portion of the womb whatever, though more rarely at the fundus than elsewhere; which is probably owing to the circumstance of the fibres in this region being more active, so that the detachment of the placenta, when it is inserted at the fundus, is accomplished much sooner. The encystment may be recognized without much difficulty; for, by palpating the lower part of the belly, two tumors are detected just above the pubis, formed by the body of the uterus; the larger of which contains the after-birth, and the other, placed below or towards one side, and joined to the first by a kind of neck, constitutes the remainder of the uterine globe. And, by following the cord with the index finger up into the cavity, we find its lower portion but little retracted; though further up the finger detects a small rounded opening, the orifice of the cell through which the cord passes; and beyond it are the irregular walls of the cyst, enclosing the placenta. Here, also, the accoucheur ought to wait, if the encystment is not complicated by any accident; endeavoring, however, in the meanwhile, to favor the return of the womb to its normal form, by a resort to the measures before advised. When any dan- ger threatens the mother's life, he ought to dilate the orifice of the cyst with the ends of the fingers, and thus penetrate carefully into its cavity. (See Fig. 135.) While these attempts are being made in- ternally, the other hand, placed on the hypo- gastrium, must grasp the fundus, and keep it in position. Douglass, who devoted particu- lar attention to this subject, avers that the placenta is generally still adherent; but Rams- botham, Dewees, and several others assert, on the contrary, that it is usually detached. In Fig. 135. Mode of dilating the strictured part. the former case, the operator would have to attempt its separation ; always taking ARTIFICIAL DELIVERY. 871 the precautions mentioned below. It is to be delivered by taking hold of one border, with a view of making it clear the mouth of the cyst more readily; and if it is but partially encysted, the index finger is entered and passed around that portion of the placenta held by the periphery of the opening; in this way both relieving the stricture and disengaging the encysted part. Instead of attempting to dilate the mouth of the cell, which is often very diffi- cult, M. Dubroca, of Bordeaux, has suggested a new plan, which is styled by him the method of erosion ; it consists of the introduction of a finger into the opening of the cell, and then, with it, tearing up and reducing the placenta to fragments, which are afterwards expelled. He says this mode proved successful in some instances in which he could not succeed in passing two or three fingers into the cyst in the usual way. D. Spasmodic Contraction of the whole Organ.—M. Stoltz relates an instance in which he was called to a woman who had been delivered an hour previously, by a midwife, after the administration of two scruples of ergot; the latter, being unable to extract the after-birth, thought proper, before sending for him, to ex- hibit a sixth dose of eight grains. On his arrival, he found the woman's general condition favorable; the fundus of the uterus extended nearly up to the umbili- cus, and the entire organ was developed as much as at the fifth month ; but its walls were contracted to such a degree that it was quite firm and hard. Follow- ing up the cord, the index finger reached the external orifice, which was greatly retracted, and scarcely permitted the introduction of the first phalanx; every part of the womb within reach was firm and contracted, just like the fundus and body. Of course, the delivery of the after-birth was out of the question; be- sides, no complication indicated its necessity. It was then about half-past two o'clock in the morning ; a draught, consisting of half a drachm of Hoffmann's anodyne liquor, and twenty minims of the common tincture of opium, was ad- ministered. The fundus of the womb did not seem to be any less contracted at nine o'clock in the morning; but, by operating with care, 31. Stoltz succeeded in dilating the orifice, and in passing three fingers up to the root of the cord; but, being unable to get any further, he withdrew his hand, and directed injec- tions of a decoction of belladonna and hyoscyamus. These were repeated every half hour, and, at the fifth injection, the midwife found a portion of the placenta engaged in the vagina; she forthwith drew upon it, and succeeded in extracting it, twelve hours after the child's birth. Should a similar case again occur, the prudent course of the Strasbourg professor ought certainly to be followed. In addition to which, venesection, tepid bathing, &c, might be resorted to, if indi- cated by a plethoric condition of the patient. On the whole, then, it would appear that the irregular contraction is generally partial, though it may be seated at any or every part of the organ; and, further, that all these cases are to be treated in the same way. That is: lst, to wait patiently; 2d, in the course of a few hours to resort to frictions over the fundus, to titillations of the os uteri, and the opiate preparations by inunctions or injec- tions, belladonna to the cervix, either in the form of extract or decoction, vene- section, and general or local bathing. Burns recommends the sudden application of cold compresses. In most instances, the administration of antispasmodics by the mouth, such as sulphuric ether, hyoscyamus, belladonna, or opium, is of un- questionable service; and 3d, when there is any complication that endangers the 872 DELIVERY OF THE AFTER-BIRTH. patient, the forced, though slow, gradual, and careful introduction of the hand, and extraction of the placenta. § 5. Abnormal Adhesions. In the present state of our science, it is very difficult to point out a satisfac- tory cause for these abnormal adhesions of the placenta. According to most authors, they are owing to a fibrous transformation of the cellular filaments which hold the placenta and uterus together, whereby they acquire a degree of solidity sufficient to withstand the uterine forces. These adhesions1 have also been re- ferred to the degenerations of the placental tissue itself, as well as to various osseous and calcareous concretions. In a ca$e detailed by M. Stoltz, the bond of union was evidently formed by a layer of coagulated blood, which had served to arrest a hemorrhage at the fourth month of gestation. 31. Dubois appears to accept this view (Oral Lessons), and attributes these adhesions to patches of a whitish matter of a greater or less degree of hardness, evidently of a fibrinous nature, and increasing in density with the age of the sanguineous effusion of which they are the only remains. According to 31. Gendrin, the adhesion is made by the circle which the reflected decidua forms around the placenta. Sometimes it is only produced at a few points of the uterine surface of the placenta, by the conversion of some part of the organ into a non-vascular, cellulo-fibrous tissue, by the accidental atrophy of one or more of the placental cotyledons; which atrophy not unfrequently occurs. The generally-received opinion, of the truth of which, however, I have some doubts, is, that these ab- normal adhesions result in consequence of an inflammation of the placenta, or of the uterine wall during gestation, which is terminated by the exudation of plastic and coagulable lymph between the contiguous surfaces; and to this effused mat- ter most modern writers attribute the adherence. The resistance varies, they say, according to the progress of the inflammation; that, where the latter has been acute, and the plastic lymph is soft and recent, the utero-placental adhesions are scarcely any stronger than in the normal state. But, on the other hand, if its chronic character has afforded the effused matter time enough to become orga- nized and condensed, the adhesions will prove very troublesome. The thickness of this species of false membrane is very variable. Wrisberg declares that, in a case where it covered the whole uterine surface of the placenta, it amounted to two lines and a half at the interlobular fissures, and a line and a half upon the face of each cotyledon. But whatever may be the cause that produces such adhesions, there are certain persons who appear to have an unfortunate predis- position to them, since they suffer from this accident at every confinement. The adhesion may be more or less extensive; sometimes existing over the whole placental surface, but at others restricted to certain parts; for instance, it 1 Dr. Dubois furnishes an instance of an abnormal adhesion of the placenta, in which the latter was covered by an osseous or cretaceous substance ; but Gooch, who reports the case, further remarks, that he found the placenta partly ossified three times in the same woman, and that he never had any difficulty in delivering the after-birth. Monro and Merriman also mention several cases where they noticed patches of ossifica- tion on the uterine surface of the placenta; in which the latter, they go on to say, adhered, perhaps, a little more than usual. artificial delivery. 873 may exist at the margin or circumference of the after-birth, the centre being detached;1 or it may be restricted to one or more points of its surface. It like- wise offers various degrees of resistance; occasionally being feeble enough to yield readily, even to moderate tractions; though it is sometimes so strong that either the placental or the uterine tissue yields rather than the bond of union. In some instances, the adhesions are so firm that they cannot be broken up with- out the greatest difficulty, even after death. For example, 31orgagni found a portion of the detached placenta hanging in the uterine orifice of a woman, who died thirteen days after her confinement;, but the other part of it was so adhe- rent that he could scarcely separate it with a scalpel. The adherent portion was indurated, and some traces of inflammation were found on the corresponding part of the womb. Whenever a considerable period of time has elapsed after the labor, without the delivery of the after-birth being effected, and yet the globular form of the uterus,2 its hardness and manifest contraction, clearly show that it is striving to detach and to expel the secundines, and where the finger, passed through the cervix uteri, does not detect the placenta, we have every reason to suppose that there is an unnatural adhesion of this mass. The following signs will then con- firm our suspicions: after drawing on the placenta by means of the cord, the latter will be found to mount up as soon as it is relaxed; during the contraction, the uterine globe becomes harder and diminishes in volume, but after the pain is over, it returns to its former condition much sooner and more perfectly than in other cases; and, lastly, the existence of this complication is rendered unequivocal by carrying the hand up into the uterus. The abnormal adhesions of the placenta may exist alone, or they may be com- plicated with some accident; its partial adherence is nearly always accompanied by a more or less profuse hemorrhage. In cases of simple adhesion, the accou- cheur should always wait, for a delay of a few hours is often sufficient to effect the separation; then, after waiting for a couple of hours, the uterus is stimulated to contraction by the various means before indicated; but, if these prove insuffi- cient, an injection of cold water is to be thrown into the umbilical vein. After having cut the end of the cord, and squeezed the vein so as to free it entirely of any blood it may contain, the cold liquid is injected into this vessel with a suffi- cient degree of force to diffuse it throughout the placental mass. This ought to be repeated, taking care to retain the fluid in the after-birth for several minutes by securing the cord. This injection evidently has a twofold operation, affecting both the placenta and the womb; that is, it distends the former by the introduc- 1 It frequently happens, says Leroux (Traiti des Pertes de Sang, page 306), that the pla- centa is thus detached at the middle, but remains adherent by its margins. The same thing was observed by Albinus, in a woman whose womb he has sketched. " The female," he says, " whose uterus is represented in several of the plates, had a detached placenta, and there was a considerable quantity of clotted blood between it and the organ; it was adhe- rent, however, around the whole border, whereby flooding was prevented." (Louis' Trans- lation of Van Swieten, t. vii, p. 145, and Heister, t. ii, chap, civ, p. 459.) 21 think, says John Ramsbotham, that I have observed a slight alteration in the shape of the uterus. It presents a less regularly spherical form, and its fundus also exhibits a cer- tain degree of conicity. (Obs. on Midwifery?) 874 DELIVERY OF THE AFTER-BIRTn. tion of a new liquid into its vessels, thereby augmenting its size and weight; and the impression of cold on the internal surface of the. latter brings on its contraction. This measure, therefore, ought not to be overlooked. Where it fails, tractions on the umbilical cord are to be resorted to; though always, as advised by Levret, perpendicularly to the surface of the placenta. If two sheets of moistened paper are stuck together, continues this author, for the purpose of illustrating the importance of his precept, and you endeavor to sepa- rate them by sliding one over the other, that is to say. by drawing them parallel to their planes, you tear rather than detach them; whilst, by pulling perpendi- cularly to those planes, you will separate them without the least effort, as also without any laceration. In order to obtain a similar result in practice, the umbi- lical cord is carried towards the side not occupied by the placenta, by the inter- vention of two fingers passed into the vagina beyond the uterine orifice. But it is impossible to carry out this rule, as Velpeau and Guillemot justly remark, be- cause both the foetal and the uterine surfaces of the after-birth are in contact with the walls of the organ; besides, the fingers can only sustain the cord below the cervix, and hence, as a natural consequence, the cord will always be parallel with, not perpendicular to, the long axis of the womb, in whatever manner it be held. The same effect is produced equally well, in their opinion, by drawing on it without this artificial pulley. Though whichever plan be resorted to, the operator must never exert force enough in making the tractive efforts to rupture the cord, and he should desist as soon as he finds it yielding. But, supposing all the local and general irritants, the injections into the um- bilical vein, and the tractions upon the cord just recommended, have proved ineffectual, what is to be done ? When the adhesions are complicated by any hemorrhagic or convulsive affection, all accoucheurs are harmonious on one point, namely, to persist in the attempts to effect the extraction. But the same unanimity does not exist with regard to cases of simple adhesion; for some, dreading the disastrous phenomena that may result from the retention and sub- sequent putrefaction of the placenta, aiid the absorption of putrid matters, are in favor of terminating the delivery at every hazard ; while others, on the contrary, fearing still more the consequences of the manipulations which are necessary for effecting the detachment of the placenta, advise us to abandon the whole to nature; at the same time recommending the ulterior symptoms to be met and combated as they arise by the appropriate measures. Our own opinion is, that the course of Levret, of Baudelocque, of Desormeaux, and 31. P. Dubois, is the best adapted to cases of this kind; that is, after having employed the various means we have spoken of, to introduce the hand into the uterine cavity, following the cord, which is then the best guide up to the pla- centa. Should this have been torn away, the latter could be recognized by the vascular ramifications which characterize its fcetal surface, by its elevation above the inner face of the uterus, by its consisteuce, and by the dull sensation felt by the patient when the fingers bear upon it. The point of attachment being discovered, the next step is to ascertain whether the adhesion is complete or partial., in the latter case, it is recommended to insinuate the open hand between the external surface of the placenta and the uterine wall, and then slit up the adhesions with the finger, just as you would cut the leaves of a book ARTIFICIAL DELIVERY. 875 with a paper-knife. (Fig. 136.) When this is done, 31. P. Dubois thinks it is better to seize the detached part with the whole hand, and pull upon it, with a view ^£- 136 of completing the separation of the rest; but, if this proves unsuccessful, he next tears and brings away all the loose portion, leaving the ulterior expulsion of those parts that still remain adherent, to nature, without resorting to any further attempts. We could bring forward numerous cases in proof of the sound- ness of this precept. For example, we have known a rash operator to perforate the uterus completely whilst striving to separate an ti i , j t j? tv The mode of breaking up the adhesions of adherent placenta; and Leroux, ot Dijon, the placenta. notwithstanding all his dexterity, had the misfortune to detach quite a considerable part of the internal muscular plane, in a case of partial adhesion, by pulling too strongly on the detached upper portion of the after-birth, in order to separate its still adherent lower part. Death soon followed in the case we allude to; and the surgeon of Dijon had a profuse hemorrhage to encounter in his, but he fortunately succeded in arresting it by the application of the tampon. When the placenta becomes separated at its central part, the margins being still adherent, a cavity is usually created at that point, in which the blood accu- mulates. Under such circumstances, the centre of the mass may be perforated, and the fingers be passed up through the opening, to complete the detachment; at least, such was the course adopted by Heister and Leroux. Furthermore, where the placenta is adherent throughout, the accoucheur operates on its ex- ternal face, by slipping up the hand behind the membranes; and when it reaches the circumference of the after-birth, he first endeavors to detach one part, and, where successful, he pursues the same course as if it had originally been a case of partial adherence. Finally, let us add, that it is not proper to persist too long, when a part, or even the whole, of the placenta holds out against the properly-conducted manipu- lations just advised ; for its expulsion will probably take place sooner or later, either all at once, or in fragments. § 6. Of the Partial or Complete Retention of the Placenta. By conforming to the rules just mentioned, we shall rarely fail in extracting the placenta completely; but we have seen that there are nevertheless some cases in which a larger or smaller portion of the after-birth is necessarily left behind, and its expulsion confided to the resources of the economy. Whether this aban- donment be obligatory, or the result of ill-directed tractions on the cord, or of improper attempts to effect the separation of the adherent placenta, it may lead to various consequences, some of which are very serious. It is, therefore, very important to determine the fact, which may almost always be done by a careful examination of the placenta. The only difficulty which could arise, would be occasioned by its separation into fragments in consequence of its very close adhesion. 876 DELIVERY OF THE AFTER-BIRTH. A. Hemorrhage is almost always the immediate consequence of the retention of any considerable part of the placenta, and its amount is generally propor- tionate to the size of the abandoned portion. Sometimes, however, no flooding occurs ; either because the uterus contracted properly after the separation of the placenta, or because the fragments left behind remain attached to the walls of the organ. In the former case, the contraction of the womb diminishes the dis- charge after the lapse of some hours; and, during the few succeeding days, ex- cepting the violent colics occasioned by the efforts of the uterus to expel the foreign body, the patient suffers little more than the discomforts attendant upon a moderate hemorrhage. It is not long, however, before these frequent after-pains seem to give rise to an unusual tenderness of the uterine tumor; and, finally, even slight pressure becomes painful. The lochia, which hitherto were composed entirely of blood, present a different character. They are mixed with a very fetid, sanious fluid, and become very irritating to the genital parts. If the temperature should chance to be high, and especially if the most scrupulous regard is not paid to cleanliness, they diffuse such a disgusting odor as to render the chamber unte- nable; and, as 31. Jacquemier observes, the assistants are liable to suffer se- verely from it. This change in the lochia is due to the putrefaction of some portions .of the placenta. As parts of the adherent mass become gradually detached, they fall into the cavity of the uterus, where they are liable to remain for some time. The contact of air which readily reaches the uterus soon gives rise to putrefac- tion, and the decomposed fragments communicate to the lochia the odor which characterizes them. B. Putrid Absorption of the Placenta.—These local phenomena rarely appear without being accompanied by a sensible alteration of the general health of the patient. After a longer or shorter time, a violent chill comes on, attended with extreme restlessness and anxiety, the pulse becomes rapid, and the skin dry and burning; the face is alternately pale and flushed, though mostly pale; the re- spiration is anxious and frequent; the tongue, which is always dry, is some- times white and sometimes red; the patient complains of pain in the head, attended occasionally with throbbing, and soon delirium, at first intermittent and and finally constant, is added to the other symptoms. The latter become more and more serious; the abdomen is distended and very tender; inclinations to vomit, sometimes even profuse vomiting, and, occasionally, frequent and invol- untary alvine discharges, show that the alimentary canal shares in the general affection. Finally, the pulse becomes more and more rapid, thread-like, and undulating; the debility and restlessness are extreme, there is no cessation of delirium, and death closes this terrible scene five, ten, or fifteen days after the invasion of the first symptoms. Peritonitis, which is in some cases indicated by the tenderness and distension of the abdomen, does not always occur, and death may result simply from the species of poisoning, occasioned by the absorption of the putrefied fragments of the placenta. The symptoms presented by the patient are then simply those of the fevers commonly called adynamic and ataxic. The result is not necessarily fatal, and especially when the disease is uncom- ARTIFICIAL DELIVERY. . 877 plicated with peritonitis, the patient may escape from the danger which threat- ened her. After a certain length of time, the retained portion of the placenta may be- come suddenly detached, and be expelled bodily; upon which, the grave symp- toms to which its decomposition had given rise, cease almost immediately. Sometimes, and under the use of frequent injections, the discharge seems to lose its fetidity and irritating qualities, and becomes more decidedly purulent. Some detached portions of the placenta are found diffused in it, and parts are also brought away by every injection; rather larger portions occasionally present at the cervix and may be extracted with the finger. Whilst the womb is thus ridding itself of the putrid matter which it contains, the general symptoms im- prove, or, at least, are not aggravated. The economy seems to resist the delete- rious influence to which it is subjected. The patient may remain in this condi- tion for several weeks with an almost constant febrile movement, accompanied now and then with exacerbations preceded by slight chilliness, and moderate disorder of the digestive apparatus, until, finally, when the remainder of the placenta is expelled, the fever ceases, the strength returns, and the patient is restored to health. These serious accidents, which are always to be feared when a considerable portion of the placenta is retained within the womb, do not, however, always result from this retention. It may remain there for a long time after the deli- very without seriously affecting the woman's health, and be disposed of in two different but equally strange ways. I allude to the late expulsion and absorp- tion of the placenta. C. Late Expulsion of the Placenta.—The retention of a portion of the pla- centa is almost always attended by a profuse hemorrhage. This, however, does not invariably occur when the entire after-birth remains in the cavity of the uterus, which rarely happens except after abortions. If, in short, the adhesions are nowhere destroyed, and the utero-placental vessels are unruptured, the reason of the absence of hemorrhage, and often even of the lochial discharge observed under these circumstances, is evident. The flooding then comes on only when the uterus at last contracts in order to expel the foreign body. This expulsion may be accomplished at once, and the completely-separated placenta be discharged whole. The hemorrhage, which had lasted four, five, or even ten days, being the time sometimes necessary for its separation, ceases im- mediately after, as by enchantment. This hemorrhage is always far less pro- fuse when the detachment of the placenta takes place at a remote period from the expulsion of the child. The constant contraction of the uterus, which tends unceasingly to resume the dimensions-of the unimpregnated con- dition, necessarily lessens the calibre of the vessels and almost obliterates them, so that their rupture at that time is an affair of little moment. On examining the placenta, it is found to have undergone no alteration, it exhales no unplea- sant odor, and although it may have remained several days, weeks, or even months, in the cavity of the uterus after the expulsion of the child, it is as fresh as though the latter were just born. Its vitality had been preserved by the integrity of its vascular connections, and its prolonged retention been thus rendered innoxious. 878 DELIVERY OF THE AFTER-BIRTH. I have just had occasion to notice a case of the kind, afforded by a young woman three months and a half gone, who miscarried twenty-four days ago. The placenta had remained siuce then within the cavity of the uterus, and a profuse hemorrhage having occurred in consequence of its detachment, I was obliged to extract it artificially. It was already engaged in the cervix, and its withdrawal presented no serious difficulty; the extreme weakness of the patient forbade temporizing. It had no appearance of decomposition. Unfortunately, the slowness with which the detachment of the placenta some- times takes place, may so prolong the discharge as to give rise to another acci- dent. When, in fact, a cotyledon is thus separated, it no longer shares in the circulation of the adhering parts, and remains suspended within the cavity of the womb. After a time, it becomes detached from the rest of the placenta, and if its size or the contraction of the orifice prevents its being discharged imme- diately, it decomposes, and may give rise to some of the accidents already men- tioned. Generally, however, its expulsion is not long deferred, or else the practitioner deems it proper to extract it; still, it is impossible to avoid the hemorrhages, the repetition of which on the occasion of each partial separation at last weaken the patient greatly, and may even endanger her existence. D. The complete absorption of the placenta is so extraordinary a phenomenon, that the first observations published were received very doubtfully. Nothing short of the great authority of such names as that of Naegele, together with the strict detail with which the cases are related, were required to obtain for them a place in obstetric science. Yet it is so easy to be deceived in such cases, that even after the observations of Naegele, Salomon, and Velpeau, doubts will occasion- ally suggest themselves. Is it not possible, indeed, that notwithstanding the strictest surveillance, the placenta might have been expelled unconsciously ? Is it not possible that the species of sanious detritus to which its decomposition gives rise, may have formed a part of the putrescent lochia discharged in such cases ? Finally, may it not have been that its prolonged retention and late ex- pulsion, were regarded as instances of absorption ? Iu fact, that after a woman had thus retained her placenta for several months without her health having suffered materially, it may have become detached without a great deal of hemor- rhage, and small and shrivelled as it was, have been discharged during strainings at stool without the patient herself being aware of it. 31ost of the published cases are, doubtless, liable to one or the other of these explanations; yet it must be confessed that there are others, in which there would seem to be no doubt that the placenta had really been absorbed. After all, analogous phenomena are not wanting. In extra-uterine pregnancies, has not the fcetus often been found reduced to its bony portions in consequence of the absorption of the other fluid or solid parts ? Has not the same thing been known to take place within the uterus when a dead foetus had been retained for a long time ? The absorption of a placenta is certainly not more wonderful, especially in cases of abortion, when the placentas are small and imperfectly formed, as in most of the instances mentioned. The possibility of the occur- rence cannot, therefore, as yet be absolutely denied, though it should be received with a certain degree of reserve. Indications.—We have dwelt sufficiently upon the proper means of preventing ARTIFICIAL DELIVERY. 879 the entire or partial retention of the placenta, and have but a word to add re- specting the prudence which should govern all attempts at extraction. Although the dangerous accidents to which the woman is exposed, require that we should attempt all that is humanly possible in order to effect its extraction, it should be remembered that too long-continued efforts, whether to introduce the hand through a contracted orifice or to rupture the too strong adhesions, are liable to produce equally serious consequences; in fact, that post-puerperal inflammations and even ruptures of the uterus have frequently resulted from these forcible de- tachments; and, finally, that a placenta retained wholly or in part within the uterus, may not be expelled until after the lapse of several months, or may be absorbed without sensibly affecting the health of the mother. Although these latter occurrences are rare, they are yet sufficient to justify, and even require the relinquishment of all violent and dangerous efforts. It were impossible to fur- nish here an absolute rule of action, and it must be left to the intelligence and prudence of the practitioner, to determine how far he shall proceed in such cases. The indications to be fulfilled, when a portion of the placenta has been left behind, either voluntarily, or through awkwardness, vary according to the period at which our services are demanded. Very often a quite profuse hemorrhage is the first accident to appear, and efforts should be made to restrain it by means of cold applications to the hypo- gastrium, groins, and thighs, by frictions upon the body and neck of the uterus, and, with the object of obtaining a more thorough contraction of the organ, ergot should be administered. These measures will very rarely be found insufficient, provided the uterus is properly contracted, but should the accident be compli- cated by inertia, the measures to be indicated hereafter should be resorted to. Care should be taken as regards relieving the violent after-pains which torment the patient, by the use of opiates, since the contractions of which they are the result, tend to separate and expel the adherent mass. The ulterior conduct of the practitioner must be governed by circumstances. If the neck of the uterus appears to be strongly contracted, if the lochia are moderate in amount, and especially if their composition is unaltered and their color and smell unchanged, he should be satisfied with watching the patient closely without interfering with the tendencies of nature by an untimely mter- ^IHoon as the lochia become sanious and fetid, he should resort to the best means of averting their dangerous influence upon the economy. Intra-vaginal and intra-uterine injections practised frequently, and continued until the return- ing fluid is no longer imbued with the odor of decomposition, are very useful. M Vullvamos recommends the use of large quantities of water; he throws up an injection consisting of the warm infusion of marshmallows, by means of a large svringe, every five minutes; he prefers cold water, however in cases of flooding This operation is effected by the use of a long gum-elastic tube one end of which is fixed in the uterine orifice, and the other extends beyond the vulva, or even the foot of the bed, so as to obviate the necessity of uncovering her; the "turn- ing fluid is collected in a basin placed under the patient. (Gaz. Med., 493, 1840 ) I think it would be more prudent to make use of a double tube. The patient should also be examined frequently, in order to ascertain whether 880 DELIVERY OF THE AFTER-BIRTH. any portion of the placenta presents at the cervix, and if so. it should be ex- tracted immediately, either with the fingers, or with Levret's abortion forceps. The injections, indeed, are not always sufficient, being incapable of bringing away moderate-sized fragments. Extreme fetidity of the lochia might possibly authorize the use of slightly chlorinated injections. The patient should also have the advantage of the best hygienic measures. The chamber should be thoroughly ventilated and purified by every appropriate means, and the linen changed as often as possible. If, notwithstanding these precautions, upon which too much stress cannot be laid, symptoms of general infection should appear, complicated with peritonitis, purgatives, baths, calomel, and mercurial inunctions, should be used at the out- set; but the first adynamic or ataxic phenomena must be met with the tonic and stimulant treatment used in the latter stages of low fevers. Water containing wine, preparations of cinchona and acetate of ammonia, may all prove very useful. ARTICLE III. OF THE ACCIDENTS THAT MAY COMPLICATE THE DELIVERY OF THE AFTER-BIRTH. The principal of these are hemorrhage, convulsions, and inversion and rupture of the womb. § 1. Of Hemorrhage. Of all the accidents that may precede, accompany, or follow the delivery of the placenta, flooding is certainly one of the most frequent, and, at the same time, most terrible in its consequences. It may occur conjointly with either of the difficulties just described in the preceding article; and, when this does take place, the indications then laid down ought to be followed up more promptly. But, in addition to those circumstances, a hemorrhage may likewise take place after the child is born; and this claims our special attention, since it is nearly always accompanied by the complete or partial inertia of the womb. We have therefore to examine successively the causes, symptoms, diagnosis, prognosis, and treatment of this inertia, considered with particular reference to the accident in question. We shall thus complete the history of puerperal hemorrhage, which was hitherto only described in part; namely, during the first six months, in the article on Abortion; and during the last three months, as also pending the labor proper, in that on Accidental Dystocia. A. Causes.—After the delivery of the child, and even during the progress of its expulsion, the uterine tissue becomes gradually retracted by the exercise of its contractility of tissue, whereby the cavity of the organ is considerably dimi- nished ; thus constricting the vessels that ramify in the substance of its walls, and reducing their calibre in a greater or less degree, thereby interrupting the circulation, and of course preventing the utero-placental vessels, which are torn by the detachment of the placenta, from becoming the source of a profuse hemor- rhage. Now, under certain circumstances, this contractility of tissue is very ARTIFICIAL DELIVERY. 881 feeble, and in others it is altogether wanting; in the former case the inertia of the womb is partial, in the latter it is complete; again, it may be total or partial, according as it affects the whole or a part of the uterine walls. All which various degrees of the affection may be developed under the influence of the same causes. The causes of hemorrhage from inertia are either predisposing or determining; under the former head, writers have enumerated, lst, a plethoric and sanguine habit, a precocious and usually copious menstruation; more particularly when venesection has not been resorted to in anticipation, during the latter months of pregnancy; 2d, a lymphatic temperament; for those women who have a soft and lax fibre, or possess but little muscular power, and who are nervous and irritable, are more liable than others to this affection; 3d, the occurrence of profuse flood- ing after former labors. We might bring forward numerous cases, all tending to prove the unfavorable influence of previous floodings; and, therefore, from the mere fact of their occurrence at one or more antecedent labors, the accoucheur ought to take suitable measures to prevent their reappearance. Under the head of the so-called determining causes, we may classify, lst, the exhaustion incident to a protracted and painful labor; or, in other words, all the obstacles that may oppose the natural delivery of the foetus; 2d, a very short labor, and its rapid termination from the stupor of the walls, caused by the rude and hasty depletion of the organ; hence a very large pelvis, a laceration of the cervix, and a want of resistance at the perineum, all which facilitate the rapid expulsion of the child, may, from that fact alone, become sources of inertia; 3d, an excessive distension of the womb, whether dependent on a dropsy of the amnios or a twin pregnancy, may paralyze, as it were, the contractility of the uterine tissue; 4th, according to Madame Lachapelle, we must further add a dragging of the uterus, in consequence of an adhesion contracted with the omen- tum during gestation; whereby the perfect retraction of the organ after labor is impeded. There can be no doubt that the various circumstances just alluded to, may ot themselves give rise to inertia; but, as a general rule, their influence will be of short duration and easily set aside, if it is not favored by the existence of some predisposing cause. It is to the latter, especially, as 31. Guillemot observes, that we must refer the chief part in the production of those hemorrhages that occur after the child is born. In fact, where they exist conjointly in the same woman, there is every reason to fear the occurrence of that accident; whilst, if absent, the supposed determining causes usually have but little or no effect. The influence of those causes is ordinarily manifested in the course of a few minutes after the child is born ; though sometimes the inertia is secondary, as it were, not coming on for several hours, or even not until several days afterwards The womb having contracted properly immediately after the delivery of the child or after-birth, then becomes relaxed by degrees, and ultimately gives rise to a frightful hemorrhage. . B Sumptoms —Where the uterus contracts properly as soon as the labor is over, a hard, globular, rounded tumor is found in the hypogastric region, occupy- ing nearly all the space between the umbilicus and pubis. This tumor is the seat of intermittent pains of variable intensity, and is always harder while they 56 882 DELIVERY OF THE AFTER-BIRTH. last. An absence of these characters indicate inertia of the organ; that is, by palpating the lower part of the abdomen, we find nothing but softness and flaccidity throughout; for the abdominal and uterine walls are so easily depressed, that they can be pushed back against the posterior ventral parietes; and, indeed, where the inertia is complete, it is even impossible to make out which are the uterine and which the abdominal walls. Again, by carrying the hand up into the womb, it readily passes through the relaxed cervix, and finds the uterine parietes everywhere flabby and wrinkled like a bit of old rag. Should the inertia be partial, the uterine structures seem to be thicker, and to have a more marked consistence; but tbey are still readily distended, and are far from offering their characteristic resistance. This condition may exist without hemorrhage, if the placental adhesion still remains intact at every part of its uterine surface; but, whenever a separation has occurred, flooding is clearly inevitable. Of course, the latter will be the more copious as the detachment is nearly or wholly completed at the time the inertia is manifested. The signs by which the existence of hemorrhage is recognized are easily made out; but the discharge is sometimes so sudden and profuse, that it is not de- tected until the woman's life is already seriously endangered. The patient gene- rally complains of a feeling of .weight about the stomach; and, soon after, pallor of the face, dimness of vision, smallness of the pulse, weakness, syncope, and all the most alarming general symptoms are manifested. To these are added some phenomena peculiar to the uterine discharge; such as, pains in the loins, a spas- modic chill, and a dragging sensation at the epigastrium, sometimes resembling that caused by hunger; and, in the latter moments, there not unfrequently comes on a hysterical attack, or even some convulsive movements. As regards the local signs, they are variable; and hence, in this respect, the flooding has been characterized as the external and the internal. When it is external, the blood, which inundates the patient's bed, soaks through the mattress, and trickles down on the floor, cannot possibly permit any mistake as to the cause of the general phenomena just indicated. But when it accumulates in the uterine cavity, the nature of the accident may escape detection, or at least, may only be recognized when it is too late to remedy it. Every circumstance whatever that constitutes an obstacle to the ready dis- charge of the blood through the uterine orifice, may give rise to an internal hemor- rhage : thus, a very considerable obliquity of the womb, in which the neck is carried high upwards and backwards; occlusion of the os uteri, by a part or the whole of the placental mass, or by large coagula; a badly applied tampon, or the closure of the vulva by cloths; a spasmodic contraction of the os uteri (although, in cases of inertia, this contraction is seldom considerable enough, of itself, to obliterate the outlet), must necessarily favor the formation of a clot that might easily block up the already diminished cervix. Let us add further, that the elevated position in which the pelvis is designedly placed for the purpose of arresting an external discharge, may prove a cause of internal hemorrhage. Whenever any obstacle prevents the escape of the blood, the latter accumu- lates within the uterine cavity, the walls of which readily yield to distension. If the hand be then placed on the belly, the womb will be found much enlarged, ARTIFICIAL DELIVERY. 883 occasionally even attaining the height it had during the latter months of gesta- tion ; the ball, formed by the retracted organ, is no longer felt at the usual place, its volume has increased, but its hardness has decreased; the finger in the va- gina finds the uterine orifice, which is carried far backwards or is spasmodically retracted, obstructed by the placenta, or by a clot; and when passed up into the womb, it detects there a large quantity of coagulated and fluid blood. (C. Bau- delocque. C. Diagnosis.—It is scarcely possible to mistake the nature of the accident, when the hemorrhage is external; but this is far from being the case when the blood accumulates in the uterine cavity; for, although we have enumerated the general debility, syncope, &c, and the enlargement of the abdomen, as pathog- nomonic signs of flooding, yet these circumstances may all be met with and still there may be no hemorrhage. The increased size of the belly may be owing to the fact that the intestines, after having been so long compressed by the developed organ, become expanded by the gas they contain ; and thus cause the abdominal walls, which are still soft and flabby, to swell up nearly to their previous size. But any errors from this source will be corrected by the resonance of the abdomen on percussion, by the vaginal examination, and by palpating the uterine globe. "Sometimes," says Madame Lachapelle, "owing to the extensibility of the vagina, the womb is carried up by the distended bladder filled with urine, thereby singularly augmenting the size of the belly. In one instance that came under my notice, the pupils had become much alarmed by this circumstance ; but I relieved their anxiety in a moment by the introduction of the catheter. For the prominence of the bladder, which is so easily recognized by an experi- enced person, satisfied me at once as to the nature of the case; and, besides, it was not accompanied by any of the general symptoms of flooding." The accoucheur ought also to bear in mind that a syncope, occurring after childbirth, does not always depend on the loss of blood. It is not unfrequently observed shortly after very rapid labors; for then the womb being emptied at once, the compression to which the hypogastric vessels had been subjected during the latter months of gestation is suddenly removed; the circulation in them be- comes free and unobstructed, and the rapid determination of the blood from the head and upper extremities, towards the vessels of the lower parts, often gives rise to fainting. When it occurs, the horizontal position and the application of a moderately drawn bandage around the belly, are usually sufficient to relieve the affection. An hysterical attack, coming on immediately after the labor, might be mis- taken for those nervous phenomena that so often signalize the unfavorable termi- nation of grave hemorrhage. But in all such cases, by resorting to the vaginal touch, and the palpation of the hypogastric region, the accoucheur will clearly ascertain the retraction of the organ; and, therefore, will not be likely to confound them with the symptoms dependent on inertia of the womb. D. Prognosis.—Flooding after labor is an exceedingly dangerous accident; for a few minutes may decide the woman's fate. Of course, the discharge will be the more profuse as the inertia is more complete and the separation of the 884 DELIVERY OF THE AFTER-BIRTH. placenta more advanced. Other things being equal, an internal hemorrhage is more dangerous, as a general rule, than an external one; simply because it is more apt to escape detection. Of the symptoms that are common to both varieties of flooding, there are some which more particularly indicate the imminency of the danger, and even a speedy death; such, for instance, as severe chills or convulsions, increasing dyspnoea, prolonged syncope, sharp and continued pains in the loins, together with vertigo and loss of vision. " It should also be remarked that the pupil is usually dilated, that it is at times agitated by oscillatory movements, and that the dilatation is particularly evident when the syncope is most profound." (Lachapelle.) E. Treatment.—The treatment of uterine hemorrhage from inertia is either preventive or curative. The preventive treatment consists in breaking, up the predispositions just alluded to, and in preventing the action of those causes which might determine an inertia of the womb after labor. In women of a full habit, whose menstrual discharges have usually been copious, and in whom plethoric phenomena become manifested during pregnancy, it would be proper to resort to repeated blood- lettings in the course of the latter months; and, even during the labor, if the fullness of the pulse, headache, and flushing of the face, seem to require. In those of a feeble and delicate constitution, who have suffered from flooding in their former labors, measures calculated to arouse the contractility of the uterine tissue ought to be employed in the latter stages of parturition; that is, to stimu- late the action of the uterus by external frictions and pressure, by the application of compresses soaked in some cold fluid acidulated with vinegar, over the belly, and more especially, by the exhibition of fifteen to thirty grains of ergot, divided into three doses, about twenty minutes or half an hour before the child is born. Dr. Robert Lee (London Med. Gaz., 1839, p. 713) recommends the following course, namely : to rupture the membranes at the commencement of the labor, in those women whose previous history would cause us to fear a profuse hemor- rhage after the delivery ; without waiting for the dilatation of the os uteri, or at least for the development of strong pains; he then applies a bandage around the abdomen, and gradually tightens it as the labor advances. The subsequent pro- gress is abandoned to nature; taking care to keep the apartment cool, and for- bidding the employment of stimulants of any kind. I have, he says, several times adopted this plan with success. There are still some other prophylactic measures of great value, when there is reason to fear inertia of the womb. For instance, the best way of modifying the action of the determining causes, is to retard the termination of a rapid labor as much as possible, particularly in women of a lax fibre and lymphatic tempera- ment; but, on the other hand, to accelerate a long and painful one by aiding the inefficient powers of nature before the patient is wholly exhausted, and before the womb falls into a state of atony. Doctor Clarke very properly advises the hand to be placed over the fundus during the expulsion of the child, with a view of affording it support, both during and after the contraction. Burns adds, that moderate pressure on the abdomen after the delivery proves beneficial in keeping up, and stimulating the action of the organ. ARTIFICIAL DELIVERY. 885 " But," says 31adame Lachapelle, "if, notwithstanding all your exertions, and notwithstanding the most perfect rest, and the express charge to the patient not to bear down, you find the accouchement progressing with a fearful rapidity, you still have one resource left, that is, to leave the placenta in the womb until fresh pains are excited. For, in most instances, this body is not entirely detached, and it resists the flooding so long as the stupor of the womb, caused by its too sudden evacuation, persists. In the opposite case, that is, when the labor has been too long, the placenta js ordinarily separated from the uterine wall, at least, in a great measure; and hence it can no longer oppose the discharge of the blood. From that time its presence will only serve to keep up the feebleness of the uterus, and by irritating its walls, exhaust it without any benefit; you should therefore pro- ceed at once to the delivery of the after-birth, free the womb from it entirely, and take advantage of the little energy remaining to the latter to procure its proper retraction." (Pratique des Accouchemenls, t. ii.) The English accoucheurs have taken advantage of the sympathy which appears to exist between the mammae and the uterus, in order to overcome the tendency of the womb to inertia in certain women. Relying upon the well-known fact, that putting the child to the breast often excites after-pains within the few days immediately succeeding the delivery, they recommend this to be done as soon as possible after the child is born. So great is their confidence in this measure, that, according to 3Iarshall Hall, no practitioner would be justified in leaving a woman who is predisposed to inertia of the uterus, without directing a proceed- ing which is at once so simple, and so sure to be effectual. Beside the sympa- thetic excitement of the womb thus produced, the suction would have the addi- tional advantage of diverting the blood from the uterus by directing it toward the breasts.1 I cannot too strongly insist upon the administration of from 15 to 30 grains of ergot whenever there appears to be a tendency to inertia after delivery. It is always an innocent remedy, and one which, I am sure, has prevented many a flooding. Curative Treatment.—There is one special indication presented after the child is born, namely, that if arousing the uterine contractions, which alone can put an end to the hemorrhage, as soon as possible. The means suggested for this purpose are exceedingly various, but we shall endeavor to estimate their respec- tive values. Of all the various measures recommended for the flooding dependent upon inertia of the womb, the easiest and most certain is a direct irritation made simultaneously over the body, and on the neck of this organ, by placing the hand on the lower front part of the abdomen so as to rub, press, and squeeze the uterine wall, whilst at the same time two fingers are passed into the vagina to irritate and titillate the os uteri. If these do not effect the object, the whole hand is to 1 Rigby advises, that whenever there is reason to fear hemorrhage from inertia after de- livery, the child be put to the breast as soon as the mother is changed and put to bed. He assures us, that in several grave cases, in which all other means had failed, the uterus contracted strongly and permanently as soon as the child had seized the nipple. In one case only did the usual effect fail to take place, and this, Rigby thinks, was due to the fact of the child of another woman having been made use of. 886 DELIVERY OF THE AFTER-BIRTH. be carried up into the cavity of the organ, with a view of irritating and stimu- lating its internal surface with the fingers, the other hand keeping up the fric- tions on the hypogastrium in the meanwhile. The operator is sometimes obliged to compress and knead the organ, as it were, by bearing strongly on the abdomi- nal surface, while the hand in the cavity serves as a point of support. This measure is preferable to all others, because it can always be resorted to without alarming the patient, and is not. likely to bring on an inflammation of the organ, as is the case with most of the astringent and stimulant articles advised by some writers. The injection of rectified alcohol, oil of turpentine, spirit of vitriol, &c, into the uterine cavity, recommended by Pasta to be used in such casus as a caustic, ought to be banished from practice. Even the employment of strong vinegar requires the exercise of much discretion. Should the irritation made by the hands prove insufficient to arouse the con- tractility of the uterine tissue, we must resort to an application of cold, which acts both as a sedative to the circulatory system, and as an astringent on the muscular fibres. Compresses dipped in iced water are to be applied over the lower part of the abdomen, the genital organs, aud upper portion of the thighs; and a quantity of cold water might be injected into the vagina at the same time. taking care to pass the extremity of the canula into the uterine cavity. In a serious case, the example of 31. Evrat might be advantageously followed; this gentleman carried a peeled lemon up into the womb, and then expressed its juice with his hand, so that the citric acid, by coming into contact with all parts of the internal surface, would stimulate the organic contractility. Or that of M. Desgranges, by introducing a sponge dipped in vinegar, then squeezing out the fluid, and abandoning it in the uterine cavity; having previously taken the pre- caution of passing a silk cord through it, by which it can easily be withdrawn, when deemed advisable. Again, some persons have suggested that a piece of ice be passed up and left for a few moments in contact with the uterine surface. But the employment of this measure, as well as the external application of cold, must not be persisted in too long; because, as 3Iadame Lachapelle has judiciously remarked, the pro- longed application of snow, ice, cold irrigations, douches, and sponging with very cold water, that has been so much vaunted by some authors, is not unattended by danger to the patient; and, therefore, the use of cold ought to be restricted within moderate limits. Most generally, it becomes ineffectual in the course of five or six minutes; often, indeed, it proves positively injurious, either by redu- cing the woman to a state of mortal torpor, or by exposing her to a violent in- flammatory reaction. There are some cases of obstinate hemorrhage, in which all the measures yet spoken of prove ineffectual. For such cases other remedies have been recom- mended, which now claim our attention. These are the tampon, the introduction of a bladder into the womb, the approximation of the uterine walls by immediate pressure, the compression of the aorta, the use of ergot, of opium, and transfu- sion. 1. The Tampon.—Leroux reports quite a number of cases of inertia of the womb, in which the tampon arrested the flooding where it seemed to be inevit- ably fatal. But, as Desormeaux remarks, it often happens that men, even those ARTIFICIAL DELIVERY. •887 who are otherwise worthy of credence, are often more successful with remedies of their own invention, than any one else. In fact, the only effect of the tampon in many cases is to convert an external into an internal discharge. In order to obviate this disadvantage, it has been suggested to combine its employment with compression of the uterine walls by means of the hands. M. Chevreul,who is favorable to its use after the delivery, adds that it is necessary to irritate the organ externally as much as possible. But in the cases mentioned, both by him and Leroux, where the tampon was apparently successful, it was not, as 31. Baudelocque avers, so much in preventing the discharge of blood, and determin- ing its coagulation, as by irritating the internal surface of the womb, and thereby producing a retraction of its vessels, that the plug could have had a salutary effect. The tampon itself, or rather the irritating substances 31. Chevreul satu- rates it with, conjoined with external stimulation, may indeed bring on the con- traction in many cases ; but the mere plugging up of the vagina, as directed by Leroux, is useless, to say the least; and therefore the introduction of some old linen, steeped in vinegar, into the uterine cavity, is in reality the only efficacious part of the plan; but even this will prove still more beneficial when accompanied by a compression of the hypogastrium, and by frictions and stimulations of the organ above the pubis. 2. The introduction into the womb of a hog's bladder, which has been softened by holding it a short time in warm water, is even a worse measure than the pre- ceding ; and it is really astonishing that Gardien seems to be in favor of its em- ployment. The presence of a bladder would evidently be a continual obstacle to the retraction of the womb. Great stress has been laid upon the compression, which it might make on the vascular orifices, but to no purpose: for, even were tbis a constant result, which however is far from being the case, since we are never sure of filling the uterine cavity precisely, the difficulty would only be delayed, as the hemorrhage might reappear as soon as the bladder is withdrawn; and then, after all, we should have to fall back on the contraction of the organ. 3. 31. Deneux conceived the happy idea of pressing the uterine walls together, in a desperate case, by means of a folded napkin, which he applied over the hypogastrium, and retained in position by a tight body-bandage; this arrested the discharge of the blood completely. Notwithstanding M. Baudelocque has accorded the original suggestion of this plan to M. Deneux, it was long since recommended, particularly by the English writers. This procedure has been unjustly censured by certain practitioners, since it certainly may prove very useful in an extreme case. In saying that, from the disposition of the posterior plane of the trunk, the uterine walls can only be brought into contact with each other at the point corresponding to the sacro-vertebral angle, Madame Boivin has evidently confounded the bare skeleton with the one still covered by its soft parts. . . 4 Quite recently, 31. D'Ornellas has defended a thesis on the compression ot the aorta as a remedy in uterine discharges, and he brings forward numerous cases in support of his theory. 31. Baudelocque has assured me that he has several times succeeded in arresting a flooding in this way, which threatened an early fatal termination. This gentleman, who disputes with Dr. Trehan the honor of its revival, appears to have great confidence in the efficacy of the mea- 888 DELIVERY OF THE AFTER-BIRTII. sure; and we may add, that a very great number of facts now militate in favor of his opinion. He recommends the compression to be made in the following manner : first, flex the patient's superior and inferior parts on the pelvis; then depress the abdominal wall immediately above the fundus of the womb with the four fingers of one hand, when the pulsations of the aorta will be more distinctly felt than the beating of the radial artery. The compression may be kept up for a considerable time without causing any particular inconvenience to the woman ; M. Baudelocque states that he has persisted in it for more than four hours. This compression, however, is only considered, even by its author himself, as a mode of gaining time; for he administers the ergot almost immediately, by the action of which the uterine contraction is soon established. The compression of the aorta, though long since recommended, had been generally proscribed because the modes of effecting it were very imperfect. Thus, some directed the pressure to be made through the ventral surface and the double uterine wall; while others introduced the hand into the cavity of the uterus, and then subjected the vessel to pressure through the posterior wall of this organ. But both of these modes ought to be rejected, because they impede the retraction of the womb. Notwithstanding the numerous successes which have been attributed to this operation, several authors, amongst whom 31. Jacquemier is conspicuous, contest its utility, and even go so far as to consider it injurious. " In the profuse flood- ings following delivery, the blood which escapes," says 31. Jacquemier, " proceeds in great part from the veins, and the compression of the aorta could only favor the reflux of venous blood into the vena cava and the branches which empty into it." It is not to be supposed that the utero-placental arteries could furnish the enormous amount of blood that sometimes escapes in a few moments from a recently-delivered woman, and there can be no doubt that a great part of it is discharged from the large, gaping venous orifices left upon the internal surface of the uterus by the detachment of the placenta. Though agreeing with 31. Jacquemier as regards this point, I cannot unite with the conclusion which he draws from it. Such, in fact, are the relations between the aorta and vena cava, that it is almost impossible, unless it be done expressly, to compress one without compressing the other. I am very willing to admit that a mistake may have been made in respect to the nature of the service thus rendered, and that all the credit hitherto accorded to the compression of the aorta should be transferred to the flattening of the vena cava; but of what importance is this as regards the practical result, since the arrest of the hemorrhage is no less the consequence 1 M. Jacquemier has done a real service in pointing out a theoretical error, but I would almost blame him for it, should he thereby deprive the practitioner of an invaluable resource. I therefore accept his theory, but shall nevertheless con- tinue to compress the aorta, although convinced that I shall compress the vena cava at the same time. Still another objection has been made to the proceeding. Although compres- sion of the aorta, it is said, may prevent the blood from arriving by the uterine arteries, it must necessarily increase the amount that passes through the ovarian arteries, inasmuch as it is generally performed below the origin of the latter. . . . The objection loses much of its value from the fact that the hemorrhage is ARTIFICIAL DELIVERY. chiefly venous. But of four arteries supplying blood, two only are permeable after the compression of the aorta; so far, therefore, it is a marked advantage. M. Jacquemier also regards the administration of ergot during the compression as useless and irrational. " How shall we admit," says he, " that this agent, whose effects are so prompt though evanescent, can stimulate the uterus, since the arterial blood is cut off from it ?" It is by first acting upon the nervous centres and stimulating the excito-motor properties of the uterine nerves, that the drug exerts its special action on the uterus ; therefore, to suppose that after having been absorbed by the stomach the medicament can only act by being carried by the circulation into contact with the uterine fibre, involves, I think, a physiological error. Hitherto, compression of the aorta has been recommended only for the purpose of suspending the discharge of blood, and of giving the measures for restoring the uterine contractility time to act. I think that it is capable of rendering- great service even after the discharge is suspended and the womb contracted. The fact is, that when flooding has been profuse, all danger is not at an end from the moment that we have succeeded in arresting the hemorrhage and bring- ing about the contraction of the uterus; for although not a single drop of blood should be discharged afterward, the amount of this fluid remaining ih the body is no longer sufficient to supply all the organs, and the brain at the same time, with the stimulus necessary to the maintenance of the integrity of their func- tions ; so that women sometimes expire two or three hours after the arrest of the hemorrhage. Death then takes place, because the remaining blood, being equally diffused throughout the entire extent of the circulatory apparatus, the brain, and especially the spinal marrow, receive too small a proportion of it, and conse- quently are not sufficiently stimulated to enable them to support the respiration and the movements of the heart. This being admitted, it is easy to understand that if, by compressing the abdominal aorta, we can prevent the blood discharged by the left ventricle from descending into the lower parts of the body and infe- rior extremities, it will necessarily be obliged to flow back towards the brain in greater quantity, and thus secure for this organ the degree of stimulus which it requires to enable it to react in its turn upon the functions of the heart and lungs. The compression of the aorta may be assisted powerfully by placing the woman on an inclined plane, so that the head shall be the lowest part of the body. . ., I think, therefore, that the compression of the aorta and vena cava is useful whilst the flooding continues to be profuse; but also, that when the patient has lost a great amount of blood, it should be continued for several hours after the arrest of the hemorrhage and thorough contraction of the walls of the uterus. In the latter case, however, it is important to separate the aorta from the vena cava, so that the compression may act on the former vessel exclusively.1 i Compression of the aorta was once resorted to by M. Roux in the case of a wounded patient, who was exhausted by frequent hemorrhages. I think, however, that I was, myself, the first to suggest and perform it, in the floodings of newly-delivered females. In the month of March, 1845, after stating the physiological principles upon which I based my conclusions, I proposed the operation in a formal manner, m a communica- 890 DELIVERY OF THE AFTER-BIRTH. 5. Ergot has been recommended, as stated above, as one of the measures cal- culated to prevent the occurrence of hemorrhage in women who, by their consti- tution and previous history, seem to be highly predisposed to it. This remedy may also be resorted to in the curative treatment; unfortunately, however, the time necessary for procuring it, and for the development of its action, is always too long to secure a sufficiently prompt effect ;* and hence, in an alarming hem- orrhage, one dependent on a complete inertia of the womb, for example, the patient would certainly die before any benefit could be hoped for from its em- ployment. Under such circumstances, it would prove highly useful to compress the aorta in the meanwhile. But with the exception of these, frightful cases, where a few minutes decide the woman's fate, the secale cornutum ought to be employed; and its use would be nearly always followed by success. In some females, the uterine hemorrhages have a marked tendency to relapse. Consequently, a few grains of this substance ought to be administered as soon as it has occurred, whether it seems to be finally arrested or not. For, in the former case, it can do no harm, and, in the latter, it will prevent a return of even a partial inertia; which is not an indifferent matter to a woman who is already exhausted from the previous loss, and who is liable to succumb under a fresh discharge, however inconsiderable it may be. 6. The English authors (Burns and others) recommend the use of opium in full doses, both as a preventive and a curative remedy in cases of flooding from inertia. They bring forward some cases in support of their opinion; but I do not deem them conclusive; because, in every instance, they combine the exhibi- tion of opium with the employment of those general measures just indicated as proper for arresting hemorrhage. Besides, I cannot understand how opium, when administered alone, can have any influence whatever over the contraction of the uterus, which is here the only hope of safety. 7. Transfusion, which has been so highly praised by certain English writers, in whose hands it seems to have succeeded quite a number of times, has not been followed by the same success in France. It is one of those extreme mea- sures which might be employed in desperate cases, though it cannot be relied upon; because the extent of the flooding, the extreme debility of the patient, and the slowness of its operation, generally render it ineffectual; without refer- ring to the nervous and inflammatory symptoms, and the phlebitis, which very frequently succeed the operation. Besides, it evidently could only be practised with any chance of success after the flooding had ceased, and the uterus was thoroughly contracted, and then I think that compression of the aorta would have almost all its advantages without any of its numerous dangers. I once saw it performed at the Hotel-Dieu without any benefit whatever. In some of the reported cases, a notable improvement was effected by a moderate quantity of blood (three or four ounces); in others, it was necessary to inject as much as ten, and even as high as thirteen, ounces. tion to the Medical Society of the department of the Seine. I am the more particular in stating this fact, as the same suggestion has been made in other quarters without acknow- ledging my priority. 1 Accoucheurs, especially those who reside in the country, should always be careful to have with them a little ergot in the grain. ARTIFICIAL DELIVERY. 891 In M. Nekton's case, he injected first six, and five minutes afterwards eight, ounces of blood. The operation was conducted as follows: The median basilic vein was uncovered by an incision three-quarters of an inch in length, then isolated, and raised by a loop of thread so as to flatten it and stop the circulation in order to prevent any loss of blood. The anterior wall of the vein was next seized with a pair of forceps, and half divided obliquely from below upward, so as to form a V-shaped flap, which might be raised or restored at pleasure. The blood drawn from one of the resident surgeons was received in a dish warmed to the temperature of 77° F., and poured immediately into a syringe heated to the same degree. Everything being thus prepared, whatever air remained in the syringe was expelled, the little V-shaped flap was raised with the forceps, the tube of the instrument introduced into the vein beneath it, and the injection performed slowly. The second injection was made five minutes afterward, and the wound in the arm closed by means of collodion. 8. Inertia of the womb, and the consequent hemorrhage, often come on before the delivery of the after-birth; and the retention of the placenta here presents some special indications which are important to be known. Whenever a hemor- rhage takes place, a more or less considerable portion of the placenta must evi- dently be detached; sometimes, even, it is wholly separated from the uterine wall, being left free and movable in the cavity of the organ. The directions given by authors in this case are very variable: thus, some advise us to extract the secundines at once, together with any coagula the uterine cavity may con- tain; others, on the contrary, to try first to remedy the inertia, which is the sole cause of the accident. We do not hesitate to recommend the latter advice; because, if the placenta is partially removed, we would certainly augment^ the sources of hemorrhage by completing its separation. Hence we look upon it as an absolute rule not to attempt the extraction, and more particularly the detach- ment of the placenta, until the accoucheur, by stimulating and irritating the organ with his hand, has secured its diminution and contraction to such an extent, that it drives, as it were, the coagula and after-birth beyond his hand. Should the adhesions of the placenta be unusually firm, the injections into the umbilical vein, spoken of in the last chapter, might be resorted to. But when the placenta is completely detached, or adheres to the uterus by only a very small portion of its surface, it should be extracted together with the clots which may have collected within the cavity ofHhe uterus. Their presence there prevents an energetic action upon the walls of the womb and may impede their contraction. When the physician has been fortunate enough to overcome the hemorrhage by a resort to the various measures just alluded to, he should still continue with his patient for several hours, carefully watching the character and amount of the discharge from the vulva, and occasionally placing a hand over the hypogastrium, so as to detect any increase of volume in the uterine globe. He ought also to take the precaution of applying cloths steeped in vinegar, or alcohol or even in cold water, over the belly, and to retain them there by a moderately-drawn body- bandage ; absolute quiet is to be insisted on. As nourishment, the patient might have some light cordial, broth, sweetened wine, &c, &c. 892 DELIVERY OF THE AFTER-BIRTH. Usually, the patient is put to bed an bour after her delivery; but after severe floodings, she should be carefully protected from any sudden motion, and it is often necessary to let her remain in the same position for eight, ten, or twelve hours. The least movement might cause a mortal syncope. After a profuse hemorrhage, the patient is naturally inclined to sleep; some persons think it better to prevent her from slumbering, lest the discharge be re- newed without her knowledge. But, as this repose repairs the exhausted forces, it ought not to be hindered: but she must never be left; for the pulse, the uterus, and the vaginal discharge require a constant oversight. The patients are frequently tormented, after considerable floodings, by vomit- ing, or at least by sick stomach, nausea, and retchings. Independently of the pain they occasion, these gastric symptoms are not wholly devoid of danger; for the vomiting, from the fatigue caused by the straiuings to which the woman gives way, may produce a syncope, during which the hemorrhagic discharge may be renewed profusely. If there are only the nausea and inclination to vomit, the women are often so tormented thereby as to wear out the little strength they have left; and this exhaustion of the muscular power, at a time when the ute- rine contraction is so necessary, is a very melancholy condition. " Nothing tranquillizes the stomach under these circumstances," says Dewees, "so far as I have observed, like opium, in the solid form. A newly prepared pill of two grains of the opium, with a very small portion of soap, to facilitate its solution in the stomach, should be given every hour or two, until the vomiting ceases, or the stomach becomes reconciled. I have found a sinapism over the region of the stomach of great service, and it should be resorted to, if necessary." The opiates, in a fluid form, might also be used with advantage. When after profuse flooding the patients are excited, uneasy, or tormented by a feeling of extreme discomfort, a few dessert-spoonfuls of the syrup of diacodion will gene- rally serve to calm their anxiety, and procure the refreshing sleep which they so greatly need. As the patient begins to recover from the extreme weakness which immedi- ately follows a profuse loss of blood, symptoms of febrile reaction begin to appear: the pulse is small and rapid, sometimes hard, and sometimes compressible; the heat and dryness of skin are increased, the tongue is dry, and the features con- tracted : the patient is very thirsty, and feels disgust for solid food: she is startled by the least sound, or by a bright light: she complains of violent head- ache, and sometimes of palpitations and dyspnoea. She is unable to sleep, or if she dozes, is liable to be awakened by violent startings. This condition evidently results from the excitement of the nervous system occasioned by the loss of blood, an excitement which we should endeavor to calm from the outset. Evidently, the first indication is to repair the losses of the organism by food which shall be easily digested, and frequently administered in small quantities at a time. Broths or light soups are eminently suitable. The best means of calming the excitability of the nervous system, are perfect rest, cold aspersions upon the hands and face, but especially opiates, given fre- quently and in small doses. ARTIFICIAL DELIVERY. 893 § 2. Secondary Hemorrhage. In order to complete the history of puerperal hemorrhages, we have yet to speak of some accidents which occur at a variable period after delivery, and which on that account have been styled secondary hemorrhages. These floodings, which are so profuse as seriously to endanger the health and sometimes even the life of the patient, have been treated of very imperfectly in the most recent treatises, and we ourselves committed the mistake of passing it over with a very slight notice in the earlier editions of this work. Dr. Clintock has recently performed a valuable service in calling attention to the various circum- stances which may give rise to them. Sometimes these causes begin to act very shortly after the delivery of the placenta, and the thorough contraction of the uterus, sometimes not until after two or three days, and occasionally even after three, five, or six weeks. But at whatever time their influence is manifested, their mode of action is nearly always the same as at the other periods of the puerperal state; and the hemorrhage may then be accounted for either by secondary in- ertia, by a too active congestion, a real molimen hcemorrhagicum, or, finally, by an alteration of the blood, consisting in a great increase of its fluidity. The hemorrhage, or rather the inertia which produced it, is not confined to the period of delivery, or to that which immediately succeeds it; so that as re- gards the time of its appearance, we may distinguish a primitive inertia, which is that just described, and a secondary, to which attention has been especially called by Ramsbotham, and of which we have ourselves observed several examples. A. Secondary Inertia .— Some moments, hours, and sometimes even several days after the delivery,1 the uterus, which had contracted properly and had re- mained so during all that time, may suddenly become relaxed. Its walls become softer, and it increases in size. At the same time the patient grows weak and pale, the pulse loses its strength and quickens, and if the genital parts be care- fully examined, it is found that very little blood is discharged, and that the cloths are but slightly soiled. But if the uterine tumor be compressed slightly, or the organ be incited to contraction by friction upon the hypogastrium, a considerable amount of coagulated blood is suddenly discharged by the vagina. After this evacuation the size of the uterus is diminished, it is harder, and'remains so, so long as the hand continues to press upon it; but if the pressure be removed, the softened walls are soon found to become afresh distended, and then contract again, driving out another quantity of clots, provided the accoucheur renews the pressure and frictions calculated to excite their contractility. This series of occurrences may take place several times, if the accoucheur relinquishes too soon the use of the proper means for making the uterus contract permanently; and if i Mr Fergusson reports (New York Medical Journal, Sept. 1850) a case of grave hemor- rhage occurring thirteen days after delivery. The cause was secondary inertia. The au- thor examined statistics in reference to this subject, with the following result: out of 16,654 labors observed by Collins in the Dublin Hospital, there were 43 cases of hemorrhage imme- diately after delivery, and 40 twelve hours afterward. The flooding, in one case, occurred only on the fourth, in another on the sixth, and in still another on the tenth day. Drs. Clintock and Hardy observed one on the seventh day, and Dr. Stimever another on the tenth. 894 DELIVERY OF THE AFTER-BIRTH. the cause of the hemorrhage should not be discovered, it might cost the woman her life. Now several circumstances are liable to lead into error. In the first place, the physician had previously ascertained the condition of the womb, and it does not immediately strike him that it may have become relaxed in a secondary manner, after having remained so long properly contracted. Again, it frequently happens that the patient, exhausted by the fatigues of the labor, falls asleep, and does not herself perceive her extreme weakness, until her condition has become irre- mediable. Nothing but an examination of the uterus is capable of clearing up the diag- nosis. This organ is then found to be much larger than it was after the labor, and the finger carried up to the internal orifice, finds it blocked up by a clot of considerable size. The accoucheur should use every effort to procure the contraction of the walls of the uterus, and especially to render it permanent. For this purpose, several napkins folded on each other are placed on the fundus of the womb, and by means of a body-bandage tightly applied, the organ is held strongly pressed against the opening of the superior strait. I am in the habit of administering immediately fifteen grains of ergot, and of repeating it every half hour or hour, according to the degree of tendency to relaxation, in doses of from six to eight. graius. B. Congestions of the Uterus.—Under this title, 3Iadame Lachapelle has described a flooding, which comes on some time subsequent to the parturition ; and which is produced, as she supposes, under the influence of a peculiar moli- men hamorrhagicum. This variety is occasionally developed even without any inertia of the womb. " We have known," she continues, " a woman to perish seven or eight days after her confinement, from a profuse discharge of serous blood, which transuded from all parts of the utero-vaginal surface, and saturated, by imbibition, the most solid tampon; the womb was soft, but not distended with the blood." I have twice known a hemorrhage to take place after the delivery of the after-birth, says 31. Velpeau, although the womb had been contracted in the one case for four and in the other for seven hours. He further states that this accident is,occasionally manifested subsequent to the first twenty-four hours. These congestions, which in certain rare cases are inexplicable, may usually be attributed to certain easily-detected, general, or local causes. We have already spoken (page 875) of the liability of the retention of a por- tion of the placenta to give rise to these hemorrhages, and we would now simply add that the presence of a large clot within the womb might have the same effect. Both Collins and Madame Lachapelle report cases of flooding coming on eight and ten days after delivery, and which ceased only upon the artificial extraction of the coagula. The determination of blood may also be occasioned by the retention of a por- tion of the membranes, as in the following case. I was sent for by a physician to see a lady living in Rue Gros-Caillou. On arriving there, I found 31. P. Dubois, who was called at the same time, but who preceded me, engaged in extracting a considerable portion of the membranes, which had been imprudently left behind whilst delivering the placenta. The ARTIFICIAL DELIVERY. 895 child was born at nine p. M., and half an hour afterward hemorrhage came on, which could not be arrested until half:past one in the morning, at which time the foreign body was extracted. The uterus had remained perfectly contracted throughout. The extraction of the foreign body, in the latter case, generally dissipates the symptoms; in the former, a resort to revulsives to the upper parts of the body, to cold applications, and even to venesection, is evidently indicated. These will be materially aided by a regulated diet, and absolute rest in the horizontal posi- tion. Intra-uterine polypi have several times given rise to mortal hemorrhage two or three weeks after delivery. It has been thought that these bodies occasion the flooding only by preventing the contraction of the uterus. We are disposed to reject this opinion, because, as Oldham observes, in these cases the strongly-con- tracted uterus can readily be felt above the pubis. Besides, the cessation of the flooding after ligation of the polypus without excision, justifies the belief that the latter does not act simply as a foreign body, for, were it so, the discharge would continue after the ligature was applied. Irritation of the neighboring organs may give rise to hemorrhagic congestion of the uterus. M. 3Ioreau mentions a case of hemorrhage which occurred on ■the eighth day after delivery, and which he very properly attributed to a collec- tion of hardened feces in the large intestine. Injections were used without advantage, and he was obliged to empty the rectum by using a sort of scoop. As soon as this was accomplished, the discharge ceased. For a long time after delivery the uterus continues to be a centre of fluxion, toward which the general disorders of the economy seem to converge. There appears to be no other way of explaining such floodings as are apparently due to violent moral emotions, the abuse of stimulants, &c. C. Alteration of the Blood.—31. Blot also mentions, in his excellent thesis, the case of a woman whose uterus was firmly contracted, and who died in con- sequence of a sero-sanguineous discharge succeeding flooding after delivery. This hemorrhage, which nothing was capable of arresting, is attributed by M. Blot to albuminuria and the consequent impoverishment of the blood. I have already had occasion to remark, that new observations are necessary to prove the correctness of this assertion. I cannot however, agree with Madame Lachapelle, who thinks that these floodings are produced by an accidental congestion, a sort of molimen hcemorrha- gicum I think, on the contrary, that they are the result of a serous condition of the blood, preventing the formation of obliterating coagula, and allowing the fluid to exude from the internal surface of the uterus. This sometimes takes place from the surface of wounds in certain patients affected with anaemia scurvy, &c. But to admit with M. Blot that it is caused by albuminuria, would be going rather too far. The use of the tampon, assisted by compression of the uterus by means of a bandage drawn tightly around the abdomen, would be proper under these cir- cumstances Ergot has often been used, without any advantage whatever, in these dangerous cases. Some English physicians approve highly of styptics aken internally. In a case of flooding occurring nine days after delivery, Mr. 896 DELIVERY OF THE AFTER-BIRTH. Clintock used the tincture of Cannabis Indica with success. Oxide of silver is also recommended, in the dose of from half a grain to a grain, three or four times a day, in connection with a small quantity of opium. A large blister over the sacrum has also been applied successfully. Hemorrhage from the Umbilical Cord.—In twin pregnancies, a hemorrhage may take place from the cut placental extremity of the cord, after the first child is born. For, although no vascular communication habitually exists between the two placentas, yet the contrary has been too often observed to leave any doubt with regard to the fact at the present day; and hence it is admitted by most practitioners. Besides, we find cases recorded by 31ery, Baudelocque, and Solayres, which fully prove that, even in single pregnancies, a hemorrhage profuse enough to endanger the mother's life may occur after the division of the cord; as also, that the umbilical vein is the sole source of this discharge. " As regards the bleeding from the placental end of the cord, other than in cases of twins, I can aver," says 31. Chevreul, " having observed it three times in women whom I had delivered with the forceps; having cut the cord in a hurry without applying any ligature, the blood continued to flow abundantly from that portion connected with the placenta, whilst I was devoting the necessary atten- tions to the child. I resorted to all the modes of irritation advised in such cases, for the purpose of rousing the contractions; but the discharge was only arrested by tying the cord. The delivery of the after-birth shortly occurred, and was followed by no untoward accident." Quite recently, 31. Guillemot has met with a very similar case. Dr. Albert, of Wiesentheid, saw the blood spring from the extremity of the cord, in a stream as thick as a straw. The hemorrhage, which was considerable, could not be arrested except by pressure upon the umbilical vessels; and a ligature had to be applied. By reflecting on the mode of vascular connection heretofore studied in the placenta, it really seems impossible to understand how the mother's blood, in a natural condition of things, can pass into the ramifications of the umbilical vein, and thence escape in such prolusion. But are we on that account to reject such facts, advanced by experienced men of high standing ? I think not; besides, the explanation would be rendered very intelligible by supposing some vascular anomaly in these exceptional cases. I therefore consider a hemorrhage possible from the placental extremity of the cord, for I cannot question the testimony of the imposing authorities just quoted. Under such circumstances, ligature of the cord is evidently the only resource. § 3. Of Inversion of the Womb. This is-an affection in which the fundus of the organ, being indented or de- pressed, is more o'r less inverted into its cavity, or even passed down through the os uteri into the vagina, or out at the vulva. The inversion of the womb exhibits many different degrees; from a simple depression of the fundus to a complete inversion, in which case the organ is turned inside out, the internal or mucous surface becoming the external one, and vice versa. For the purposes of description, we shall admit three principal de- grees : in the first of which the fundus is simply depressed, approaching to, but not engaging in, the os uteri; the second is a partial inversion, in which the ARTIFICIAL DELIVERY. 897 fundus actually engages in the orifice, and protrudes into the vagina; and the third is a complete inversion, in which the uterus is turned inside out, appear- ing at the vulva, or even protruding beyond it. 1. When the depression commences at the fundus, a concavity is produced in the tumor above the pubis, having its highest borders nearer to the latter than to the sacrum; or it may commence at the sides ; and when it is the front one that is indented, the posterior border is higher than the anterior, but when the reverse happens, the posterior is the lower : again, when it is depressed laterally, the concavity in the top of the womb is inclined towards one of the iliac fossae. If the placenta is still undetached, the indentation is augmented by pulling on the umbilical cord. Finally, when the finger is passed into the cavity of the womb, it finds the fundus within half an inch, more or less, of the orifice. 2. When the inversion is partial, we can detect a hemispherical tumor by the vaginal examination, varying in its size, according to whether the placenta is detached or still adherent; the neck of the womb encircles this tumor at its upper part like a collar The ball usually formed in the hypogastric region by the uterine globe, is no longer felt on palpation ; a considerable depression being found in its place. 3. Where it is complete, the tumor may either fill up the vagina without passing beyond the vulva, or it may hang down between the woman's thighs. In the former case, the whole vaginal cavity is occupied by a voluminous tumor, the upper part of which can scarcely be reached; in the latter, which is the most serious of all, the pelvic cavity is altogether empty, and nothing can be felt there by the hand; but a large tumor is found between the patient's thighs, having the placenta attached, wholly or in part. The top of this tumor is either simply concealed between the labia, or extends up into the vagina. In some instances, the latter has also been implicated in the displacement, and has been inverted in a great measure, thereby giving a considerable length to the tumor. "We cannot, however, say that the inversion is strictly complete," says Burns, " for, in most cases, the lips of the os uteri hang down, and the inversion terminates at the lower part of the cervix." Some writers assert, not- withstanding, that the lips may be completely inverted. This accident is always accompanied by general phenomena, which are the more serious as it is the more considerable. The patient not only suffers from pain, but she is harassed by a constant desire to urinate, and by strainings at the close-stool, which are often sufficient to render an inversion complete, that would otherwise have only been partial. The pain becomes excruciating, and the frightened sufferer falls into a state of syncope; the pulse is feeble, and some- times is nearly or quite imperceptible. The intensity of these general pheno- mena varies with the state of retraction or relaxation of the cervix, and with the degree of inversion. For instance, it is much less in a simple depression, than where the inversion is more complete. Furthermore, the pains and dangers are ' much greater in the latter case, if the cervix uteri is firmly contracted, than when it is dilatable. Again, should the placenta be partially detached at the time of the accident, there will be a profuse hemorrhage; but, on the contrary, when it is firmly adherent throughout, no discharge occurs, since the latter only begins with the separation of the after-birth, and increases as this progresses. 57 898 DELIVERY OF THE AFTER-BIRTH. Lastly, when the inversion is complicated by inertia, which unfortunately is usually the case, the flooding is frightful, and can only be moderated by the con- traction of the womb. The inversion is sometimes produced by attempting to effect the delivery of the after-birth before it is entirely separated, by pulling imprudently on the cord. It may also result from a very rapid labor, more particularly if the woman hap- pens to be standing at the time when the child is born; for if the umbilical cord is unusually short, or is wound around some part of the child, the fundus may be pulled down by the strain on the cord, and thus become inverted. An inversion from this latter cause is far more unusual that one would sup- pose; because the cord is generally broken under such circumstances, incompre- hensible as the fact may seem, when we reflect on the amount of force required to rupture it. The rarity of the inversion, however, is more readily explained by the powerful contraction at the instant the foetus is expelled, and by the dif- ference in the line of axis of the two straits; the axis of the superior strait form- in°- nearly a right angle with that of the inferior one, or rather with that of the vulva. In other words, the cord passes around the posterior part of the sym- physis pubis, as over a pulley; and, therefore, the greater amount of the tractive force is spent on the symphysis before reaching the fundus. It may happen, from the uterus being in a momentary state of inertia after delivery, that the pressure made by the intestinal mass indents its fundus like the bottom of a bottle. Again, in cases of complete inertia, should the placenta be attached directly to the fundus of the organ, its weight alone might pull it down. Such accidents are usually corrected by the force of the contractions; though, should the operator pull on the cord before noticing the depression, he might increase the difficulty by converting it into a partial inversion.1 Dr. Tyler Smith supposes that inversion of the uterus is always occasioned by 1 Although I am only treating of uterine inversion here, as a complication of the delivery, I cannot refrain from mentioning a very curious case, narrated by Ane, at the Sociili de Midecine, of a woman who had a complete inversion of the womb twelve days after her confinement, and which resulted in consequence of severe strainings at stool. This case, which was confirmed by Baudelocque, who was called in consultation, can leave no doubt as to the possibility of such an accident, however extraordinary it may appear. A still more wonderful case is related by Mr. Ebenezer Skae, as occurring in a woman who suf- fered complete inversion of the womb, two days after aborting in the fourth month of gestation. (The Northern Journal of Medicine) I will further add, that the observations of Sabatier would seem to prove that such an inversion may not only take place when the fundus of the womb is depressed by a polypus, but also in a state of perfect vacuity. The' responsibility of the assertion must rest with the author. M. Roussel communicated a case to M. Martin, in which the inversion did not take place until nine hours after delivery. The patient had a frightful flooding at the time of the extraction of the placenta, which M. Roussel arrested by the ordinary measures; after which, he remained with her until fully satisfied of the contraction of the womb. It was then about eight o'clock in the evening. At five the next morning, he was summoned in great haste; when it appeared that the patient had got up to evacuate her bowels, and the womb immediately fell down to the vulva. On his arrival she was senseless, and the pulse imperceptible; the finger, passed into the vagina, found there a large tumor, formed by the inverted fundus, around which the os uteri had firmly contracted, and doubtless had thus contributed to the diminution of the hemorrhage. ARTIFICIAL DELIVERY. 899 irregular contractions of the organ ; even in the cases generally attributed to pre- mature tractions on the cord, he considers that the pulling does not act mechani- cally, but only by producing an excitement of the fundus of the uterus, where the placenta is inserted, which occasions an irregular contraction, and conse- quently a simple depression. This first degree of inversion, according to him, is immediately followed by a sudden contraction of the fibres above the depressed point, which tend by their action to expel the latter through the cervix, in abso- lutely the same manner as they would act upon a foreign body. Dr. Smith's explanation of the mechanism of inversion may be true for some cases; but when the walls of the uterus are in a state of complete relaxation, it is difficult to allow that violent pulling upon the cord of an adherent placenta should be incapable of producing inversion. When a simple depression occurs immediately after labor, it will scarcely attract attention, unless the placenta happens to be detached, and a hemorrhage is thereby developed. It ought to be reduced, as soon as detected, by placing the patient on her back, and having the abdomen and breech raised higher than the chest; the legs and thighs are flexed and held apart, and the head inclined forwards on the breast; then the operator carries his hand into the uterine cav- ity, and gently pushes out the fundus with his fingers. M. Chevreul sums up so well the indications presented by the partial and com- plete inversions of the womb, with reference to the delivery of the after-birth, that I cannot do better than transcribe here his remarks on this subject. He says, " A partial inversion is easily reduced when detected shortly after its oc- currence. Of course, the placenta may either be separated wholly or in part, or it may be still adherent throughout to the womb, at the time of the accident. If wholly detached, the hemorrhage is very profuse, and requires immediate attention. The accident is remedied by placing the woman in a suitable posi- tion, and then, introducing the whole hand into the vagina, the fingers take hold of the inverted portion of the womb and endeavor to return it, by first pushing up the part that came down last. Should the placenta be partially de- tached, and the remaining adhesions be feeble, its separation ought to be entirely completed, by passing the fingers between it and the uterine wall; after which, the reduction is to be effected as in the former case. But if it is still adherent throughout, the whole is to be returned together; and then we may either wait for the spontaneous delivery of the after-birth, or we may attempt to separate it by the hand, according to circumstances. Where the inversion has existed for several hours, it occasionally happens that the protruding portion of the womb is strangulated, as it were, by the os uteri, which constitutes a serious obstacle to its reduction. Under such circum- stances, it is not advisable to use forcible attempts to surmount the difficulty,, lest some serious accident might result; but rather to have recourse to venesec- tion, to tepid bathing, to fomentations, to the use of the ointment or the extract of belladonna, and opiates; in a word, to all the means likely to relieve the constriction of the os uteri, and to moderate the force of the inflammatory symptoms. The inhalation of chloroform, which has been used with such for- tunate results in analogous cases by MM. Barrier, Valentin, Charles West, and G. Gonney, might here also be of very great service. But if still unsuccessful, 900 DELIVERY OF THE AFTER-BIRTH. the patient will have to endure this disgusting infirmity for the remainder of her days.1 Where the inversion is complete, and the placenta is detached, we must first apply a soft and dry napkin upon the tumor, and then, having brought the fin- gers together in the form of a cone, depress its central part with their points, so as to make the fundus and body of this viscus gradually pass up through its orifice, and thus regain its primitive position. Should the conjoined fingers prove too bulky, the stick proposed by 31. Depaul might be substituted for them with advantage. When the womb is once reduced, the napkin should be with- drawn. Should the placenta be partially detached, its separation is first com- pleted, and then the operation is terminated in the same way. Again, if the adhesions are very extensive, or if they exist throughout, we ought to attempt the reduction of all together, by proceeding as in the first case, excepting the use of the napkin; but, if the orifice is not dilated enough to permit the womb to pass through with the placenta, it would be necessary to separate the latter, and then reduce the former as promptly as possible. Whatever be the degree of inversion, the hand is always to be kept in the womb for some time after the reduction, for the purpose of preventing a return of the accident, and for soliciting the contraction of the organ. The inertia, if any, must be remedied by the appropriate measures. It is found by experience that whenever an inversion has occurred in a former labor, it has a tendency to be renewed at the subsequent ones. Consequently, no tractions on the umbilical cord, with a view of extracting the placenta, should ever be resorted to in women who have previously suffered from this accident. In cases of this kind, many practitioners prefer the introduction of the hand into the uterine cavity, so as to act directly on the placenta itself. Such patients ought also to be advised to remain in bed for a long time after their confinement; and, by the use of mild laxatives, to obviate the necessity of strainings at stool. For the proper course to be pursued in cases of puerperal convulsions, we refer the reader to the special articles on that subject. (Accidental Dystocia.) § 4. Rupture of the Womb. A rupture of the uterus is one of the most terrible accidents that can occur in the course of pregnancy or parturition. But as it only claims our attention here, with reference to the difficulties it may create in the delivery of the after-birth, we shall not revert to the minute detail already given in the Fourth Part of this work. Several different conditions may here be met with; as, for instance, the child, having partially or wholly escaped into the peritoneal cavity, has permitted 1 However, two cases are reported, the one by M. Delabarre (Ace. de Chir.), and the other by Baudelocque, which fully prove that a spontaneous reduction of the womb may take place, even after it has been completely inverted for a long time. M. Daillies endeavors to explain this natural reduction, in his excellent thesis, by the tonicity of the Fallopian tubes, and of the round and broad ligaments; which, after having been drawn down, at the moment of the accident, will necessarily return to their proper position in the course of time ; and thus, by acting on the organ that involved them in its descent, will gradually elevate and return it to its original position. ARTIFICIAL DELIVERY. 901 the organ to retract; and this retraction of its walls may have driven the pla- centa into the vagina, and then beyond the vulva j1 or the placenta may remain adherent to the internal surface of the womb, the child having passed into the peritoneal cavity; or again, it as well as the foetus may have passed entirely into the cavity of the abdomen. In the former case there is evidently nothing to be done. In the second, if gastrotomy is resorted to, and it is found impossible to withdraw the placenta through the double wound in the abdomen and womb, owing to the closure of the lips of the uterine rupture, it would be advisable to cut the cord as soon as the child is extracted; and then, by means of some long, solid, and flexible instrument, to bring down the cord through the rupture, the cervix, and the vagina, and out at the vulva; after which the delivery of the placenta is to be effected in the usual way. In the third case, when the after- birth has passed into the peritoneal cavity along with the foetus, it ought to be extracted immediately after the latter, either by the natural passages, if the child is removed in that way, or through the abdominal incision, if a resort to gastro- tomy be deemed necessary. 1 This spontaneous expulsion may take place either immediately after the accident, or not for several days; as occurred in the case reported by Saucerotte. (Melanges de Chi- rurgie, t. ii, p. 295.) PART VI. OF THE HYGIENE OF CHILDREN FROM BIRTH TO THE PERIOD OF WEANING. Having carefully detailed the services to be rendered by the accoucheur to the child immediately after its birth, we have now, in order to complete the study of subjects which must subsequently claim his attention, to treat of the physical education of children. As the full details into which we have entered have already brought the work up to a considerable size, we are obliged to curtail greatly what we had proposed saying in regard to the hygiene of early childhood. The old and classic division of Halle might be advantageously applied in this place, so that, if space allowed, we would treat successively of the ingesta, applicata, percepta, &c, &c. But, inasmuch as we are obliged to limit ourselves to a somewhat detailed account of alimentation, we shall treat of the other parts of infantile hygiene in a general way only. BOOK I. OF THE ALIMENTATION OF CHILDREN. Although the existence of the new-born child is generally styled indepen- dent, its physiological connection with the mother is not entirely severed by the delivery. It does not immediately cease to derive nourishment from the mater- nal organism ; for although no longer connected with the uterus, nature has pre- pared another organ for the elaboration of the fluid designed for its future sup- port. This fluid is the milk. The function by which it is secreted is called lactation, and the mode in which it is taken by the new-born child is termed suckling. LACTATION. 903 CHAPTER I. LACTATION. As stated whilst treating of the phenomena of pregnancy, the breasts begin to enlarge from the first month of gestation. Their active vitality, under these cir- cumstances, soon gives rise to the secretion of a sero-lactescent fluid, which be- comes more abundant as the term of gestation draws near. To this fluid, which is viscid and yellowish, the name of colostrum is applied. Under the microscope, it presents the appearance of globules, much smaller than the ordinary milk glo- bules, united together by a viscid matter. Some irregular milk globules are scat- tered amongst them. Peculiar bodies (granular corpuscles), more or less globular in form, yellowish, and varying from -003 to -019 inches in diameter, are also observed. M. Donne asserts, that there is an almost constant relation between the com- position of this fluid secreted during pregnancy, and that which will be exhibited by the milk after delivery; in other words, the examination of the colostrum and its principal characters will enable us to judge of the probable abundance and quality of the milk. In reference to this, M. Donne divides women into three classes : 1. If the amount of colostrum secreted is so small that barely a drop can be obtained by the best directed pressure, if it contains but very few minute, imperfectly-formed milk globules, and a very limited number of granular cor- puscles, the milk will almost certainly be scanty, poor, and insufficient for the nourishment of the child. 2. If the woman secrete an abundant, but fluid, watery, and easy-flowing colostrum, resembling a thin solution of gum Arabic,— if it no longer presents strise of a thick, yellow, and viscid matter, and if it be poor in milk globules and granular corpuscles, she may have a greater or less amount of milk, but it will be poor, watery, and unsubstantial. 3. Lastly, when the colostrum is obtained readily and in abundance, when it contains a more or less thick yellow matter, and resembles somewhat the rest of the fluid as regards consistency and color; when the microscope shows it to be rich in milk globules, well formed, and of good size, and containing granular corpuscles in greater or less amount,'we may be almost certain that the woman's milk will be*>oth rich and abundant. , w. This examination may be made with especial prospect of advantage about the eighth month.....It is well, however, to be aware, that certain acci- dental causes, such as cold, or moral affections, may occasion a momentary dis- cordance with the results of experience (Donne). For the first days following the delivery, and until after the milk-fever, the fluid secreted by the mammae retains the properties of colostrum, but is more abundant than during pregnancy. When the milk-fever comes on, the milk globules begin to present a more definitely rounded contour, and are more regu- lar Some histologists assert that the granular corpuscles disappear about the ninth day; but M. Godez states, that he has often met with them after the fifteenth day, and even after the twentieth, though only in the milk of moderately 904 HYGIENE OF CHILDREN. good nurses. They generally become more rare as a longer time elapses from the period of the milk-fever, and they disappear the more quickly, or, in other words, the milk is sooner formed when its quality is good and the woman in a satisfactory condition. The fact of their remaining after the first fortnight is an indication of an indifferent nurse. After the milk-fever is over, the mammary secretion generally tends more and more to assume the characters of true milk. The latter is a white, opaque fluid, of a sweet, sugary, and very pleasant taste. Of all the fluids of the economy, it approaches the nearest to the blood in composition, and like it, separates into two parts upon standing. One of these parts is solid and the other fluid. The solid part, whieh is held in suspension, is formed of globules of fat or butter; the other holds in solution a special, azotized, and coagulable animal matter (caseine), sugar of milk, salts, and a little yellow matter. These several parts, says 31. Donne, when mingled together are not dis- tinguishable by the naked eye; but if a drop of milk be spread out upon a plate of glass, and examined through a microscope magnifying two hundred diameters, a multitude of rounded, transparent granules, brilliant as little pearls, will be discovered swimming in a limpid fluid. These small granules, which are rather less than -0003 inches in diameter, are the milk globules, and are formed of a fatty matter or butter. In pure and unmixed milk, nothing beside these small globules is visible, and this purity of the milk is a certain indication of its good quality. The amount of globules is liable to variation, their greater or less abundance representing with considerable precision the richness or poverty of the milk; that is to say, the more of these globules the milk contains, the richer and more substantial is it, the caseine and sugar being themselves in proportion to the amount of milk globules which represent the fatty matter or butter. Not only does the milk vary in richness in different individuals, but it varies greatly in the same woman according to the time when drawn, her state of health or of disease, and the hygienic conditions in which she is situated. We shall, hereafter, have to study these variations when endeavoring to judge of the characters by which to determine whether a woman is or is not a good nurse. The lacteal secretion is, as we have said, intimately connected with the function of generation; still it must not be supposed that it can only take place in preg- nant or recently delivered females. It has several times been known to occur in consequence of frequent excitation of the nipple. Thus Belloc relates, that a domestic who was obliged to sleep in the same chamber with a recently weaned child, being annoyed by its cries, took it into her head to put it to her own breast. In a very short time she had milk enough to satisfy its appetite. 3Irs. B-----, says George Semple, mother of nine children, the youngest of whom was thirteen years old, lost her daughter-in-law a year before, she having died four days after her delivery. After her death she took charge of the infant, which was thin and puny, besides being so complaining and hard to pacify that after passing several sleepless nights, she allowed it to take her breast. Not more than from thirty to thirty-six hours had elapsed, before Mrs. B. was astonished to find her breast become painful and enlarged, and immediately afterward the secretion of milk was established as freely as had been customary after her confinements. LACTATION. 905 For an entire year, the child nursed at the same breast which had given suck to its father twenty-four years before. Baudtlocque mentions a little girl eight years of age who presented the same peculiarity ; and the following case is re- lated by 31. Audebert: Angeline Chauffaille, sixty-two years of age, and who had not had children for twenty-seven years, undertook to nurse her granddaughter artificially. From time to time, in order to amuse it, she presented it with her nipple; but what was her surprise when she suddenly found both her breasts full of an apparently good, healthy, and nutritive milk ! She continued to nurse it for a year, and the secretion had not entirely ceased after the child had been weaned two months. At this juncture, her daughter again became a mother, her milk dried up, and the grandmother was able to nurse the second child. (Audebert, Gaz. Med., p. 250, 1841.) The duration of lactation varies greatly even in women who do not suckle. In some, it lasts several months in spite of all that can be done to put an end to it. I have just delivered, for the third time, a young lady who had an abundance of milk after her first two confinements, for the space of three months, and this although her courses returned in six weeks. The secretion of milk in nurses sometimes lasts long enough to enable them to suckle two and three children successively. A lady in every way worthy to be believed, says Desormeaux, assured me that she had known a woman to suckle five children consecutively, which must have involved a lactation of at least six years' continuance. I find amongst my notes the following case, the origin of which I am, unfortunately, unable to discover : A woman had so abundant a secretion of milk for the forty- seven years succeeding the birth of her first child, that she was not only able to nurse six of her own children, but seven others also. She always menstruated regularly during the lactation, and at eighty-one years of age, her breasts still yielded a small quantity of milk. On the other hand, the lacteal secretion often begins abundantly, then declines, and ceases without our being able to discover the cause. Many gradations are observable between these extremes, but the average duration of lactation in women is from twelve to eighteen months. The quantity of milk varies still more than the duration of the secretion, even when no account is taken of the hygienic and moral influences, which have an undoubted influence over it. One woman, in other respects healthy, may barely be able to supply the amount required for the nourishment of a single child, whilst another may be able to suckle several at a time. Haller says, that women have been known to furnish in a single day a pound and a half, or even two, three, or four pints of milk; in one case, the woman gave three pounds more than was required for her child. Unfortunately, it is difficult to know before- hand what the quantity of milk will be. The results obtained by 31. Donne, may, indeed, enable us to form a probable diagnosis, but are far from being certain. Even when the flow of milk is well established, as in the case of a nurse for example, it is very difficult to say what will be its amount. The nurse's age, and the size' and form of the breasts, are, doubtless, matters of importance, but still insufficient. Generally, when nurses are too young, as under eighteen or twenty years of age, or too old, as over forty years, 6they give a less amount of milk. Finally, it would seem that in certain individuals the amount of milk in- 906 HYGIENE OF CHILDREN. creases with the birth of every child, inasmuch as they have it in much greater quantity after the second or third confinement than after the first. Women of a lymphatic temperament, also, have less milk than others. Is the quantity of milk affected by the kind and amount of food ? Although such is not proved to be the case in the human species, the fact is too well established as regards the females of the superior animals, not to lead to the same conclusion as respects women. For my own part, I knew a nurse whose flow of milk was sensibly increased after several times partaking of ground lentils. The quality of the milk may be sensibly affected by numerous circumstances which have next to claim attention. A. The health of the nurse is a matter of the highest importance. Chemical analysis shows, that in diseases of any kind, the proportion of solid constituents increases at the same time that the proportion of water decreases. According to the analyses of MM. Becquerel and Vernois, this fact is more observable in chronic diseases than in acute febrile affections. Now, as M. Bouchut judiciously observes, this increase in the proportion of the solid principles of the milk is an unfortunate alteration, causing the child to be frequently affected with indigestion and consecutive enteritis. The milk of women suffering from chronic diseases, phthisis for example, exhibits great alteration of the milk globules. Every one knows that when an acute affection appears in a recently-delivered female, the breasts are scarcely swollen whilst the disease lasts, and even after recovery the lacteal secretion is sometimes but imperfectly established. A slight and evanes- cent affection during lactation appears to have but little influence, which is far from being the case when it is more severe and prolonged. The secretion some- times ceases, and even when it continues without presenting any appreciable alteration to our means of investigation, the state of the child, which is observed to become rapidly emaciated, and to digest badly, indicates an alteration of the milk as certainly as the best chemical reagent. An inflammation, an acute irri- tation of an important organ, or a considerable discharge of some kind, lessens it, or even stops it altogether. The diseases of the breast, the inflammatory en- gorgements, phlegmons, and glandular abscesses, merit especial attention, not only because they diminish the secretion of the diseased organ considerably, but because they communicate dangerous properties to the milk. Nothing more than a simple engorgement is needed to produce a reformation of the granular cor- puscles and a viscid condition of the milk ; and should an abscess be formed, the microscope shows its presence even before the exploration of the breast distin- guishes the collection of pus, by exhibiting the characteristic globules of that fluid with their granular appearance, their opacity, and the property of being completely dissolved in alkalies and of resisting the action of ether. B. Moral affections, such as fright, anger, disappointment, &c, undoubtedly have a very great influence upon the quantity and quality of the milk. Often have I been astonished, after choosing nurses with abundance of milk, to find the secretion cease a few days after having given up their own child for a strange nursling; and several, whom I had discharged simply because they had no more milk, returned a few days after in excellent condition. Sorrow, at being removed from their country and separated from all that are dear to them, especially the relinquishing of their children, may often account for this momentary suppres- ♦ LACTATION. 907 sion. A violent emotion is often found to occasion an engorgement of the breasts, or else their sudden subsiding. Children are often rendered sleepless, and affected with colic and diarrhoea, sometimes even with convulsions, in conse- quence of violent anger of the mother. A nurse in the Hospital Cochin was very irascible, and indulged in high discussions with her neighbor. On one occasion she was more angry than usual, and her child had violent convulsions on the morrow. She left the hospital, but returned again some months after. Similar scenes were again enacted, and followed by the same effects as regarded the nursling. This woman had already lost her first two children by convulsions. C. Influence of the Genital Functions.—1. Menstruation. Most women cease to be regular whilst they are nursing. Others have their courses to appear after four, five, or six months, and some again menstruate as regularly and freely as usual. Various opinions are held respecting the influence of menstruation upon the lacteal secretion, and the diversity is certainly due to the fact that this influence varies greatly in different individuals. There can be no doubt, that whilst it is slight in some cases, it is very decided in others. In endeavoring to judge of it, much greater regard must be had to the state of health of the child than to the microscopic or chemical examination of the milk. Some authors have manifestly been led into error by asserting that the appearance of the courses was a matter of indifference, for there are certain alterations of the milk which escape the closest examination, but which are nevertheless indicated by the effect which they produce upon the health of the child. _ The milk of animals is very different in the rutting season from what it is at other periods; and this fact should have led to an anticipation of what takes place in women, whose menstrual epochs have the strongest analogy with the period of heat. The following points are proved by experience in relation to nurses who have their courses; some, in consequence of the uterine discharge in connection with that from the breasts, fall into a state of debility and maras- mus; some have their milk to diminish in quantity, and to become more serous; the child too emaciates, although their general health does not appear to be sensibly affected. Under either of these circumstances, the rarest of all, it is true, the mother ought to relinquish nursing. The milk of some women does not appear to be altered, nor the nutrition of the child to suffer, except during the flow of the menses; in which case, the mother's deficiency may be tempo- rarily supplied by the use of cow's milk diluted. Finally, in many cases the children's health is in no wise disordered, either during or after the menstrual PeTnere are certain substances whose excess in the blood is necessary to the nutrition of the child, phosphate of lime for example, which are in great part eUm nated by the menses; nor were it, perhaps, unreasonable to trace some re\*- t^ of causality between'the rachitis of children and the regular occurrence of the menses during the greater part of lactation. A fact mentioned by Godey would seem to prove, that contrary to what is generally observed, the mammary secretion may be excited by ^^A £ woman, thirty-two years of age, entered the Lourcine Hospital to be treated for uterine hemorrhage. At twenty-five years of age she was suckling her own child, but took another one to nurse at the same time. Her business soon 908 HYGIENE OF CHILDREN. obliged her to give up this double nursing, and the secretion of milk ceased with- out any functional disturbance; a month after, her courses reappeared, and with them a slight swelling of the breasts, which discharged a small quantity of milk. At each succeeding period, the lacteal secretion appeared in greater abundance, and after some months became so great, that the painful distension of the mam- mae obliged her to have them drawn by another woman, as also to use pumps to assist in their disengorgement. Each menstrual return, since then, has always been accompanied by a secretion of milk, though in much smaller quantity, which coincided remarkably with the uterine hemorrhages for which she had been treated eighteen months previously, and for which she of late entered the Lourcine. 2. The supervention of pregnancy during lactation, is almost always an unfor- tunate circumstance. It is very rare for the quantity of milk not to be conside- rably diminished, or, at least, to lose a great part of its nutritive qualities. The child almost always wastes away in consequence, nor, for my own part, have I ever known a single woman whose child did not suffer from it. I have several times been consulted by young mothers, whose children, put out to nurse at several leagues distance from Paris, were sensibly emaciated, and I have always been able to determine, or at least elicit an acknowledgment, that the subsidence of the breasts was occasioned by pregnancy. I, therefore, do not hesitate to re- gard pregnancy as incompatible with proper nursing. It is true that cases are recorded of women who did not leave off nursing throughout the entire duration of a new pregnancy, and who even, like the one mentioned by Van Swieten, gave the breast to a child of a year old during the early pains of labor; still, these cases are so exceptional as not to invalidate the general rule which we have laid down; and besides, it is not stated whether the woman who acted thus and had fine children, suckled them exclusively, without frequently administering in addition cow's milk and often soups or broths. 3. Sexual intercourse, of itself, I should regard as of little danger, unless it should be repeated too frequently, or with too much ardor; in which case it might act like any strong moral affection. It might doubtless result in preg- nancy, which should be avoided, and on that account is interdicted to mercenary nurses. The case is much more difficult for women who nurse their own chil- dren. For, on the one hand, there are certain constitutions which might suffer from a complete abstinence, and on the other, there are certain conjugal exigen- cies which it is impossible not to satisfy. Only great prudence and reserve should, therefore, be recommended. D. Effect of certain Alimentary or Medicinal Substances.—A multitude of daily observations show that the smell, taste, and even the color of certain sub- stances, may be communicated to the milk : this is the case with garlic, beete, turnips, the bitter taste of wormwood, and the peculiar coloring matter of madder and saffron. This peculiarity of certain substances by which they communicate a portion of their properties to the milk has long been taken advantage of in therapeutics. Thus, Haller cured certain colics in children by causing the nurses to eat the fruit of the Anisum pimpinella. Certain purgatives, as rhubarb and gratiola, purge the child when administered to the mother. Iodide of potassium and the proto-iodide of mercury, when taken by the latter, cure the former sim- ultaneously of congenital or acquired syphilis. NURSING. 909 A new-born child, says M. Godey, refused to take the breast for three days, and the pump had to be used three times in order to empty it. Finally, it con- cluded to suck, and immediately afterward vomited the greater part of the milk ingested. The same thing occurred for several days in succession. During the night, it took the breast of another nurse who had been delivered for a month, and no longer vomited. The mother's milk was abundant, but very serous; under the microscope it presented numerous granular corpuscles and very small milk globules. Nitric acid produced in it, after a few minutes, a lilac rose color, which was retained under the microscope by the masses of coagulated caseine. This woman had inhaled ether during her labor, and it is a question whether that penetrating fluid may not have affected the mammary secretion, so as to pro- duce the disgust and regurgitation remarked in the child ? It can only be deter- mined by further observation. CHAPTER II. NURSING OF CHILDREN. It must be evident from what we have stated, that everything is wonderfully prepared at the time of delivery for enabling the mother to suckle her child; but inasmuch as all are not equally fitted for fulfilling the latter duty, several kinds of nursing have been distinguished, each based upon the source of the milk designed for the new-born child, as also upon the mode of its administration. Generally, the mother supplies her infant with its first nourishment, and her lac- teal secretion is entirely sufficient to satisfy all its demands. The mother may possibly be unable in some cases to furnish of herself all the milk that her off- spring requires, and be obliged to supply her insufficiency by food from other sources. Sometimes she is altogether incapable of suckling her child, which is then confided to another nurse. Finally, there are cases in which, notwithstand- ing the impossibility of nursing on the part of the mother, she is unable to pro- cure either a wet-nurse or an animal, and is compelled to have recourse to artifi- cial nourishment. The order which we shall follow in describing the various modes of nursing is based upon the varieties just indicated, and we shall treat successively: 1, of nursing by the mother; 2, of mixed nursing; 3, of wet-nursing; 4, of suckling by animals; and 5, of artificial nourishment. ARTICLE I. NURSING BY THE MOTHER. The mother's milk, being designed by nature for the nourishment of the child, is certainly the best adapted to its requirements. Therefore, whenever the female is in good health, when her strength is not prostrated by any serious 910 HYGIENE OF CHILDREN. disease, when the antecedents of the family are such as to remove all doubts on the score of hereditary influence, there is every reason why she should yield to the promptings of nature. There is no necessity for being so strict towards the mother, as regards vigor of constitution, quality of the milk, and development of the breasts, as it is proper to be in choosing a nurse. Were we, in fact, to regard those women only as capable of nursing, who have the robustness and strength which we require in mercenary nurses, we should be almost obliged to relinquish the idea of seeing the majority of females in the upper classes suckle their own children. We often find persons of this description, who have but little milk, and that of medium quality, who yet raise very fine children ; and what is sin- gular, if these very same women should nurse another child, it is found to become emaciated for want of sufficient nourishment. Without admitting that suckling protects newly-delivered women from many diseases to which they are liable when they do not nurse, and whilst acknowledg- ing that it exposes them in an especial manner to fissures of the nipple, and to engorgement and abscess of the breast, I regard it as so important to the child that 1 make it a point to recommend it in the absence of any formal contra-indi- cation, such as, a very lymphatic constitution, the presence of skin disease, or of predisposition, hereditary or otherwise, to phthisis pulmonalis. When a pregnant woman proposes suckling her child, the physician is often consulted iu regard to her fitness for the task, and the future qualities of her milk. This question is usually very difficult to answer. Still, by taking in con- sideration the state of the constitution, the changes which the breasts undergo, and the quantity and quality of the sero-lactescent fluid which they furnish (see Lactation), we may be able, in the majority of cases, to form a tolerably correct opinion. Sometimes the anticipations of the physician seem to be at fault during the first weeks subsequent to delivery. There are some individuals, who, having commenced nursing in opposition to the advice of their accoucheur, and finding their milk abundant at the outset, think themselves excellent nurses and make light of our fears; but, as 31. Donne observes, this abundance at the first is not always a surety for the future: the least promising women often have consider- able milk at the commencement, and the first milk is always rich enough for a new-born child. Everything seems to go on well, and it is not until aftep the lapse of six weeks or two months, that the diminution of the milk, the emaciation of the child, or the disordered health of the mother, begin to be perceived. $ 1. Precautions to be observed in relation to women who propose Nursing. 3Iost of the preliminary precautions have reference to the conformation of the nipple. The varieties which it presents may call for the employment of some preparatory measures, and even, in some cases, constitute a formal contra-indica- tion to the nursing. Thus, certain women have a very short nipple, so that it barely reaches the level of the breast, whilst in others, its place is occupied by a depression rather than a projection; lastly, in some, the nipple is extremely sensitive even before pregnancy, and during the cold season becomes chapped and fissured. When the nipple does not project at all, and especially when its NURSING. 911 place is occupied by a depression, suckling would prove so difficult for the child and so painful to the mother, that I advise its relinquishment altogether. Although the means employed hitherto for drawing out, and, as it were, mould- ing the nipple, are sometimes effectual when it is only too short, they rarely succeed in making it project when it does not exist at all, and often give rise to serious accidents. Thus it has been recommended : 1. To titillate the nipple frequently during the last two months of gestation; but this is irritating, often becomes painful, and has finally to be given up. 2. To use nipple shields. These are little concave plates of turned wood, having a small excavation in the centre for the reception of the nipple. The patient applies this plate when she is dressed, and draws the gusset of her corset so as to pi ess strongly upon it. The compression being applied on all parts ex- cept the nipple, causes it to project strongly, so that after wearing it for two or three months, the nipple is lengthened to the extent of three-eighths of an inch. When the mere application of the shield is not found to answer, a pump is adapted to its extremity, each stroke of the piston of which draws upon the nipple and occasions it to project. But as the skin of the nipple is subjected to incessant rubbing against the sides of the shield, it is liable to become inflamed in consequence. The same remark applies to the species of vials, furnished with a narrow opening, which is applied upon the nipple, and provided with a long curved tube, which enables the woman to produce tractions by exhausting the air with her mouth. 3. Direct and repeated suction is, doubtless, the best means that can be em- ployed. This may be performed by the husband or an intelligent servant maid. In the want of a sufficiently accommodating individual, a large puppy may be used, first taking care to wrap up its paws. The reason why suction is the best means that can be used is, that the gutter formed by the tongue keeps the nipple extended, and prevents the oscillating movements communicated by the pump. Besides, when the nipple is moistened by the saliva, it becomes more supple and extensible. After this suction, says Gardien, the nipple is to be washed with warm wine, iu order to give firmness to the cuticle. The washing completed, they should be covered with tubes of white wax or gum elastic, to keep them elongated and protect them from rubbing. To make the nipple covers of wax, a piece of this substance is put for some time in warm water, in order to soften it, and its centre is next depressed with the finger or a thimble to a sufficient extent to receive the nipple. The extreme sensibility of this part in some women who have never had chil- • dren, also calls for the use of some means of hardening, of tanning a little, the skin which covers it. This is easily effected by the use of lotions, consisting of alcohol and water or astringent solutions, continued for several months. These precautions, judiciously employed, often render nursing possible and even easy, which without them would have been impossible, or at least very painful at the outset. § 2. Rules of Nursing. Everything being properly prepared, the mother is about to suckle her child. Now, in order to present in a regular manner the practical precepts which should 912 HYGIENE OF CHILDREN. govern the nursing, it will be useful to divide the time of its continuance into several principal periods, which, being characterized dsy peculiar phenomena on the part of both mother and child, give rise to special indications. We shall divide the nursing into three periods : the first ending with the milk-fever, the second extending beyond the term of six months, and the third until weaning. First Period.—The first period is of very short duration, constituting, so to speak, the transition stage between the intra-uterine nutrition, whereby the child derived the nutritive elements ready elaborated from the maternal economy, and the suckling, properly so called, by which it still receives, indeed, a special nutri- ment from the mother, but one which has to undergo elaboration in its own in- testinal canal before being assimilated. The phenomena which mark this period are, in fact, preparatory on both sides; on the part of the mother, whose milk gradually loses the characters of colostrum, to assume those of a more nutritive fluid; and on the part of the child, who gradually becomes accustomed to, and skilled in the performance of the new function, and who also finds in the fluid provided by the mother, purgative qualities, which clear out the intestinal canal, and thus prepare it for the digestion of more substantial food. As we have already stated, the colostrum secreted by the mammae at the time of delivery, or shortly after, is sufficient in quantity to satisfy the requirements of the child. It may, therefore, strictly speaking, be put at once to the breast, and the doing so would in many cases be attended with no inconvenience whatever. The efforts which it makes to suck are generally sufficient to excite or increase the secretion of milk in primiparae. Still, as the mother's strength is often ex- hausted by the pains of labor, aud she needs a season of rest and quiet after several sleepless nights, it would be cruel to oblige her to nurse her child, imme- diately, there being really no occasion therefor. On this account, it is customary to defer it for seven or eight hours, after which time she is presented with her child. But as the latter would be inconvenienced by remaining so long without food, it is well to give it a few dessert-spoonfuls of warm sugar and water, about an hour after its birth. This should be repeated every two hours at the soonest, or every three hours at the latest, until it is convenient to the mother to put it to the breast. This mode of procedure has the advantage of clearing the mouth and fauces of the mucus which so often obstructs them. Should the mother from any cause be unable to give it suck for several days, a substitute should be prepared, by adding about one quarter the amount of cow's milk to the sugar and water. Some persons have imagined that the putting of the child to the breast might be deferred with advantage for twenty-four, thirty-six, or even forty-eight hours; and some authors would even have us wait until the milk-fever is over. This plan is liable to several serious objections. Thus, the child is deprived during all this time of a fluid whose nutritive qualities are perfectly suited to the con- dition of the intestinal canal, and whose laxative properties enable us to dispense with the purgatives so often required to expel the meconium in children which are brought up artificially. On the other hand, the sucking of the child facili- tates the flow of the milk, prevents the inordinate swelling of the breasts and the pain which so often results therefrom; it gives form to the nipple, which is seized with much greater difficulty when the breasts are swollen and tense, and obviates the milk fever almost entirely. Therefore, in the interest of both mother and NURSING. 913 child, we think it right not to nurse immediately after delivery, but also not to postpone it longer than from six to twelve hours. Before putting the child to the breast for the first time, it is important to wash the nipple with warm water, in order to remove the concretions of sebaceous matter which may have collected in the bottom of the grooves in which the lacti- ferous ducts discharge. The washing has the additional effect to moisten it, make it more supple, and render it less unpleasant to the child. It is necessary at the outset to put the nipple in the child's mouth; for, as it is guided only by a blind instinct, it takes anything presented to it, and might seek for a long time without success. Most children perform very well at the first attempts; but this is not always the case, for, independently of the difficul- ties due to the shape and size of the breast and nipple, which difficulties we shall speak of hereafter, there are others depending upon the manner in which the breast is presented to it: thus, the face of the child being applied against the breast, if care be not taken, its nose will be stopped at the same time that its mouth is filled by the nipple, and, being unable to breathe, it withdraws from the breast. Therefore, it should always be seen to that the nostrils are kept free. At other times, the nipple, instead of being grasped by the upper surface of the tongue, into the concavity of which it should be received, is placed beneath the point of that organ upon the floor of the buccal cavity, whence suction is impos- sible. Levret mentions a remarkable disposition of the tongue, which is curved into a gutter, and adheres to the palate ; in this case, it should be detached with a spatula. The motions of the tongue are sometimes hindered by shortness of the frsenum, which also prevents it from being projected forwards. In this case, the fraenum should be cut.1 i The fraenum linguae is sometimes, but more rarely than those accoucheurs seem to think who cut it in most new-born children, too long from before backward, at the same time that it is too short from below upward. The point, being then arrested against the lower parietes of the mouth, remains behind the alveolar ridge, and can hardly be put forth be- tween the lips. When the child cries strongly, the tongue is seen to be held downward and forward by a transparent partition, which prevents it from being raised and earned f°™" operation to be performed is of the simplest character. The head of the child being held slightly backward, an assistant pinches the nose to oblige it to open its mouth. I he freenum'is engaged in the slit of the plate attached to the grooved director, and then raising the tongue forcibly, the surgeon, holding a pair of blunt scissors in his right hand> d Vlde^ the fraenum at a single stroke, taking care to direct the point of the scissors downward and the farthest possible from the tongue. tnn«nm The accidents to which the operation is liable are: 1, the falling backwa d of the tongue into the pharynx, witnessed three times by J. L. Petit, and which would have suffocated thechild'had'noUhe organ been promptly restored to its position by f^\^ £ rhage from wounding the ranine veins. It is the more important to detect and suppress his hemo™rage, as ft would be kept up by the constant movements of .action or deglu- i "on It is remedied either by touching the bottom of the wound with a fluid can Uo or bv cauterising the injured vessel by means of a stylet heated to whiteness; or lastly, by Pet ndage. This consists of a fork of wood, an inch and a quarter - ength, covered wh linen, one end of which rests against the symphysis of the lower jaw whils the other embraces the apex of the wound. It is held in place by a small bandage placed across the mouth, assisted by another turn, then crossed below the jaw, and carried up above the ears, to be fastened to the child's cap. 58 914 HYGIENE OF CHILDREN. As other circumstances which may render nursing difficult or impossible, should be noted certain sublingual tumors, hare-lip with division of the hard and soft palate, and the facial hemiplegia which so often follows the use of the forceps. As the latter accident is generally evanescent, the artificial nursing need be but temporary. The sublingual tumors should be incised or extirpated as soon as possible. The division of the hard and soft palate renders suckling almost always impossible. Some children, either from congenital debility, or from sloth, or want of ac- tivity, seem as though they would not take the trouble to suck. After putting the nipple far back in the mouth, the mother should be directed to move it about, in order to tickle the tongue and solicit its action. With the same object, the nipple might be pressed a little, so as to project a few drops, or what is better, since, this is difficult in primiparae, a piece of linen dipped in sweetened water should be squeezed upon the base of the nipple, which would conduct the fluid between the lips applied to its extremity. Notwithstanding all these efforts, certain children seem unwilling to make any attempt to suck, neither do they indicate any want by their cries, but sleep almost constantly. The mothers are gratified by this repose of the child, which affords them opportunity of enjoying the quiet which they so much need, and are careful not to disturb it by putting it to the breast. But when it awakens after a longer or shorter time, or when, becoming anxious on account of its pro- longed sleep, the parent takes it up, it is found to have lost all its energy, cries very feebly, and is unable to suck. No time should then be lost in endeavoring to stimulate it in every manner possible. It should be undressed, placed before a warm fire, and rubbed actively with flannels either dry or moistened with cam- phorated spirits. It should be obliged to take the nipple if possible, and not succeeding in this, it should be put to a nurse, whose milk flows freely, and who can gradually express a few spoonfuls into its mouth. These poor children can generally be restored in this manner; but we are often obliged to let them re- main for a few days with a wet-nurse, whose milk flows so freely as scarcely to require any effort at suction, before returning them to their mothers. The condition just mentioned is far from being uncommon; and, for my own part, I have several times had charge of children who, in this way, have inspired me with the greatest anxiety. Therefore, we should always advise the mother never to allow more than two or three hours to pass without giving drink or suck to her child, and, at any rate, always to waken it. The first attempt at sucking soon fatigues it, which is explained both by its weakness, and the effort which it is obliged to make. Thus, during the first two days, it can hardly perform more than four, six, or eight regular and continuous suctions, before it is obliged to stop and begin again after a few moments. The interval between each attempt is generally longer as the child becomes weaker, either on account of its increased debility, or because it has nursed so recently. Sometimes it even falls asleep upon the bosom after some efforts, and has to be awakened by striking it lightly upon the cheeks, buttocks, or feet. The acts of sucking are occasionally so distant, that the child may remain in this way at the breast for half an hour, or even longer. Now, this slow nursing may become very painful to the mother. In France, NURSING. 915 women generally sit up in bed for the purpose, and when obliged to remain long in that position they find it very fatiguing. It is precisely to avoid this that I would desire to popularize the practice that I have seen adopted with the greatest Buccess by American women, namely, to lie on the side corresponding to the one on which they intend to nurse, and placing the child lengthwise with the breast, allow the nipple to fall into its mouth. They may retain this position for a long time without experiencing any fatigue. During the first days, it is very important to watch the child very closely whilst at the breast, so as to be sure that it really sucks and swallows the milk. Either because the milk comes with too great difficulty, or because the child ■ will not, or cannot, make the necessary effort, it is seen, indeed, to make certain motions of the cheeks resembling suction, and yet does not swallow. If a finger be placed upon the larynx, we shall be able to tell by its movements during deglutition whether the latter is accomplished. Besides, a sort of rust- ling sound is often heard produced by the passage of fluid from the mouth into the oesophagus. When the child has been put to the breast from the first day, the milk-fever will rarely be considerable. The frequent emptying of the breasts by the child also prevents them from becoming distended and painful. Some women, how- ever, have so much milk at this time, that the mammae are exceedingly swollen and the nursing becomes, temporarily, more annoying to the mother and difficult for the child. It is more troublesome to the mother, because the sucking gives pain and the swelling of the gland extending even to the axilla, causes suffer- ing when the arm is brought down to the chest, which has to be done in order to hold the child properly; it is more difficult for the child, because this extreme distension renders it less able to seize the nipple. The swelling of the mammae effaces or depresses the latter, until it can no longer be grasped by the lips of the child When this occurs, it is often necessary to empty the breasts by means of a pump. The withdrawal of a certain amount of milk relieves the pain caused by the swelling, and restores the nipple to its usual length. As the child obtains but very little milk at a time for the first few days, it should be put to the breast at very short intervals. Still, it is well to accustom it to a certain regularity in the time of taking its repasts. Children always suffer from irregularity in their meals, sometimes leaving too long an interval between them, and sometimes introducing a fresh portion of milk into the^stomach be- fore giving them time to digest what they had recently taken. Without pre- tending to mathematical precision, we would state that the new-born child ought to nurse at intervals of about two hours at the shortest, and of three hours at the longest. When it is feeble, or born prematurely and therefore able to take but very small quantities at a time, the intervals might be short- n d We 1st, Tthink, allow it to judge for itself of the amount that it shal Uke at each time, except under peculiar circumstances. What would be plenty r on , would be insufficient for another, besides, as children are capable of re- jecting the surplus from their stomachs, there is no great harm in allowing them +n +mVp nther more than they really need. 10 &wX.W.-When the milker is over, the breasts are ,n n; ^ and from that time commences the nnrsing properly so called. Although it .s 916 HYGIENE OF CHILDREN. unusual to have to contend any longer with the difficulties mentioned as pertain- ing to the preceding period, there are yet some precepts which may be usefully applied. The first care to be taken before giving the child suck, is to be sure that it really needs it, for it ought never to be put to the breast for the sole purpose of stilling its cries, as, unfortunately, most young mothers are nearly certain to do. The fact is, the cry is not always to be taken as an expression of suffering or of real want. The child cries as we speak; very often, it is simply an act whereby it indicates its individual existence, and is so habitual during its earliest days, that it sometimes seems to indulge in it as a matter of enjoyment. Some chil- dren cry without any appreciable reason, and yet, notwithstanding their continual agitation, and often long sleeplessness, do not seem to be any the worse for it. Such children the nurses commonly call bad, and the epithet is tolerably well deserved. To judge whether the cries of a child are indicative of a desire to nurse, we should take into consideration the other signs which accompany them, as also the time of its last repast. The cry of hunger is generally attended with active movements of the upper extremities. The child turns its head from right to left, and opens its mouth as though seeking for the breast; it seizes eagerly the end of the finger, or any soft and round body that may be placed between its lips, and sucks at it repeatedly. When the proper moment arrives, before presenting the breast, the nipple should always be moistened either with a little milk or saliva. Then, the mother holding the child in her arms and resting its head upon one of them, puts the nipple in its mouth, taking care to press slightly upon the areola so as to project a little milk, and intimate, as it were, to the child, that it can suck with advan- tage. These precautions are hardly necessary except during the earliest weeks, for after this, it throws itself upon the breast and seizes it so powerfully, as to make it a painful operation. In some cases even, so far from exciting it, it is necessary to restrain its avidity by withdrawing the nipple from time to time, as when not having nursed for several hours, it swallows in a rapid and gluttonous manner. The mother should put it to both breasts at the same meal; they are thus kept disengorged, and by dividing the service, the nipples have time to rest from the effort of suction which often irritates and inflames them. The child is also thus early accustomed to nursing from both sides. If, as often happens, it appears to prefer one side in particular, and refuses to nurse from the other, that breast should be first presented which it seems to prefer the least. Hunger will soon overcome its repugnance, so that after some hesitation it will conclude to take the breast which it would have refused if presented the last. It is well to watch the child attentively whilst nursing, at least during the first weeks. It will then be ascertained whether the sucking is apparent or real by observing the motions of the larynx during deglutition, as also by hearing the sort of rustling of which we have spoken. The amount of milk which it takes, can be judged of more certainly by noting the length of time which it rests though still retaining the nipple in its mouth. It often sleeps after nursing; the warmth which it receives from the mother whilst lying in her arms, and the sort NURSING. 917 of enjoyment which it finds in keeping hold of the nipple, also, when it has sucked quite recently, the repletion of its stomach, all tend to invite slumber. As soon as the child is discovered to be sleeping, it should be awakened at once and caused to suck again, if there is reason for thinking that it has not had enough ; but when the contrary is the case, it should be taken away immediately and laid in its cradle. The infant soon contracts the habit of falling asleep and sleeping with the nipple in the mouth, and ere long it becomes impossible to put it to rest otherwise. It is plain that the practice must be fatiguing to the mother, especially at night. It is very difficult to determine the quantity of milk that it should be allowed to take at each repast, and how long it ought to be permitted to suck. The latter will evidently v^Lry with the abundance of the milk, the ease with which it flows, and the length of time that the child rests. As we have said, there is no objec- tion to allowing it to become satisfied in the absence of special indications sug- gested by disease. The child should be nursed less frequently as it grows older. After the first two or three weeks, it will be sufficient to give it the breast every three hours, and if the milk is of good quality, the intervals between the repasts may be still further lengthened towards the third or fourth month; this distribution must, however, be somewhat modified in the day or the night. The intervals of nursing at night must be greater from the beginning, so that it shall suck but three times from ten o'clock in the evening to five or six o'clock in the morning. After a month, even the intermediate repast may be relinquished. If the child sucks but little at a time on account of debility, and therefore seems to require the breast oftener, a little diluted cow's milk may be given once or twice in its stead. There can be nothing absolute as regards this determination of the hours for nursin^; for although we have recommended that the child's sleep be interrupted in order to give it food, this should not be done at a more advanced age. A child of from two to three months old will always awaken spontaneously when it feels the want, and the dangers that we have spoken of are no longer to be feared. Therefore it may be allowed to sleep on. Still, these precepts should be conformed to, for by leaving a proper interval between the repasts, the child receives sufficient food, it has time to digest what it has taken, and the acid re- gurgitations, and the passage of curdled but otherwise unaltered milk, the sure indications of a bad digestion, are avoided ; besides this, it has the advantage of preventing the enormous embonpoint, the puffy cheeks, and dead hue of the skin which sometimes indicate a weak constitution. This plan is attended with the happiest results, especially for women of the upper classes, for whom sleep, and that undisturbed, deep, and sufficiently long, is even more necessary than food to the reparation of their forces. Most of the nervous women of large cities should have at least six or seven hours of good uninterrupted sleep, under the penalty of being obliged to wean their children very early; then, after having nursed the child about five o'clock in the morn- ing, they may take another nap of two or three hours, if they require it. It would be a great mistake, says M. Donne, to suppose that the children suffer from this system. When observed from the beginning, they sometimes become accustomed to it, without having any trouble in sleeping as long as their mother, 918 HYGIENE OF CHILDREN. and they never suffer from the cow's milk that is given to them. They are thus trained to take the bottle, so that should anything afterward oblige the mother to suspend nursing temporarily, there would be much less difficulty in engaging them to accept the artificial nourishment, for which children who have never known anything but the breast sometimes manifest an invincible repugnance. Sleep is so necessary to nursing women, that not only should they never give suck, but whenever possible, the child should be kept from its mother at night. Having obtained an intelligent and faithful nurse, she should be intrusted with the care of watching over the child, giving it drink at night, and taking it to the mother only at stated times. Third Period.—As the object of the first period was to prepare the child for receiving a special elementary nourishment, it is proposed in theflatter, gradually to remove it from the mother, and so accustom it to all kinds of food ; in a word, to render its existence entirely independent. Therefore, the office of the physi- cian is limited to determining the period at which other food may be added to the mother's milk, as also the time when it may be proper to wean the child entirely. Practitioners are far from being unanimous in relation to the period at which other food than the mother's milk should be given to the child. "Nurses from the country," says Desormeaux, "are usually in the habit of giving to their chil- dren a sort of pap made of fine wheat flour and cow's milk, after the first week, they are impressed with the idea that this food relieves the colic, to which new- born children are very subject. Whether it really has this effect, or whether the digestion, by being made still more difficult, throws the child into a kind of tor- pid condition, it is often observed to be more quiet after taking it; at the same time it produces a favorable change in the color aud consistence of the excre- ments. On the other hand, when the children are confined to the mother's milk, provided it is sufficiently rich and abundant, they are not more subject to flatu- lent colic than others. From all this I am disposed to infer, that the first method, when prudently followed, is without inconvenience in the majority of cases, whilst in certain others, it may be advantageous. Nevertheless, I am per- suaded that the latter is the best and surest, especially for weakly children." Desormeaux's conclusion seems to me to lack precision, and I only quote it here for the purpose of opposing the tendency it might have to encourage certain prejudices which, unfortunately, are but too widely prevalent. The paps, soups, &c, which are given to children in certain countries almost as soon as they are born, are at least useless aud often dangerous. There are, doubtless, strong and robust children who may swallow them without inconvenience. But would they have thriven less had they been confined to their mother's milk ? This is what I deny, and have at the same time no hesitation in asserting, that such a regimen would prove dangerous to the greater number. When the mother is a good nurse, that is to say, when the performance of her duties does not fatigue her, and the milk remains unchanged in quality and amount, the child should be restricted to it as far as possible for the first six months, with the exception of the additions mentioned for the night. We shall see hereafter, when treating of the mixed method, what the reasons are which may lead to a modification of this rule, and to which I shall submit unreservedly NURSING. 919 whenever a hired nurse is concerned. Desormeaux thinks that the air of large cities is generally less pure and stimulating than that of the country; and there- fore, that the child should be supplied sooner with a species of nourishment capable of supplying, to some extent, the deficiencies of the air. He adds that the same is true as regards children brought up in low and moist places, as also for those of a lymphatic temperament, or whose parents are feeble. Neither can I agree on this point with the celebrated accoucheur. Doubtless, when the bad constitution of the children is due to the mother's weakness or the defective quality of her milk, cow's milk, and not broths or pap, should be substituted for it; but I cannot think that a residence in cities, or in low and moist places, is a sufficient reason for an earlier administration of food, which is unnatural to the child. Infants living under bad hygienic conditions, suffer from a susceptibility on the part of the intestinal canal, to which the robust children of the country, whose digestive powers are far more developed, are not liable. To give a feeble and delicate child food of difficult digestion, is to task the alimentary canal be- yond its powers, and could only result in incomplete elaboration and imperfect assimilation; fortunate indeed would it be, should it not give rise to chronic enteritis, with its attendant diarrhoea and emaciation. Kinds of food.—Farinaceous substances ought to be prepared, such as wheat and rice flour, potato starch, and arrow-root, in connection with milk, so as to form a well-cooked pap of variable consistency; wheat flour slightly dried in the oven, taking care to avoid roasting or browning it, which would injure a portion of its nutritive elements, is generally chosen. This flour, which contains a large proportion of gluten, is very nutritious. The articles mentioned may, however, be varied to suit the taste and condition of the child. Thus, rice cream would be preferred if the child were somewhat debilitated, potato starch as a refreshing diet, and arrow-root as a light food. Panada made of well-baked wheaten bread, dried in the oven and then reduced to a coarse powder, forms an excellent diet. It is boiled for several hours with a sufficient amount of water, and afterward passed through a silk or hair sieve. About five or six dessert-spoonfuls of these preparations may be given at first every morning. Before long, they may be administered twice a day, besides having added to them shortly, semoule or veimicelli, well cooked. When the child is seven or eight months old, it may take chicken broth or light soups. A little later it can have the yelk of a boiled egg, carefully rejecting the white, and finally, it may be allowed to suck a piece of fowl, or preferably, a bone of fowl, also a crust of bread which it can chew and swallow only after having moistened it sufficiently with saliva. The water reddened with claret and sweetened slightly, which M. Donne re- commends giving after the age of six months, should, I think, be withheld rather longer, and even then, ought to be administered very carefully. As the child becomes accustomed to other food, it seeks the breast with less avidity, although still retaining a marked predilection for it. The mother can then suckle it less frequently without disadvantage. Toward the seventh or eighth month, she need nurse it but four or five times a day, and still later, two or three times, in the meanwhile ceasing to give it the breast at night altogether. 920 HYGIENE OF CHILDREN. This progressive diminution habituates the child to doing without the breast, develops its taste for other food, and, also, decreases the flow of milk; so that weaning becomes easier for the child and less troublesome to the mother. ARTICLE II. WEANING. At what age ought the child to be weaned? The natural period is that at which the first dentition is accomplished; for not until then is the child provided with the organs necessary to the mastication and insalivation of the food. But it often happens that the first dentition is not completed for a year or a year and a half, and it is very unusual to defer taking the child from the breast so long as this. The delay would be attended with serious disadvantage to both mother and child; the mother would become exhausted by her long nursing, and her milk finally lose its good qualities; besides this, the children themselves, after a certain age, seem to require more substantial food ; some, in fact, retain a pallor and puffiness of the features, as well as general debility so long as they continue to nurse, and assume a rosy hue, a lively and happy expression, and firmness of flesh, as soon as they become accustomed to a more nutritious food. When care has been taken to habituate the child to something else than milk from the time it is six or seven months old, but little difficulty will be experienced in weaning it completely; and nursing may be given up without disadvantage, as soon as dentition has made considerable progress. Still, I think it very im- portant to take into account the greater or less rapidity and facility with which the evolution of the teeth is accomplished. As a general rule, weaning is not to be thought of, before the child has from eight to ten teeth, which would be about the age of twelve or sixteen months. But if the dentition is delayed, painful, or accompanied by some of the affections to which the child is liable in its second year, there is an advantage, whilst giving the child other food, to keep it at the breast, allowing it to suck at least two or three times a day. It is, indeed, an invaluable resource during the sufferings of painful dentition. The child then refuses other kinds of food, and will take nothing but the breast, so that it would be very difficult to nourish it if weaned prematurely. Therefore, a system which at once provides it with food and alleviates its sufferings, must be very desirable. In cases of retarded and painful dentition it would be pru- dent to continue the nursing till the child is eighteen or twenty months old. To fix upon any particular period for weaning, says M. Trousseau, is simply absurd, and for this reason : Weaning should always be subordinate to dentition. The fact is, the period of the first dentition, from the appearance of the first in- cisors to that of the last molars, is fraught with peril to the child. It is subject to a multitude of disorders affecting the abdomen, the chest, and the head, especially the former. Now, as the so-called disorders of digestion are the most frequently observed, it is important to be provided with a diet which the child shall not refuse, and which can neither aggravate its condition, nor give rise to any other disease. But dentition lasts for three years : must the suckling be continued all that time? No, not absolutely; we should be guided by the following rules, they are very easily remembered. NURSING. 921 The teeth are evolved in groups. How do they appear? There are several series, as follows: in the first, appear the two lower median incisors; in the second, the four upper incisors; in the third, the four first molars and usually after them the two lower lateral incisors; in the fourth, the four canines; and finally, in the fifth, the four last molars. These are the deciduous teeth. Let us next see how the groups make their appearance : 1. The first incisors come through at an interval of from one to fifteen days, though generally, on the same day; and when these two first do not appear within two or three days of each other, the dentition is irregular. When this is over, the child rests; a fact of immense importance as regards therapeutical measures. It rests from three to six months. The two first teeth usually appear between the seventh and eighth month, and the child has afterward at least six weeks of quiet. 2. The four upper incisors are a month in coming through. First the mid- dle, and then the lateral ones appear, and that between the tenth and twelfth month. 3. From the twelfth to the fifteenth month, those of the third series come through : then the child rests for four or five months, during all which time the evolution of teeth is suspended. 4. Between the eighteenth and twenty-second month, the four canines make their appearance, and are three months in coming through, after which there is a very long repose. 5. Lastly, the child gets its four last molars. It is well to know that the teeth appear in groups, inasmuch as the child is sick during the period of a dental evolution. It coughs and has fever, but after the teeth are through, recovers with astonishing rapidity. Thus it is, through- out the entire period of dentition. Now, what is the right time for weaning ? Evidently, it should be in the interval between one evolution and another, and about seven or eight days after the teeth are through, and while the organs are in a state of rest. We have thus an advantage of several months, wherein the child can be accustomed to a new diet. After which of these evolutions is it best to wean the child ? After that of the canines, as being the most dangerous : the latter appear singly, and are the only ones which are crowded. The others meet with no impediments, and none but the canines are embraced by the neighboring teeth, which they are obliged to press asunder. Therefore it is, that the cutting of these teeth is accompanied with more severe symptoms. When it is decided to wean a child which has been for some time accustomed to eating, it is generally better to do it at once than to leave off nursing gradu- ally ; for by continuing to allow it to suck only once or twice in the twenty-four hours the milk becomes altered, and might prove injurious. It is, however, advisable to begin at night, and, without considering it a matter of great impor- tance, I would prefer the spring or summer to winter for commencing. The mother ought, as far as possible, to give up her child to another person, who should supply it with drink, and render it all necessary attention. Some children, so long as they know that their mother is near them, refuse to take any other food, and it is hard for a parent to resist the tears and entreaties of her 922 HYGIENE OF CHILDREN. infant. Should it be impossible for the mother to put away her child, she ought to try to disgust it by covering the nipple with some substance of disagreeable taste and odor, such, for instance, as aloes or mustard. I have rarely failed to succeed with the latter, for most children reject the breast with disgust after having once tasted or even smelled it. ARTICLE III. REGIMEN OF NURSING WOMEN. We have but few remarks to make in relation to the precautions which should be observed by a young woman who proposes nursing her child. A good diet is indispensable for women who have to support the fatigues of nursing. Rich and succulent food, beef broth, white and dark meats, whether roast or boiled, should, doubtless, form in great measure the principal elements of the meals ; still, they ought not to be debarred from vegetables, milk, chocolate, and boiled prepara- tions of the various farinaceous substances. They should avoid highly-seasoned ragouts, and an excess of salt, pepper, vinegar, and other strong and indi- gestible condiments. The usual drink should be claret and water, the use of pure wine, alcoholic liquors, and coffee, require great discretion, and it were far better to abstain from them altogether. The number of meals should generally be governed by the habits of the indi- vidual. • It is well, however, that they should not be too far apart, nor so copious, as to give rise to indigestion. We have already insisted on the propriety of the mother's obtaining a suffi- cient amount of sleep, and revert to it only for the purpose of fixing attention upon its importance; for without it, most of the females in large cities would find it impossible to nurse. A nursing mother ought to breathe a pure air, avoid dampness and cold, and take a sufficient amount of exercise. The warm bathing which some persons prescribe, I approve of when not too long continued, and only for the preserva- tion of cleanliness. A residence in the country certainly is one of the best hygienic conditions both for herself and child, which often finds in frequent insolation and pure air a substitute for deficiencies in the quality of the milk. The breasts should be carefully protected from the air, especially at the out- set, and the child should not be suckled iu a cold and damp garden. I have known several ladies to be attacked with inflammatory engorgement of the breasts from a neglect of this precaution. The chest ought to be kept constantly covered with a piece of soft linen folded in several thicknesses, and changed as soon as it becomes moist. When the breasts are very large, they should be supported by corsets with ample gussets; for the mere weight of the glands is sometimes sufficient to render them painful and give rise to engorgement. Some women have so much milk, that when the child sucks on one side, it escapes freely from the other. To prevent the linen from becoming too much NURSING. 923 moistened in this way, the nipple is sometimes introduced into the neck of a sort of very flat bottle, which receives the milk as it escapes. Finally, nursing women cannot be too strongly recommended to avoid sadness and violent moral emotions; we have already explained at length the effect which they might produce. "It may be said, in a general way," M. Donne remarks, "that calmness and equanimity are what young women most frequently lack So essential a condition is this, that I take into deep consideration the nervous condition of the mother when judging of the propriety of her nursing, and if she is too excitable, I prefer intrusting the child to a wet nurse. A mother whom the least cry of her child fills with anxiety, and who cannot see it fretful or in pain without being overcome, will hardly fail to make a bad nurse. A child is rarely brought up without suffering some derangement or other of its health, and sometimes even serious disease. It is precisely on such occasions most important to have the milk perfectly pure, which it never can be from the breast of a mother who will not, or cannot control her emotions. ARTICLE IV. OF THE CIRCUMSTANCES WHICH MAY RENDER NURSING BY THE MOTHER DIFFICULT, AND OF THE ACCIDENTS THAT ARE LIABLE TO INTERFERE WITH IT. § 1. Impediments to Nursing. We have already treated of such malformations of the nipple as may sometimes be remedied by timely interference. There are some, however, such as the ab- sence of this part, and its entire imperforation, which render nursing impossible; but even those of the kind first mentioned, such as shortness of the nipple, may make it equally impracticable, when not discovered until after the birth of the child, and when about to put it to the breast. This shortness of the nipple may be only relative, that is to say, though long enough for a strong child accustomed to sucking, it is too short for the new-born infant, who cannot take it, or is unwilling to do so. In such cases, it is well before putting the child to the breast to render the nipple rather more project- ing by titillating it with the fingers, drawing it out by a pump, or having it sucked by a puppy, an adult person, or, still better, by a child from six weeks to two months old. The latter is preferable when it is reasonable to suppose that the difficulties resulting from the shortness of the nipple are increased by the weakness or the unwillingness of the child. A strong and vigorous infant, fur- nished by another nurse, would be able to take the breast of the recently-deli- vered female, and give shape to the nipples, whilst, on the other hand, the new- born child, deriving its nourishment with ease and in abundance from the breasts of the nurse, grows rapidly stronger, becomes accustomed to sucking, and after a few days may be returned to the mother, who is then able to present it with properly-formed breasts. Care should be taken not to select too old a child ; for, knowing its nurse, it would be unwilling to take the breast of another woman. Finally, as a last resort, the artificial nipples, in their most modern and im- 924 HYGIENE OF CHILDREN. proved form, may be tried. Those made by M. Charriere of softened ivory, I think preferable to any others. § 2. Erosions, Excoriations, Chaps, Fissures, and Cracks of the Nipple. These various affections, implicating the nipple or its base, bear the strongest resemblance to each other, and hardly differ except in extent, and more espe- cially in their situation. Excoriation, of which erosion is but the first degree, is a small, superficial wound of the skin, in which the derm is laid bare by the removal of the epi- dermis. When it has become so large and deep as to destroy the surface of the derm, it constitutes an ulceration. It has no special seat, but may affect the entire surface, or only one or a few points of the nipple. Its surface is often of a bright red color, granulated, and frequently swollen; sometimes it is always moist, at others covered with thin scabs. Occasionally, sucking is followed by a slight effusion of blood. The chap results from the drying up, and imperfect removal of the epidermis, the dried cells of which resemble small scales. The fissure is an elongated ulceration, generally deeper than the simple exco- riation. It forms at the bottom of the furrows, and takes their direction; usually, and then too it is the most painful, it occupies the groove separating the base of the nipple from the rest of the skin. Cracks are an exaggeration of the fissures, from which they almost always originate. They differ from the latter by the cracked, swollen, and extremely sensitive condition of the surrounding skin. Inflammation of the skin of the nipple is the usual cause of the erosions, exco- riations, and ulcerations which succeed them; though in some cases, according to M. Deluze (Inaugural Thesis), they are formed in the following manner: When the child seizes the nipple, it is placed in a gutter between the tongue and the palate, so that all the efforts at suction are brought to bear upon the extre- mity of the nipple towards which the fluids tend; as this part is supported by nothing, it gives way, and a small, bloody streak can be detected upon it after nursing. In some cases, the only effect of the suction is to raise the epidermis, and form a sort of pouch or red spot, beneath which a slight ecchymosis is dis- coverable ; finally, either in consequence of another act of nursing, or sponta- neously, the raised portion of epidermis dries and falls off, and excoriation follows. The extension of the latter into the grooves of the nipple gives rise to the fissures. Simple excoriation is far more common than fissures produced at once or by rupture. Thus, of 17 cases observed at the Clinique by M. Deluze, there were but 4 cases of a spontaneous character. I regard exposure of the nipple to cold, when yet warm and moist after suck- ing, as the most frequent cause of chapping. Fissures and cracks may, no doubt, also take their origin in inflammation or the impression of cold, inasmuch as they so often follow ulcerations, and chaps; but besides this, they may often be pro- NURSING. 925 duced mechanically, by the violent tractions upon the nipple during the act of sucking. They occasionally appear after the child has taken the breast two or three times. The sucking first produces acute pain, followed by violent smarting. A superficial examination of the breast discovers nothing; but if the nipple be drawn upon gently, so as to widen the furrows which traverse it, a slight redness with serous effusion will be found at the bottom of one or several of them. The fissure is not yet formed, but soon makes its appearance after a few more nurs- ings; as each application of the child to the breast tends to increase it, a true crack is shortly formed, which becomes covered with a scab or crust, beneath which it is common to find a small amount of extravasated blood. However produced, these accidents generally occur in the early days of lacta- tion. The normal sensitiveness of the nipple is not as yet blunted, nor has the skin covering it had time to become accustomed to the pressure and tractions which it is destined to undergo. However, although these ulcers or cracks rarely occur after the tenth day, I have known them to be formed at a much later period, in which case they seemed to me to have been occasioned by the biting of the child, and sometimes by an aphthous inflammation affecting the latter. These slight accidents are generally suffered by women who nurse for the first time: such as have a fine and irritable skin, whose breasts were very sensitive even before pregnancy, those whose nipples are badly formed, or who wait for several days for the milk to come before putting the child to the breast, thus obliging it to grasp the nipple more strongly with its lips, and to make greater effort to extract the milk, are peculiarly exposed to them. Slight excoriations and ulcerations are generally supported without much trouble; which is far from being the case with the fissures and cracks, which are commonly exceedingly painful. Those situated at the base of the nipple, I have thought, occasion the most suffering. When we remember the painful sensations resulting from the cracks that are liable to form on the median line of the lower lip in winter, we may easily imagine the effect of those on the nipple. The evi- dent tendency of each act of suction is to separate the margins of the little ulcer. Notwithstanding her desire to nurse the child, the mother dreads the approach of the stated times, and instinctively recoils when the babe is brought for the purpose. At the moment of seizing the nipple, she is often compelled to cry out, and continues to groan for several minutes. Generally, the sensation is less acute after the first few moments, but is renewed with dreadful intensity when- ever the child recommences sucking after having stopped, and especially when it seizes the nipple again greedily, after having relinquished it altogether. The suffering is sometimes so intolerable, that these unfortunates are observed to bite their clothes or coverings, to avoid crying out, whilst others writhe or are even affected with convulsive movements. If the crack is deep and the suction strong, some blood flows from the edge of the wound. This becomes mixed with the milk and is swallowed. Should the child vomit, it is found in what is thrown up, but if not, it is expelled in the stools, and leaves its mark on the diaper. The physician should remember this fact, for he is often consulted by parents who inquire in great alarm the meaning of these bloody passages. The explanation is almost always to be found in 926 HYGIENE OF CHILDREN. fissures of the nipple, of which the woman had not, perhaps, complained hitherto; but should he neglect making the examination, he might suspect hemorrhage of the bowels, and thus help to continue fears wrhich are really without foundation. The irritation affecting the fissures is very often propagated to the skin of the nipple, thence to the areola or the cellular tissue which lines it, and next, more deeply to the gland itself or to the interlobular tissue, thus giving rise to ab- scesses of the areola, or to those of a phlegmonous or glandular character. On the other hand, the suffering is sometimes so severe that the mother avoids nursing from the affected breast as much as possible, thus helping to produce its engorgement and the abscess to which it gives rise. We would add, finally, that in consequence of the long detention of the milk in the ducts, it becomes dete- riorated, and assumes the characters of colostrum. The sufferings occasioned by these ulcerations of the nipple, and the serious accidents which often result from them, show, evidently, that they ought to be prevented, and when they exist, to be cured as soon as possible. The difficulties in nursing due to the shortness and malformation of the nipple being generally the cause, the best prophylactic means are those already men- tioned. (See page 923.) The delicacy of the skin, and extreme sensitiveness of the nipple, will be advantageously treated by astringent lotions, frequently ap- plied during the latter months of gestation. Without having any great confi- dence in the value of ointments for producing this result, M. Dubois made some experiments for the purpose of testing them. He caused frictions with the fol- lowing compositions, to be made for a month before delivery, viz., tannin, one drachm; lard, one ounce; or with a mixture of equal parts of cocoa butter, oil of sweet almonds, and tannin. For my own part, I prefer theastringent lotions; they have not, like most fats, the inconvenience of soiling the linen, becoming rancid, and sometimes of irritating very delicate skins. Like 31. Trousseau, I am convinced that when the woman begins nursing, the best prophylactic measure is simply to wash the nipple with a fine sponge assoon as the child quits the breast. Its saliva is acid, and should a little caseine re- main behind, nothing more is required to produce excoriation. It is well to make these lotions with a slightly astringent solution. They should, however, be done quickly, so as to expose the breast to the air for the shortest time possible, and the nipple ought to be covered at once with a little hood of lead with a hole through its extremity, in order to protect it from the contact of cold air and the friction of the clothing. The use of prophylactic measures cannot be insisted on too strongly, for, un- fortunately, the curative means hitherto employed leave much to be desired. They are, however, numerous, and I know of no disease against which so many ointments, solutions, &c, have been recommended; but here, as is alw'ays the case in therapeutics, abundance means dearth; there is much less seeking when an infallible remedy is at hand. In order to account for the popularity which some of these preparations have enjoyed, it is only necessary to be aware that happily, in a great number of in- stances, these fissures or excoriations get well of themselves. The poor mother gradually becomes accustomed to the pain ; she continues to nurse, and when the cracks are not very deep, and especially when not situated at the base of the nipple, they undergo spontaneous cicatrization. NURSING. 927 The cessation of nursing is the best remedy of all; but it must be confessed that this is too discouraging to certain mothers who attach great importance to suckling the child. We shall therefore mention some of the chief topical appli- cations which have been used with a certain amount of success. M. Trousseau recommends, that when excoriations or fissures appear around the nipple, that lotions with warm water should first be practised, and followed by a weak solution of nitrate of silver. If these are not sufficient, a solution of sulphate of copper or of zinc may be employed; and, finally, when the affection persists, he would have recourse to the white precipitate ointment, viz : White precipitate,1 .... 4 grains. Lard, . . . . . . 2 to 4 drachms. I have used this ointment with some success at the Clinique. It is necessary to clean the breast well before putting the child to it, and to renew the ointment immediately afterward. Although I have observed nothing which could be attri- buted to absorption of the ointment, there is reason to fear lest the health of the child might suffer if the breast is not carefully wiped. M. Dubois appears to have tried, without advantage, the oil of cocoa, nitrate of silver, collodion, and creasote. The first acts like any other fatty matter, by pro- tecting the wound from contact with the air. Collodion, which promised much in the way of shielding the diseased surface from the action of the infant's mouth, and of preventing the dragging of the lips of the wound, whilst per- mitting the nursing to continue, has failed. The saliva gradually detaches the solidified lamina of this substance, and not unfrequently it is loosened by the cutaneous perspiration. The application of creasote is very painful to the mother and its smell is so repulsive that the child refuses to take the breast. Cauterization with the nitrate of silver sometimes succeeds when the pencil is finely-pointed and carried to the deepest part of the ulcer; but almost always upon condition that the nursing shall be suspended immediately afterward. This, however, is not practicable when both breasts are affected; it exposes greatly to engorgement when it can be done; and facts which have come under my observation, incline me strongly to believe that the cauterization itself may give rise to phlegmonous inflammation of the breast. Finally, I would add, that if nursing is resumed too soon after the ulcer is cicatrized, it would open again upon the first suctions. It is, therefore, upon the whole, useless when the nurs- ing is continued, and uncertain, and often dangerous, when the latter is inter- rupted. Mr. Startin, a London physician, has recently extolled the use of glycerine, or the sweet principle of oils. It is a substance produced abundantly during the saponification of fats, and especially in the manufacture of stearine candles. Glycerine does not evaporate at ordinary temperatures; on the contrary, it absorbs moisture from the air; it is soluble to any extent in water, so that it may be easily removed from the part to which it is applied. iThe white precipitate (precipite blanc) here alluded to, is the same as the precipitated calomel of the Dublin Pharmacopoeia: not the white precipitate (hydrargyrum ammonia- tum) of the United States Pharmacopoeia —Translator. 928 HYGIENE OF CHILDREN. The following are Mr. Startin's formulae against excoriations and fissures: R\.—Gum Tragacanth (pure),......2 to 4 drachms. Lime Water, ........ 4 ounces. Distilled Rose Water,......3 " Purified Glycerine,.......1 ounce. M. A soft jelly, to be used as an ointment or embrocation. Against fissures of the nipple: I£.—Biborate of Soda,.....half a drachm to a drachm. Purified Glycerine,.....half an ounce. Distilled Rose Water, . . . . 7£ ounces. M.S. For lotions to the affected parts. All these measures may be greatly assisted by the use of artificial nipples, which should be had recourse to whenever the child will submit to them. To overcome the repugnance which some evince for their employment, it is well to fill it with warm milk before applying it, so that the milk will flow readily into the mouth with the first suctions. The child soon becomes accustomed to it, for whilst emptying the artificial nipple it forms a vacuum, and draws out the mother's milk gently. If the child can be prevailed on to accept it, the artifi- cial nipple will almost always be sufficient of itself when the fissures and cavities are situated upon the free portion of the nipple, especially when the former are parallel with its length. Uufortunately, the case is very different when the fis- sures have a transverse direction, and especially when situated at the base. The artificial nipple, it is true, protects the natural one against the direct contact with the lips and tongue of the child, but is incapable, in the latter case, of preventing the separation of the edges of the wound. If, notwithstanding all these precautions, nursing is so painful that the mother defers suckling too long, and there is danger of engorgement, pumps for extract- ing the milk artificially will have to be made use of. I should give preference to the one invented by 31. Tier, and called teterelle, for its action is but slightly painful to the mother, and the lower chamber receives the milk, which may sub- sequently be given to the child. A new instrument, for the same purpose, was presented to the Academy of Sciences by Dr. Lamperiere, of Versailles, but not having seen it operate, I am unqualified to judge of the many advantages claimed for it by the inventor. Beside these altogether local lesions, there are some other accidents which may require nursing to be given up, either because they injure the milk or deteriorate the general health of the mother. § 3. Circumstances which may Interfere with Nursing. Whenever the mother suffers an attack of acute disease shortly after delivery, the secretion of milk is generally so far suspended, as no longer to be sufficient for the wants of the child. The same is the ease with some others, who, al- though apparently in good health, have no milk before the fifth or sixth day, without our being able to account for the delay. Lastly, the strength of some women is so exhausted by a tedious labor, that it is indispensable to allow them two or three days of perfect rest. Under NURSING. 929 all these circumstances, the place of the colostrum must be supplied by a little sugar and water mixed with one-fourth the quantity of milk; and should the mother's recovery be postponed longer than three or four days, the child ought to be given temporarily to a wet nurse, which were far preferable to arti- ficial feeding. Even when lactation has commenced regularly and properly, accidents are still liable to happen, all tending to lessen the quantity and injure the quality of the milk. A. Alterations in quantity.—The quantity of milk may be altered in two ways: there may be too little of it or none at all, or there may be far more of it than the child requires. The former condition has received the name of agalac- tia, and the latter that of galactorrhoea. Agalactia.—Nature seems to have left her work unfinished in some women, who, although capable of becoming mothers, are often unable to nurse their child on account of their having little or no milk. The agalactia may be either com- plete or partial: complete, when the secretion is absolutely wanting, and partial, when merely insufficient for the nourishment of the child. In both cases, it may be either original or accidental: original, when the breasts are the seat of no fluxion whatever after delivery, or when what secretion may take place, is in- sufficient for the requirements of the child; secondary, when the milk, though abundant at the outset, lessens considerably in amount or even ceases to be secreted altogether. It is very difficult to determine the causes of primitive agalactia. Imperfect development of the mammary gland, its atrophy, and the various diseases to which it is liable, may certainly occasion it in some instances. There are others, however, in which, unless we attribute it like M. Trousseau to deficient vital energy, due probably to imperfect development of the vessels supplying the gland, it is almost impossible to explain it. We have already studied the causes which may give rise to accidental agalactia, in the chapter on Lactation. It is generally quite easy to ascertain the existence of complete agalactia; but when the nurse has any interest to practise deception, it is necessary to be very careful, if we would detect it when only partial. The firsfrand best sign is the emaciation of the child, or, at least, its arrested development. On examination, the mother's breasts are found to be soft and flaccid, even when the child has not sucked for a long while. The latter is always hungry, and even putting it to the breast does not quiet its cries; it abandons the nipple at every instant, and sometimes even discards it angrily, as though enraged at finding nothing in it; finally, if after allowing it to suck for a long while, it is presented with a bottle of milk and sweetened water, it takes it with avidity. When the absence of milk is due to an organic cause, all hope of re-establish- ing the secretion will have to be given up and the mixed method resorted to, or else the child committed to a wet nurse altogether. But when it is accidental, and especially when it is the consequence of a violent moral emotion, of a slight indisposition, or an evanescent febrile movement, it will be necessary to rest satisfied with artificial nursing.for a few days; and after the cause is removed, the gland may be excited by frequently putting the child to the breast. I have very little confidence in the medicines or articles of food, which have 59 930 HYGIENE OF CHILDREN. long enjoyed a reputation for increasing the flow of milk. Still, we have the authority of Desormeaux in favor of anise, fennel, and lentils, which he asserts having known to increase the lacteal secretion in some of his patients. Galactorrhoea, or the too abundant secretion of milk, presents two varieties which it is very important to distinguish. In the one, the milk retains all its properties ; it is a mere hypersecretion, which ordinarily diminishes of itself after a time, and is only inconvenient to the mother and the child. The stream is so large and rapid, as to give the latter no time to swallow, so that it is every moment threatened with suffocation; often, also, the milk escapes from both sides whilst the child is nursing and wets the mother. Sometimes, again, the breasts are so swollen as to be painful, and the mother is then obliged to use the breast pump herself, or have it applied by another person. In the other variety, the milk is clear, serous, and manifestly altered; it also flows passively and almost continually from the nipple. The latter variety is the only serious one. The poverty of the milk soon injures the child; but the mother, especially, suffers from this sort of mammary diabetes. Should it continue, geueral debility, loss of appetite, notwithstanding the almost constant feeling of need of food, a sensation of heat in the stomach and fauces, and pains and drag- ging sensations in the back and chest, soon make their appearance. Rather later, symptoms of the nurse's phthisis, as Morton called it, show themselves, and these unfortunates, feeble and emaciated, are quickly brought by hectic fever to au early death. Weaning is the only means of preventing this fatal termination. The milk ceases to be secreted immediately afterward, and it then remains to restore the exhausted strength of the mother by the administration of iron, proper nourish- ment, and a residence in the country. General deterioration of the mother's health.—The strength of some women who were well at the commencement of lactation, fails rapidly after a few months. They become more and more emaciated, lose their appetite, and may suffer all the consequences of galactorrhoea. In some cases, this altered state of health seems to affect injuriously both the quantity and quality of the milk; yet I have seen others, in which the increasing debility of the mother inspired serious ap- prehensions, although the child coutinued to thrive, as though she supplied it with good nourishment at the expense of her own exhaustion; and this fact they give as a reason for objecting to weaning. I am a very good nurse, say they, for my child thrives well. Whatever may be the condition of the child's health, when that of the mother is endangered by the continuance of nursing, it should be weaned at once, under the penalty of falling into consumption. b. Altered quality of the mile.—M. Donne was the first to call particular attention to the changes which the nutritive elements of the milk are liable to undergo, and to the unfavorable effect which its poverty or richness, or its altera- tion by deleterious principles, might have upon the health of the child. I am indebted to him for the following details. Unfavorable effect of a poor milk.—A milk poor in globules or cream, is watery, aud not containing a proper amount of nutritive elements, affords insuffi- cient nourishment for the development of the child: it is one of the commonest causes of poor success in nursing, and escapes observation the more easily, as it NURSING. 931 often coincides with a notable amount of the fluid, and, apparently, with the right kind of physical properties. This coincidence is far more unfortunate than when the poverty of the milk is accompanied by diminution in quantity; for, in the latter case, not only is the child imperfectly nourished, but a milk which is at once abundant and of inferior quality, fatigues the organs by keeping them engorged with a large amount of fluid. The effect of extreme richness of the milk is far more surprising; for, at first, it would seem as though this quality could hardly be otherwise than advanta- geous. Such, however, is far from being the case, for certain very delicate chil- dren are often inconvenienced by too substantial a food. Frequent vomiting, diarrhoea, and the affection called crusta lactea (impetigo capitis) often result from it. Nothing short of microscopic examination, or the use of the lactoscope, can inform us in respect to the richness or poverty of the milk, and acquaint us with the true cause of numerous disorders or morbid conditions of the new-born child, which otherwise would remain inexplicable. The number, size, and regularity of the globules, will establish the diagnosis in both cases. Poverty of the milk, uuless it is merely temporary, requires absolutely either the addition of a certain amount of cow's milk, or a change of nurse. Its extreme richness may be remedied either by making the nurse's diet less substantial, or by occasionally giving the child a little sweetened water after each repast. M. Donne has profited by the experiments of 31. Peligot, so far as to deduce from them some modifications of the plan of nursing, which it seems to me are likely to prove very useful. It results from M. Peligot's analyses, that the milk becomes clearer and more watery the longer it remains in the breasts. He has shown that if the product of any one milking be divided into three parts, that is to say, all the milk that is given at once by a cow or she-ass, the first milk, which is certainly the longest secreted, is the most watery and the poorest, what comes next is richer, and the last is the best of all. The same has been proved to be the case with women whose milk is far more watery before than after suckling. From these facts, which are now well established, result the most important practical consequences. When, in fact, a child appears to be suffering from the richness of its mother's milk, all that is requisite is, simply, to leave a longer interval between its repasts, and not allow it to suck too long, that it may obtain each time a lighter milk, abounding less in nutritive matters; for, on the one hand, the milk is weakened by allowing it to remain longer in the breast, and on the other, the child has time to digest better what it has already taken. Alteration of the milk by the elements of Colostrum.—-The elements of the colostrum, which generally disappear a few days after the milk-fever, persist in some women indefinitely, and are discoverable in many others after a month, six weeks, aud even several months, so that the milk never attains a state of entire purity. This alteration, which can be discovered only by the use of the micro- scope, is often a morbid condition, or, at least, results from a deranged state of secretion. It is, iu fact, produced under the influence of general or local dis- eases affecting the nurse. Thus, whether they are taken with fever, or suffer from engorgement of the mammary gland, the characteristic granular corpuscles appear almost immediately. 932 HYGIENE OF CHILDREN. The result of this alteration on the child is easily determined, as it produces all the effects of imperfect nutrition. " Never," says M. Donne, " have I met with it, without at the same time finding the children puny, sickly, and more or less affected with diarrhoea." A change of nurse is then absolutely indicated, unless, indeed, the alteration is due to an evanescent affection. Admixture of Pus with the Milk.—Engorgements of the breast, whether spontaneous, or consequent upon fissures and excoriations of the nipple, are ex- ceedingly common with nursing women, and have a great tendency to end in suppuration. These abscesses, the history of which belongs to the pathology of the female, will claim our attention only in respect to the alterations of the milk which they are liable to produce. In reference to this, it is very important to distinguish from all others the parenchymatous abscesses seated in the tissue of the gland itself, and those which, commencing by a true lacteal engorgement, begin in a milk duct, whose walls, inflamed and distended into a sort of cyst, secrete pus. In these only can the pus become diffused in the milk. The superficial, or submammary abscesses, which do not open into the proper milk ducts, do not affect this fluid by admixture of pus, and alter its composition only by the reaction which a morbid condition of the kind exerts upon a neighboring organ. When the glandular abscess is apparent, the presence of pus in the milk should be suspected, and nursing relinquished; but, as M. Donne remarks, it often happens that suppuration has taken place in some deep-seated parts of the gland, without being indicated by any external sign. The slowness with which the suppuration is accomplished, sufficiently explains this insidious course. Therefore, if the breast was affected at the outset with simple engorgement attended with deep-seated lancinating pains, we should be on the watch, and subject the milk to microscopic examination. If it is impossible to make this examination, which is the only possible way of removing all uncertainty, prudence would dictate the relinquishment of nursing, for there seems to be no doubt that it would prove injurious to the child. The breasts should be emptied, if neces- sary, by the use of the pumps hitherto mentioned. ARTICLE V. OF MIXED NURSING. It has been shown in the preceding pages, that a great many women are in- capable of affording a full supply of nourishment to their children. The consti- tution, health, and conformation of the breasts of some, are all that could be desired; still their lactation is defective, either in quality, the milk being suffi- ciently abundant but too unsubstantial, or, what is more common, deficient in quantity, though of excellent quality. Others, on the contrary, have very good milk, but their feeble and delicate constitution excite fears lest a too free secre- tion and prolonged nursing should injure their future health. Lastly, there are some who, in the midst of conditions apparently the most favorable, find their milk fail, and even disappear very rapidly. To supply this deficiency, it becomes necessary to give the child other nourishment than what it is able to obtain from NURSING. 933 its mother's breast. This mixture constitutes precisely what is termed mixed nursing. It should be understood that I do not include in this appellation that system of nursing in which the child is kept from the mother at night, giving it diluted milk to drink, once or twice, for the purpose of enabling her to take what sleep her condition requires. The indications presented by insufficiency of the mother's milk, vary accord- ing to the causes which produce it; they are also subject to the influence of a multitude of circumstances, foreign, it is true, to the question in its purely medical aspect, but which it is impossible not to take account of in practice. There are women who, having no great desire to nurse, and alarmed at the sacrifices which the fulfilment of this duty involves, as also by the fatigues inseparable from it, consent to nurse their child only on account of the solicita- tion of their husbands or their family, and sometimes even by a sort of respect to humanity, but who would like nothing better than a good excuse for avoiding it altogether. With a little tact and experience, the physician is soon able to know just what to depend upon, and under these circumstances he ought not to hesitate, but, provided the position of the family is such as to permit of the employment of a wet nurse, he should encourage the woman to give up the idea of suckling. On the other hand, there are women who possess the maternal instinct even to jealousy, and who cannot become reconciled to the idea of allowing their chil- dren to be nursed by another. They are fully determined to run all risks before intrusting them with a hireling. A sentiment of this kind is certainly too laudable for the physician to pass over it lightly. Besides, the advantages which the little one derives from the attentive and affectionate cares lavished upon it by its mother, compensate for the imperfection of her milk. Nor do I see why in the majority of these cases there should be any impropriety in trying the mixed method, on the condition, however, of watching carefully over the child's health, and having recourse to another nurse as soon as it shall appear to suffer from it. The same remark applies to young mothers whose condition in life does not permit them to take in a wet nurse. Children removed from the parental abode incur too many unfavorable risks, and it is so rare to meet with women who, when free from all oversight, perform the immense duty which they accept, conscientiously, that I make no hesitation in preferring the mixed method to the removal of the child. There are still some other circumstances which may render necessary the latter method of nursing. Thus, when a woman has been delivered of twins, it is very rarely that she will not be obliged to supply the deficiency of her lacteal secretion by artificial nursing. The same is the case when the mother is able to suckle from one side only; for, although it is strictly possible for a single breast to suffice, the co-operation of both is commonly necessary. During the first days subsequent to birth, the child needs so little food that it will always find a sufficiency in its mother's breasts; and, except in cases where some circumstance or other prevents nursing, it were useless to give it anything else. Besides, this first milk possesses very useful properties, which might be interfered with by paps, or the milk of an animal. However, when the mixed 934 HYGIENE OF CHILDREN. method is decided upon, it should be commenced as soon as possible, for other- wise, the child, having become accustomed to the breast, would be prevailed upon with great difficulty to take any other food. In the majority of cases, also, although there is a sufficiency of milk during the first week, there would soon be too little should the nursing be deferred. Cow's or goat's milk, given subject to the rules to be mentioned hereafter when treating of artificial nursing, are certainly the kinds of food best suited to the child, and the only ones that we recommend to be used for the first three or four months. If the child is in a satisfactory condition, the paps, panadas, &c, mentioned in connection with weaning, may be given rather sooner than in the maternal nursing proper. The child, having been long accustomed to a rather more sub- stantial nourishment than it derives from the mother's breast exclusively, may commence taking some farinaceous paps about the fourth or fifth month. It will be thus prepared for the weaning, which will probably have to be effected about the tenth or eleventh month. The mixed method, thus understood, and continued for ten months or a year, is certainly preferable to a purely artificial nursing. I confess even, that when the mothers are obliged to send their children away, if committed at all to a wet nurse, the absence of the parent's oversight is attended with so many inconve- niences, that I prefer the mixed method to putting out to nurse. Could the mother only give it suck two or three times in the twenty-four hours, I would advise her to keep her child. What has just been said applies also to women whose secretion of milk, although small in amount, is yet kept up regularly for nearly a year. But there are some who secrete abundantly during the early months, and then suddenly lose it altogether; in others the milk continues to be formed, but their health suffers so greatly from the fatigues of nursing, as to oblige them absolutely to give it up. In both cases, the choice lies between an early weaning and the continuation of nursing by a wet nurse—the mixed method being here out of the question. I begin by declaring, that whenever the general health or the antecedents of the woman are such as to cause me to fear lest she should not be able to continue nursing longer than two or three months, I would advise her not to undertake a task beyond her powers. She would thus be spared one of the severest disap- pointments that a woman can suffer, namely, that of giving up her child to another, after nursing it for several months. But, whether because our advice is not followed, or that nursing by the mother has to be relinquished suddenly on account of some accident, ought the child to be raised by the bottle, or should it be supplied with a nurse ? I am of Desormeaux's opinion, that artificial nursing is attended with far greater chance of success in the case of a child which has sucked for several months, than with one newly born; but experience has so often proved to me the great difficulties and inconveniences of artificial nursing in large cities, that I much prefer a nurse, even for a child four or five months old. I do all in my power to overcome the repugnance of the mother in reference thereto, and unless both herself and the child can go into the country to reside, I persist, in my opinion. Should the child, however, be strong and vigorous, if it is born of robust NURSING. 935 parents, if nothing but an accident has obliged the mother to suspend nursing, and if our views meet with great opposition, an attempt may be made to bring it up with the bottle, but still, on the condition of observing attentively its diges- tive functions, and having recourse to a nurse as soon as the necessity shall be manifest. Before finishing what we have to say of the mixed method, we ought to insist upon the necessity of supplying the deficiency in the mother's milk by a species of food approaching the nearest to it in quality. We repeat, therefore, cow's milk, pure or diluted, according to the age of the child, and goat's milk, seem to us far preferable during the first four months. Paps and panadas, when given prematurely, may be successful under certain exceptional circumstances; but this success, which is constantly thrown up to us, cannot make us forget the disastrous effect which it has on some weak constitutions, and on many children in large cities. We repeat, therefore, that children born in the country of robust parents, and who are constantly exposed to the vivifying influence of the sun and fresh air, derive from the good hygienic conditions in which they live, a power of digestion which enables them to assimilate with advantage a food which would be indigestible for others. ARTICLE VI. SUCKLING BY NURSES. Some women cannot, and others will not, nurse their children. Now, the latter should be subjected as little as possible to the bad effects of this incapacity or unwillingness ; and the best substitute for the mother's milk is, certainly, that of a nurse. § 1. Of Choosing a Nurse. The physician generally is, and always ought to be, charged with the selection of a nurse. Now, this choice is one of the most delicate and compromising acts of medical practice, for its conscientious performance necessitates precautions and investigations, which, to speak frankly, it is impossible to make in the majority of cases. To choose a nurse properly, is to guarantee the family a full supply of milk of good quality, and to assure them as to the excellence of her constitution, and especially that she is not, nor ever has been, affected with any disease capable of being transmitted to the nursling. Now, it must be acknowledged, that if an examination of the milk properly per- formed is capable of affording us a tolerably correct idea of its composition; if an investigation of the principal organs of the chest and abdomen, and the explora- tion of&the mouth, teeth, and cervical, and even inguinal glands, are competent to assure us as to her good health; if the development of the muscles of the body and limbs, and the color of the skin, can enable us to appreciate the strength and vigor of constitution, it is about all that we can expect to accomplish. To require a nurse to submit to a thorough examination of the genital parts and the use of the speculum, which is indispensable to a strict diagnosis, would be 936 HYGIENE OF CHILDREN. to receive an almost certain refusal. Perhaps some shameless women, or unfor- tunates, whom hunger allows to object to nothing, would not decline ; but I am convinced that we should fail with those good and chaste country nurses, whose simple habits are foreign to the debasedness of cities. Such examination could be made obligatory only by public authority, and then by confining exclusively to a single physician, who should be charged with the examination of all. These poor women would then have to submit to a single visit only. But it must not be forgotten that in Paris especially, before a woman is received by any one phy- sician, she has often been presented to ten different families. She would, there- fore, have been obliged to submit to the examination ten times. It is plain that this could not be done, or if it were, I would find it difficult to confide in one who had allowed it; for though I might feel satisfied as to her physical condi- tion, I should certainly have strong doubts as to her moral qualities. Besides, would this examination always be so conclusive as to justify an absolute assurance to the families ? Doubtless, we might be able, in the majority of cases, to certify that there does not exist, at the time, any symptom of syphilis ; but is the present any security for the past ? The local symptoms disappear, but does not the general infection remain, which may sooner or later become manifest ? We see, therefore, that were the examination always possible, the evidence of a recent attack of syphilis might be overlooked, and could give us little or no information in respect to the antecedents. I coincide, therefore, with 31. Donne, in the belief that the examination would be useful, and would even be disposed to direct the attention of the authorities to the propriety of causing a medical in- spection of nurses; but in the present condition of things, I believe it impossible that each one should require this thorough examination. After examining the chest, and ascertaining the absence of scrofulous cica- trices, the healthy condition of the cervical glands, and, if possible, of the ingui- nal glands, and after inspecting the development of the muscular system in order to appreciate the vigor of constitution, the physician should next give his attention to the milk, and the organs which secrete it. I confess regarding the color of the hair and soundness of the teeth as of minor importance; for blondes make as good nurses as brunettes, and, in some countries, the teeth are subject to early decay without the health of the inhabitants being any the less robust. Neither is it important that the nurse should be of the same age, stature, and temperament as the mother whose child is to be submitted to her charge. With- out paying too much regard to attractiveness and beauty of external configura- tion, it is proper that there should be nothing unpleasant about the woman, and especially that she should be physically agreeable to the young mother. The latter is obliged to live for a year or eighteen months almost constantly in the presence of her child's nurse, and it is far from immaterial whether she is to be in continual relation with a repulsive countenance. Much consideration should be had for whatever information is attainable in respect to her intelligence, cha- racter, and general disposition. A nurse who is gentle, good-natured, and who knows how to amuse a child, ought, other things being equal, to be preferred. It were useless to remark, that no woman should be introduced into a family of whose probity and morality there can be the least doubt: unfortunately, how- NURSING. 937 ever, we are but too commonly obliged to trust to chance in regard to the latter point.1 The nurse's age is not a matter of indifference. I think it better to choose one between the ages of twenty and thirty years; and would advise declining all who are over thirty-five. As a general rule, women who have already had several children, and who are consequently familiar with all the offices which they require, are received more willingly than primiparae. It is far better that an inexpe- rienced mother should have an experienced nurse, who is accustomed to handle and take charge of children. Besides, by inquiring of families where they have already nursed, we may have more certain information as regards their disposi- tion, their honesty, and the amount and quality of their milk in a previous nursing, which may serve, to a certain extent, as a guarantee for the future. Finally, they are much less affected by putting away their own child than primi- parae, and, therefore, are far less likely to lose their milk suddenly. The former have, therefore, undoubted advantages over the latter, but they are also liable to some objections: thus, they have acquired habits which they relinquish with difficulty; it is much harder to subject them to the regimen which you wish them to follow; lastly, provided they do not find in their new position the pecu- niary advantages, the indulgences and attentions of which some parents are lavish, they make unfavorable comparisons, and become discontented and ex- acting. The woman who offers herself as a nurse may be still pregnant, or have been delivered for some time. If she is still pregnant, it is important to be sure, in the first place, that her labor will be over at least two months before that of the mother of the child. The organs have hardly returned to their normal condition, and the woman is barely recovered before two months after delivery, and not before then ought she to be intrusted with a new nursling. Earlier than this, the new-born child would have a milk better adapted to its digestive powers; but a woman is liable to so many accidents during the first six weeks after delivery, that it is impos- sible to answer for the future. It is much more difficult to judge of the future qualities of a nurse during pregnancy, and whatever may be the result of a first examination, it is necessary to be very cautious as to what one says in regard to it. We have already noticed the points of useful information to be ascertained by an examination of the colostrum secreted during the latter months of gestation, 1 It were better, as a general rule, not to engage nurses too long in advance. I think it prudent to reserve the right of examination at the time when they shall be needed; for there are cases in abundance, in which, notwithstanding the most favorable appearances, the lac- tation" is defective. For a still stronger reason would it be wrong in parents to retain a pregnant woman without consulting their physician, because she had already nursed for one of their acquaintances, who had recommended her highly. So many circumstances are liable to interfere with lactation, and so many accidents may happen after delivery capable of seriously injuring a health which had been perfectly good up to that time, that I advise all my patients never to treat with their nurses otherwise than provisionally, and to promise only conditionally, and always subject to the final recommendation of their physician. Disregard to this limitation has given rise to many unpleasant occurrences in families. 938 HYGIENE OF CHILDREN. and we shall not recur to the subject (see page 903); it is almost the only ele- ment of importance in the question under consideration. The form and size of the breasts are of but secondary value. Voluminous breasts are by no means a certain indication of a full supply of milk in the future; for generally the entire mass is in great part made up of fat. This remark does not always apply to the size of the gland itself, which can often be distinguished from the thick layers surrounding it. It is important, in fact, that it should not be too small. But, provided it is of about the normal size, the flow of milk may be sufficient or even abundant if the veins of the breast are largely developed. Dealers in cows, says M. Trousseau, know very well that their milking quali- ties cannot be judged of by the size of the udder. Thus, a cow whose udder has a cubic capacity of four quarts may give ten quarts of milk, being six quarts more than the apparent size, which proves that milk is secreted during the act of sucking or of milking. The same is the case in the human species; the size of the breast is not an absolute indication of good nursing qualities. M. Trousseau thinks that very important information may be derived from the phenomena observed in the breasts of certain women at each menstrual period. When, says he, there is a strong determination to the breasts at each period, when the latter grow hard and painful, and the globules of the gland become more distinct and form projections, the woman is likely to be a. good nurse. . . . I have never had an opportunity of testing the value of this conclusion. When the woman has been delivered and nursed for some time, the physician ought to direct his attention especially to the amount and quality of the milk. I shall not revert to the means for determining the richness or poverty of the milk, its purity, or its alteration by heterogeneous elements. I would, however, remark, that to have ascertained, by placing a few drops of milk in a spoon, that it is opaque, homogeneous, of medium consistency, and without any peculiar taste or odor, does not obviate the necessity of having recourse to the microscope whenever possible. By it alone, can be estimated the number, regularity, and size of the globules, and, consequently, the amount of cream or buttery part which they constitute. Unfortunately, but few physicians have this instrument at their disposal or know how to use it; and still less are they accustomed to chemical analysis. In ordinary cases, and in the absence of a better process, the richness of the milk may be estimated by measuring the thickness of the layer of cream; for this purpose, 31. Donne's little graduated test-tubes may be used, or still better, the lactoscope of the same author, whose application requires but a few minutes. It is important to bear in mind the variations in the milk pointed out by M. Peligot according to the time it has remained in the breasts (see page 931)» If a woman presents herself with breasts much distended, it is necessary that she should allow her child to suck for some time, before we shall be able to form a correct idea of the density of the milk; for the first milk is much thinner and more watery than that which is secreted a short time before its extraction. Lastly, the best means of judging of the quantity of milk, is to examine the physical condition of the nurse's child; to be certain, as far as possible, that it takes no other food; ;o witness it suck several times, and determine NURSING. 939 whether its appetite seems satisfied, although the breasts still retain a consider- able degree of firmness. Again, like 31. Natalis Guillot, we may cause the child to be weighed before and after putting to the breast; the quantity of milk swallowed being indicated by the difference in weight. From 1\ to 5 or 6 ounces should be withdrawn at each suckling; but less than 2J ounces is insuffi- cient for the purposes of nutrition. The complete absence of glandular engorgement should lead us to suppose that the milk is uncontaminated with a single globule of pus; but if the condition of the breast is such as to leave any doubt in the mind, nothing but microscopic examination is capable of settling the question. This instrument is still more necessary for ascertaining the presence of the elements of colostrum at a period when they ought to have disappeared altogether. Lastly, the age of the milk should be taken into serious consideration: as we are obliged to allow the nurse at least two months for the purpose of recovering from the fatigues of labor, the accoucheur cannot supply the child with a very young milk, such, for instance, as its mother might furnish it; but it is at least better not to give it milk from a nurse who has been delivered longer than from eight to ten months. At this time, it is no longer adapted to the requirements of the child, and as most women are barely able to nurse longer than from eighteen to twenty months, there would be some risk of finding the secretion cease altogether, before the natural period of weaning A milk of from two to six months should therefore be preferred. Women who have nursed for a year or fifteen months and desire to take charge of another child, say that a young infant restores the milk, but the responsibility of the assertion must be left with the good women themselves. Most of the precepts which we have laid down for natural nursing are entirely applicable to wet-nursing; there are, however, some peculiarities which it is pro- per to indicate. § 2. Of the Regulation of Wet-nursing. At what time ought the nurse to give the breast to a new-born child?—A nurse who has been delivered for three or four months, is, at the outset, incapa- ble of providing the young infant with as suitable a nourishment as it would have derived from the mother's breast. The colostrum secreted by the mammae of a recently-delivered female, is not merely a food, but possesses laxative pro- perties eminently adapted to the expulsion of the meconium. Though slightly charged with nutritive matters at first, this colostrum is perfectly suited to the digestive powers of the new-born child; for to load its stomach with anything more substantial, would expose it to imperfect elaboration and all its unfortunate consequences. Struck with these inconveniences, some practitioners advise the mother to begin suckling for the first few days, and not to give the child to the nurse until it is better able to digest her milk. Besides, say they, it is not only for the interest of the child, but of the mother also, for the secretion of milk is a natural emunctory, well adapted by the sort of derivation it occasions to lessen the tendency to the various inflammations to which lying-in women are so fre- quently exposed. I cannot accept this view. If we regard only the interests of the child, there 940 HYGIENE OF CHILDREN. can be no doubt that the lactescent serosity furnished by the breasts at the out- set, is the kind of nourishment best adapted to its condition, and that in this respect, the milk of a nurse of three or four months would be less suitable; but we shall see how easily the too great density of the latter kind of milk may be remedied by a sort of mixed nursing, and daily observation proves, that with such precaution, the health of the child is in no wise endangered. Now, a nursing once begun, and suddenly interrupted after four or five days, is far from being devoid of danger and inconvenience to the mother. The fact is, that women suffer the most from nursing at the outset. Then it is that fissures and cracks of the nipple, lacteal engorgements, and inflammation and abscesses of the breast, make their appearance. That a female who is determined to nurse should brave all these dangers may be easily understood, for she is sufficiently compensated by the fulfilment of a grateful duty; but that one who cannot nurse should ex- pose herself to them unnecessarily, is incomprehensible, unless we suppose her willing to add to the painful sacrifice which the giving up of her child to a wet- nurse imposes upon her, Besides, we must not believe, as some physicians do, that nursing protects women from puerperal diseases. We have but too often occasion to know from experience in our hospitals, that puerperal fever, for example, attacks with equal violence those who nurse and those who do not. In civil practice, where the minutest attentions are bestowed upon the child, I can discover but few advantages for it, and many inconveniences for the mother, in beginning to nurse, when she has no expectation of continuing to do so. The case is different in our large lying-in hospitals. However carefully conducted, it has never yet been possible to provide a supply of nurses equal to the demands of all the children. In the clinic of the Faculty, for example, there are but five or six nurses for twenty children, and the number of ordinary or ward nurses being too small to give the little unfortunates the most necessary attentions, a great number perish, we are bound to acknowledge, of cold and hunger. Under these circumstances, the physician is perfectly right in requiring the mother to suckle her child until it can be provided with a nurse. For the first twenty-four hours after birth, the child will take nothing but a little sweetened water as a substitute for the colostrum; and if it should seem difficult to expel the meconium, a few spoonfuls of compound syrup of chicory may be administered. By this time the bowels will be sufficiently emptied, and it may be put to the breast. But for the first five or six days, or rather longer if the child is feeble, it will not depend exclusively upon the nurse's milk, but the latter is to be alternated with sweetened water during the first three or four days; after the fifth or sixth, it will be allowed to suck for a short time, aud the nursing be immediately followed by the administration of a few dessert-spoonfuls of sugar and water; lastly, about the tenth day, it will be confined to the breast altogether. The new-born child is rarely able to take enough milk to empty the nurse's breasts; therefore, it is well to keep her own child near her for some days, in order to avoid extreme distension of the mammae. She ought then to be ad- vised always to give the first milk to the nursling. If separated from her child, she should endeavor to decrease the flow of milk by a very moderate diet and diluent drinks; and if, notwithstanding these precautious, the breasts become painful, they must be emptied by a breast-pump. NURSING. 941 The precautions which it is necessary for the mother to observe, are not re- quired in the case of a robust nurse who is accustomed to fatigue, and she is expected to give the child suck during the night. Upon the whole, the precepts in regard to the regulation of the repasts, are as applicable here as to nursing by the mother. Some nurses are in the habit of taking the child to bed with them. This ought to be positively prohibited, as terrible accidents might result from it. Several times it has been the lot of nurses to find only a dead body upon waking, from having suffocated the child whilst asleep. The best means of being certain that the child shall be laid in its cradle after nursing, is to give the nurse so narrow a bed as to make it almost' impossible for her to sleep with the child beside her. § 3. Regimen of Nurses. The diet of nurses should be moderate but substantial. The latter quality ought not, however, to be so far insisted upon as to give them a food which is too succulent and too rich in azotized matters. They should certainly partake of a certain amount of meat, but it would be improper to confine them exclusively to it. Being accustomed from childhood to indulge freely in vegetables, they would not long support a merely animal diet without disadvantage. Nurses brought up in the country often suffer from confinement to the house in cities, and their condition is still further aggravated by the indolence which takes the place of their previous active habits. Therefore, after the first few days, they ought, if possible, to be employed in some light household duties, and, even when the child is unable to accompany them, they should be made to take exercise out of doors. The nurse may at any time lose her milk, be attacked by an acute disease, or be affected by some occurrence which lessens or alters the secretion. It is a painful thing to most families to have to change their nurse, and it is important to console them with the assurance, that the change is not so serious a matter as is generally represented. Provided the child receives a milk of good quality and enough of it, it will suffer nothing in this respect. Therefore, all that we have to do, is to choose a milk equal to, if not better, than what it has been deprived of. Under these circumstances, the change is a matter of such indifference, that when the nurse's disposition is too disagreeable, or if she does not take proper care of the child, I do not hesitate, whatever the qualities of her milk may be, to advise a change. The only precaution to be observed is, that when once decided upon, she should not be informed of the project until another one is engaged to replace her. The only difficulty is to get the child to take the breast of a new nurse. If it has attained the age of from six to eight months, it often manifests a great re- pugnance thereto. It should then be left for some time without nursing, and advantage be taken of the night or a dark place, to put it to the breast for the first time. 942 HYGIENE OF CHILDREN. ARTICLE VII. NURSING BY AN ANIMAL. Nursing by a female animal constitutes the transition, so to speak, between wet-nursing and artificial nursing. Though much in vogue in some countries, it is rarely had recourse to in Paris or most of the departments. We hardly ever recommend it, except when a child who has been weaned for a long time be- comes suddenly ill and requires a diet composed exclusively of milk, and in cer- tain special circumstances making it necessary to administer to the child a milk which has been rendered medicinal. By causing animals to swallow various remedies, such as mercury, iodine, and iron, their milk becomes imbued with most of the properties of these substances. It would be unjustifiable to subject a healthy nurse to a treatment of this kind for the benefit of the child, as it might readily prove injurious to her. The animals made use of are goats, sheep, she-asses, and cows; but most fre- quently the she-goat. The shape and size of the teats, which are easily seized by the child, the abundance and quality of its milk, the docility of the animal, the ease with which it is trained to give suck to the child, and the attachment which it is capable of forming for it, are sufficient reasons for the preference. That species should be preferred which is destitute of horns and which have long, thick, and white hair, because they possess the hircine odor in a slighter degree. A young goat which has nursed several times, and given birth recently to her kid, ought to be preferred. This mode of nursing, says Desormeaux, requires at the outset much care and attention as respects the presentation of the mamma to the child. The petulance and impatience of the animal expose it to frequent accidents, but after a time the goat comes of its own accord to give it suck. The infant should be laid in a low cradle placed upon the floor. When it is desired to communicate medicinal properties to the milk, they are made to take internally or to absorb by the skin the active principles of these medicines. Thus, mercurial ointment is rubbed into the skin of goats in order to communicate antisyphilitic properties to the milk. ARTICLE VIII. ARTIFICIAL NURSING. I have but little to say of artificial nursing; for it is admitted by all to be the worst of the various methods proposed for nourishing a child. In large cities, where it is a difficult matter to procure good milk, and where the bad health of the cows renders useless all the precautions taken with this object, most of the unfortunate children subjected to this regimen die within the year. In the country, however, the chances are far more in favor of artificial nursing; for there it is possible to be almost certain as to the health of the animal, the food it takes, and the good qualities of its milk. Besides, the excellent atmospheric conditions in which the child is placed, compensate, to a certain extent, for the imperfection of the mode of alimentation. Although a woman's milk is always NURSING. 943 preferable to any other, the artificial nursing, which I proscribe unconditionally for large cities, may be tolerated in the country, with the understanding, how- ever, that it shall be pursued with intelligence. Cow's milk is generally employed, but its administration demands some pre- cautions. Being too rich for a new-born child, it requires to be diluted with pure water, barley water, a decoction of crumbs of bread, of rice slightly sweet- ened, or gruel. Pure water should, I think, be preferred in most cases, and the proportions of the mixture must necessarily vary with the age and digestive powers of the child. During the first week, three parts of water should be added to one part of cow's milk, and during the early months the latter should be diluted one-half; after which, unless the digestion is feeble, but one fourth of water may be added until the sixth month, when the milk may be given pure. Desormeaux advises, when the children are feeble, that the milk be diluted with chicken-water, or a fluid containing animal matter. I have seen some, says he, whose stomachs were better suited by weak decoctions of meat than by milk, and I am convinced by a multitude of practical observations that the matters ingested irritate less in consequence of their being azotized, than because they are digested with difficulty. I think this regimen proper after the sixth month, but would not advise it in the earlier months, when, if used at all, it should be with great caution. It is well to sweeten slightly the children's drink. Although sugar has not the heating qualities which the women attribute to it, it must be used moderately, for it is not always digested easily. I have seen, says Desormeaux, feeble chil- dren throw up unchanged the sweetened water and solutions of gum and starch which had been given them as drink. The drinks ought to be rather more than lukewarm. When pure milk is used, it should be brought by the water-bath to the temperature it would have had if just drawn from the cow; if, on the contrary, it is to be diluted, only the fluid to be mixed with it should be heated. In no case ought the milk to be boiled; for ebullition deprives it of a part of its aroma, and of the air which renders it more digestible. The mixture of milk with one of the above mentioned substances soon fer- ments and spoils, especially in summer, or in warm rooms in winter. It ought, therefore, to be prepared only when about to be administered. We have before stated that a child, whose alimentary canal has been habitu- ated by mixed nursing to more substantial nourishment than the mother's milk, is able to take paps and solid food rather sooner than it otherwise would. The same is true after artificial nursing. There is no occasion to revert to the pre- cautions laid down in the article on Weaning. The instruments used for giving children drink are numerous. The spoon and drinkin^ cups, by whose assistance the milk is poured into the mouth, are sub- ject to some inconveniences; so that, unless they are unable to suck at all, I pre- fer the nursing-bottle as most nearly affording the conditions of natural nursing. It can be readily procured everywhere, and were it on that account alone, it deserves to be mentioned. It is either an ordinary four-ounce medicine vial or one of those small flattened bottles used by the wine merchants for exhibiting their specimens; into the neck is introduced a sponge cut for the purpose, and which projects about an inch and a half beyond it; the whole is covered with 944 HYGIENE OF CHILDREN. a piece of muslin, and fastened by a thread. The thread ought also to be drawn with a moderate degree of tightness around the sponge at its exit from the bottle, so as to compress it, and prevent the milk from flowing too rapidly. Care should be taken to keep the sponge, muslin, and thread, always in fresh clean water, and before using, pass a little milk through it and squeeze, so as to drive out the cold water, and replace it by warm milk. With all these precautions, this bottle has still some imperfections, which many instrument-makers have sought to avoid. The nursing bottle manufac- tured by 31. Charriere, I think merits special recommendation. In terminating this chapter, I cannot recommend too highly to physicians a little work by Dr. Donne, which, under the modest title of Advice to Mothers, will furnish them with an abundance of useful hints in relation to the education of children. CHAPTER III. GENERAL CONSIDERATIONS ON CERTAIN POINTS RELATING TO INFANTILE HYGIENE. 1. Of Clothing.—The clothes of the new-born child should be so loose as not to obstruct its motions. The swaddling clothes, which are still in general use, and which were formerly drawn much too tight, may be retained, but only on the condition of leaving sufficient freedom of motion to the limbs of the child. I confess that, for the first weeks, they seem to me to have some advantages over what is called the English style, by protecting the children better from the cold, especially when they are wet with urine, and also by affording greater facilities to those who have to take them up and carry them about. I therefore approve of swaddling, but would have the clothes so loose as to allow the extremities, the lower ones especially, sufficient freedom of motion. After the umbilical cord has fallen off, a folded compress, as large as a dollar, should be applied upon the navel, and kept in place by a moderately-drawn circu- lar bandage. It serves to prevent the rubbing, and consequent irritation of the umbilical cicatrix, and perhaps, also, the formation of a hernia. Pins should be used as little as possible in dressing tbe child. They may become loose, and, by sticking it, give rise to serious accidents, such as convul- sions and death. It is important, also, that the little cap string or ribbon, which passes under the jaw, should be sufficiently loose, for the cap is liable to be displaced, and the neck might be subjected to constriction. To avoid this, the string should be attached to one end of a band, the other end of which is fastened in front of the chest. After the second or third month, the swaddling-clothes should be replaced by long dresses; from this time the style of garment is subject to the fancy of the parents, and, provided the child is protected from the cold and sufficiently at its ease, the physician need concern himself no further about it. 2. Of Washing, Bathing, and Cleanliness.—Perfect cleanliness is indispen- INFANTILE HYGIENE. 945 sable to the health of children, and nurses cannot be watched too closely for the purpose of preventing their allowing them to remain in their urine or fecal mat- ters ; they should be changed as soon as they become soiled. They ought to be washed with warm water, and not merely wiped, as is done by some nurses. It is difficult to do otherwise when out walking; but the omission should be sup- plied immediately on reaching home. In some countries, cold water is used in these washings; I think, however, that it is rather hazardous within the first year, and I do not recommend it before the child is eighteen months or two years of age. I am in the habit of directing the children to be bathed every other day; but when they seem to be rather more fatigued and enervated on the day of the bath, I advise it to be performed but twice a week, and am content with a simple im- mersion, or washing all over, every morning. The temperature of the water should be from 77° to 86° F. The bathing ought to be short in proportion to the fatigue of the child, but, as a general rule, it ought not to be longer than five minutes in the first month, and rarely ten minutes in the subsequent ones. When the children are restless at night, and sleep little or badly, it is a good plan to bathe them in the evening before going to bed. When the restlessness and in- somnia are very great, I have used with advantage a bath prepared with a decoction of lettuce leaves. In winter, or when the weather is cold and damp, it is important not to allow the child to go out for several hours after bathing. Some persons are afraid to wash the child's head, yet it should be done, in order to remove the scurf which forms there, and to prevent the formation of the crusts which some persons are glad to see appear. When they are already formed they ought not to be respected, but after rubbing the head gently with a warm cloth, they may be removed by a soft brush. If this is not sufficient, the head may be greased, and the next morning they will be found to come off readily. 3. Taking the air, walking.—The child should be placed immediately after its birth, in a large, airy chamber, kept for the first week at a rather elevated temperature. If the child is weak or born prematurely, it is important, in winter, to surround it with bottles of warm water : one at its feet, and one at each side. The head of the cradle should be turned towards the windows, in order to protect the child's eyes from the too bright light. The omission of this precaution has seemed to me to favor the development of purulent ophthalmia. In winter, especially, the children should not be taken out before the fifteenth day. During the intense heats of summer, this rule need not be adhered to so strictly, provided they are strong and well. But after the first going out, they should be promenaded every day for several hours, and at three months, they ought to remain for the greater part of the day exposed to the air; in winter, autumn, and spring, they will be kept out for at least three or four hours. The air and sun are almost as necessary as good nourishment, and it is perfectly use- less to consult barometer and thermometer to know whether it is proper for a child to go out. Even in the worst days, a favorable hour can always be found and made available ; only when it is cold and freezing, the walk will be shortened. 60 946 HYGIENE OF CHILDREN. There is no occasion to fear disturbing their sleep whilst promenading, for they never sleep more soundly than then. Of latter time, some philanthropic physicians, at the head of whom I am pleased to name my colleague and friend, M. Loir, have insisted strongly, that the recording of births should be done at home, and that there should be no obligation to carry the poor children at every season to the mayoralty within the first three days. This law has fallen into neglect in most of the provinces ; but in Paris it is still observed quite rigorously, unless the accoucheur certifies that the child is in poor health, and that it is impossible to transport it thither. I am happy to unite my feeble voice with those of my colleagues, to solicit from the authorities a modification of the existing laws. The same motives of humanity induce me to express the desire that Catholic families should cause their children to be baptized at home, unless the ceremony be put off to a some- what remote period from birth. Undoubted advantages would result from it as respects both mother and child. 4. Of Sleep.—For the first days subsequent to birth, children do nothing but suck and sleep. Whilst asleep, they should be laid upon the side—some- times upon one and sometimes upon the other, in order to avoid bad habits. At first, they almost always fall asleep whilst suckling, so that it is nearly impossible to lay them awake in the cradle ; but rather later, care should be taken not to allow them to go to sleep in the arms or on the lap. Having once acquired this habit, it becomes a necessity, and on awakening at night, they will not go to sleep again except in their nurse's arms. They ought to be put in the cradle whilst awake, and allowed to go to sleep there ; for when once allowed to acquire bad habits in this respect, it is very difficult to break them. It requires great firmness to hear them cry for a long time; but with courage and perseverance, and by a temporary removal of the nurses, of whose weakness they are aware, a complete reform is finally obtained. The same remarks apply to the habit which some nurses have of rocking children. Most children at the breast sleep during the day until they are twenty months or two years old. This sleep, which is almost constant at the outset, becomes shorter and less frequent as they advance in age; but it is very rare for them not to take three or four hours of sleep daily during this early period of life. This repose is, therefore, a necessity, but there is no occasion to avoid the least sound for fear of wakening them, as they very readily become accustomed to sleeping in the midst of motion and noise; some children sleep but lightly, because they have always been accustomed to solitude and silence. Though it is well not to be too scrupulous in this matter, they ought not to be awakened too suddenly for fear of alarming them. 5. Exercise.—The only exercise of new-born children consists in slight mo- tions of their arms and legs, which, as we have said, ought not to be confined too closely. Rather later, they may be moved about in the arms; toward the fifth or sixth month, they may be exercised in standing on a carpet or coverlet, and left to themselves in order to try their strength; they begin first to drag themselves, then to creep on all fours, and soon get up by taking hold of furniture; after which they make a few steps. As a general rule, I do not think it advisable to encourage children to walk too soon by supporting them with belts of listing, wagons, &c.; we ought always to await the first promptings of nature. APPENDIX. ON THE USE OF ANESTHETICS IN OBSTETRICAL PRACTICE. In view of the wonderful results obtained by the use of ether in surgical practice, it was altogether natural to inquire whether so efficient a means of avoiding the pain of operations, might not be employed with advantage against the physiological pain which accompanies labor in the human species. But be- fore speculating upon the probable advantages to be derived from its use in this way, prudence suggested the endeavor to foresee the disadvantages also. Might not the torpid condition of the voluntary muscles produced by etherization, ex- tend to the muscles of organic life, and might not that action of the womb which is indispensable to a prosperous termination of labor, be paralyzed thereby? Supposing, even, that the uterus should preserve its contractile powers in the midst of the general paralysis, would not the want of that assistance which it receives from the voluntary contractions of the abdominal muscles, and of that synergic action which is so useful in the termination of labor, render the expul- sion of the fcetus very difficult, or even impossible ? 3Iight not the health and even the life of the child be endangered by the vapor inhaled ? And might not the latter, which has occasioned some serious accidents in surgical practice, prove an addition to the dangers which threaten the female during labor and the lving- in ? The previous solution of all these questions is of the highest importance, and we may readily understand the effect they must have had in inspiring with prudence those who were the first to employ anaesthetics against the pains of childbirth. Some of these questions are capable of elucidation by the applica- tion of certain pathological facts, others could be solved only by experiment, and this experiment had yet to be performed. Professor Simpson, of the University of Edinburgh, was the first to venture upon the administration of ether in labor The opportunity presented on the 19th of January, 1847. The woman had a deformed pelvis, and having decided to turn, he thought the occasion a favorable one for determining the influence of inhalation of ether upon the contractions of the uterus; for, supposing the con- tractility of the organ to be paralyzed by the anaesthesia, the introduction of the hand and evolution of the fcetus would only be facilitated thereby. The result was so satisfactory as to convince Dr. Simpson that, notwithstanding the complete 948 APPENDIX. abolition of sensibility, the action of the womb might continue intact. Encou- raged by the first trial, he repeated the experiment in several cases of natural and of difficult labor, and on the 10th of February communicated the results to the Obstetrical Society of Edinburgh. Almost immediately after becoming acquainted with his observations, several English accoucheurs, 3Iurphy (of London), Protheroe Smith, and Landsdown, administered ether with a like success. Fournier Deschamps was the first to use it in France, and that, only eight days subsequent to the publication of Dr. Simp- son's first observation. In the month of February, in the same year, Professor P. Dubois laid before the Academy of 3Iedicine the" result of its administration in six cases of labor under his own notice. In 31arch, it was used by Stoltz, at Strasbourg, and by Delmas, at Montpellier. In August, I made, in connection with 3ir. Smith, some experiments at the Clinique d'accouchements, then under my charge, but the first trials did not seem to me encouraging. Still later, 3131. Chailly, Colrat, Villeneuve, Roux, 31ale, and several others, published their ob- servations. In Germany, Professor 3fartin (of Jena), and afterwards, Professors Siebold and Grenser (of Leipzig), used ether in several cases of natural and of difficult labor. Lastly, in America, Drs. Channing, Clark, Putnam, and others were the first to make known the results of their experiments. In November, 1847, the substitution for ether of chloroform, as proposed by Dr. Simpson, gave a fresh impulse to the use of anaesthetics in obstetrics. The rapid action of the new preparation and its easy administration, were, perhaps, the occasion of a too ready forgetfulness of the dangers to which it might give rise, and were certainly the cause of its enthusiastic reception by at least a large number of English accoucheurs. At present, notwithstanding some opposition, chloroform is employed almost exclusively in obstetrical as well as in surgical practice. Amongst the questions which would naturally present themselves to the mind of whoever first entertained the idea of using anaesthetics in labor, there are some, whieh, as we have said, receive a degree of light from known physiological and pathological facts. Of such, are those having reference to the probable con- tinuance of the uterine contractions, notwithstanding the complete torpor of the voluntary muscles, and to the more or less important assistance received from the abdominal muscles in labor. Numerous facts at present authorize the belief that the momentary paralysis of sensation and voluntary motion does not sensibly interfere with the action of the womb. Dr. Simpson was acquainted with those cases of complete paraplegia, in which delivery had been effected with its normal regularity and almost without pain; nor was he ignorant of the many instances in which women have given birth to children during the deep stupor of drunkenness; he had often seen labor termi- nated in patients affected with eclampsia, during the period of coma attending or following the convulsive paroxysms, without their being in the slightest degree conscious of what had occurred, as also the astonishment at their delivery mani- fested on the return of their senses. Nor are examples rare of the delivery of women, during a lethargy so profound as to be mistaken for death. It is dis- tinctly proved by all these facts, that notwithstanding the momentary or perma- ANESTHETICS IN LAROR. 949 nent extinction of volition, sensation, and voluntary motion, the organic contrac- tility may not only continue, but be equal to the expulsion of the foetus. Hence it was quite probable that the condition produced by the inhalation, resembling as it does in many respects the sleep of drunkenness or the coma of eclampsia, might, like the latter, have its influence restricted to sensation and to the muscles of animal life. It was to be feared lest the anterior muscles of the abdomen should be para- lyzed like those of the extremities, and that their inaction might somewhat retard the expulsive stage. But the happy delivery of paraplegic women, and of such as, notwithstanding a complete prolapsus of the uterus, have, unaided, been deli- vered of the product of conception, naturally presenting themselves to the mind, allowed of no hesitation on the score of even a probable paralysis of the abdomi- nal muscles. Besides, in the case in which Dr. Simpson employed anaesthetics for the first time, version was to be performed, and he would be able to supply by tractions any deficiency of the expulsive powers. More fortunate than Dr. Simpson, who at the time of his first experiments had only the rational inductions afforded by physiology and pathological anatomy to support him, we are now able to appeal to experience. Let us, then, with the assistance of the numerous facts now on record, endeavor to elucidate the various questions connected with the use of anaesthetics in obstetric practice. 1. Of the effect of Anaesthetics on the Uterine Contractions.—On this point, as on many others, accoucheurs entertain various opinions. Some regard neither chloroform nor ether as possessing any power to suspend the uterine action; others think that the contractions are always retarded and quite frequently even stopped entirely. Amidst these contradictory assertions and facts, it is, how- ever, possible to discover the truth. A careful reading of all the observations will show that, with the exception of Paul Dubois, almost all authors are unani- mous in the recognition of important changes impressed by the inhalation upon the contractions. These modifications are, besides, very various: thus, whilst M. Stoltz believed that he had observed an increase in frequency and intensity, and 3Ir. Murphy, whilst turning, declared that he had never before found the operation so difficult, although the patient was under the full influence of the agent, we find MM. Bouvier, Siebold, Montgomery, &c, asserting that it retards, and sometimes even completely suspends the labor. Dr. Denham also affirms, that in six cases in which chloroform had been administered before turning, the operation was rendered easier, and that its happy effect was especially evident in one case, where the introduction of the hand having been fruitlessly attempted before inhalation, it was effected very easily after it. We shall endeavor to ac- count for this dissidence hereafter. Whatever the exact truth may be, in an unprejudiced mind, no doubt can exist of its being proved by numerous facts, that when chloroform is taken so moderately as to blunt and almost extinguish sensibility without entirely depriv- ing the patient of the power of motion or of self-consciousness, it has, ordinarily, no influence over the contractile power of the uterus; but that when carried to complete anaesthesia, the contractions may be diminished both in frequency and intensity to the point of complete extinction. The latter fact is acknowledged by Dr Simpson himself, and he regards it as of possible occurrence in some cases 950 APPENDIX. of moderate anaesthesia. The degree of the latter, he remarks, which some patients are able to bear without the womb being affected is exceedingly variable. Some are thrown into a profound slumber without interference with the uterine action. Others, on the contrary, experience interruption of the contractions by a much slighter degree of anaesthesia. These individual predispositions explain 3Ir. Montgomery's observations of the manifest diminution of the uterine con- tractions under the sedative influence of chloroform without the woman being in- sensible to pain. Besides, according to the majority of English practitioners, the retardation or the suspension of labor is the indication for the particular case, that the dose of the agent which the patient might have supported without in- convenience has been exceeded, and the best means according to Dr. Simpson of restoring energy to the uterus, is to cease the inhalations for some moments and then resume them in more moderate proportions, as soon as the patient shall evince sensibility. It is stated by the Edinburgh accoucheur, that the return of the contractions on withholding the chloroform is delayed but a few minutes only; such, also, is the view of Denham, Murphy, and others. 3Ir. Mont- gomery, however, has less confidence in this prompt return of the contractions. In a very recent case, he witnessed an interruption of the labor by so feeble a dose of the chloroform, that the patient was all the while expressing with volu- bility the delicious sensations she experienced; and notwithstanding the sus- pension of inhalation, the uterus remained inert for some hours before resum- ing its original activity. I have seen, says the Dublin professor, several similar cases. 1. To recapitulate: in the majority of instances, the contractions are unaffected by the inhalation of chloroform; 2. When the anaesthesia is pushed too far, the labor is ofteji suspended; 3. In certain individuals, the same result may be pro- duced by moderate doses of the agent, and that, before the loss of sensibility and consciousness. This difference in the results, setting aside certain altogether exceptional and as yet inexplicable idiosyncrasies, is manifestly due to the extent and duration of the etherization. The various facts, says 31. Bouisson, which have served as a basis to so many different opinions, are but the simple expression of greater or less degrees of anaesthesia, and the phenomena presented by the uterus in regard to sensibility and contractility, are themselves included in the general laws of anaesthesia. We are, in fact, perfectly well aware, that the participation of the organic movements in the depression which the inhalations produce in all the powers of the economy, is to be reckoned amongst the ultimate phenomena of etherization. 2. Influence of Anaesthetics upon the Contraction of the Abdominal Muscles.— It is well known that in the last stage of labor the womb seems to call to its aid the action of the voluntary muscles, and that the efforts of the female assist in overcoming the obstacle to the passage of the fcetus. It would appear as though, being dependent upon the animal life, the action of those muscles which accom- plish the effort would be destroyed by the ether or chloroform, as is that of the muscles of the extremities. Now, according to the majority of accoucheurs, such is not usually the case, but that unless the anaesthesia be carried farther than prudence would dictate, the auxiliary power of the abdominal muscles is ANESTHETICS IN LABOR. 951 not wanting to the uterine contraction. 3Iy friend 31. Longet thus attempts to explain this singular phenomenon. He first calls attention to the fact, that in the midst of the complete collapse, the respiratory movements are still accom- plished. Now the effort in general, and that which accompanies labor in par- ticular, are but a modification, a transitory change in the respiratory act; it is a state requiring an energetic contraction of the muscles of the chest, diaphragm, and abdominal parietes. Since in etherization the respiration is maintained in all its integrity, volition being absent, and the medulla oblongata continues to excite all the muscles that concur in its accomplishment, the effort which is the result of the action of these muscles, those of the abdomen included, should also continue to be produced. I would also willingly add, with 31. Bouisson, that since it is at the present day demonstrated that the reflex or excito-motor power of the spinal marrow, which produces movements without the participation of the will, is not abolished by etherization except when carried to an extreme degree, the part which is played by the abdominal muscles in parturition may properly be regarded as reflex in its nature. Their manifest relation with the viscera of the lower part of the abdomen leads, naturally, to the supposition that the excitement emanating from the uterus during the act, is directly re- flected by the spinal marrow upon the muscular planes of the abdomen. What tends to prove it is the fact that the abdominal muscles may refuse the con- tingent of force which they contribute to this act, provided the etherization be carried so far as to abolish the reflex power, whilst they continue to act, though more feebly, it is true, as muscles of respiration (Bouisson). I was, on one occasion, enabled to verify the correctness of this observation of the Montpellier professor. Perhaps it would have been proper, before attempting an explanation of the contraction of the abdominal muscles during the anaesthetic slumber, to assure ourselves whether, in fact, such contraction really occurs. I suggested some doubt of it in a communication made in 1848 to the medical society of the department of the Seine. Whilst admitting that women under the influence of ether seemed to make efforts, I pointed out the difficulty "of determining whether the contraction of the anterior muscles of the abdomen takes place simultaneously with that of the uterus. My own observations had failed to convince me that such was the case. It seemed to me that nothing could be more difficult in the distended and hard condition of the abdomen, than to distinguish the muscular from the uterine action, and, consequently, to feel certain whether the organ contracted alone, or was aided by the action of the abdominal muscles. The same difficulty has also presented when etherization was omitted. I am happy to find that Channing also entertains some doubts as to their simultaneous action in etherized patients. He says, the opinion of 31. P. Dubois appears to me to be founded, in many cases at least, upon an erroneous interpre- tation of the phenomena of etherization in labor. The women appear to make an effort, but this symptomatic expression is a result of the forced or embarrassed respiration which accompanies uterine contraction. In imperfect etherization, the abdominal muscles contract in different degrees; but when the anaesthesia is complete, the effort is only apparent. 952 APPENDIX. 3. Influence of Anaesthetics on the Resistance of the Perineum.—One of the advantages usually attributed to the use of ether or chloroform is such a dimi- nished resistance of the perineum as to facilitate the expulsion of the foetus, and to prevent almost certainly the ruptures which it so often suffers in labor. Were I to rely only upon my personal experience, I should find it difficult to arrive at a definite conclusion, particularly as I have witnessed very different results. Thus, like 3Iessrs. Dubois, Chailly, and others, I have sometimes known the perineum yield and distend with great facility; though more commonly, even when the anaesthesia was complete, it remained as resistant as ever, and even, as in the case reported by 31. Villeneuve (of 31arseilles), in three instances, to be ruptured very badly.1 On a still more recent occasion, 31. Danyau and myself were obliged to incise each side of the vulvar orifice very deeply, the patient being completely under the influence of chloroform. I am unable to say why these differences should exist, because the anaesthesia was perfect in all the cases just mentioned; so that different degrees of this condition cannot be alleged in explanation. Perhaps it will be well to remember how very variable is the re- sistance offered by the perineum in different individuals, and how very difficult it is to foresee what will occur in any particular case. Every day's practice shows how liable our predictions are to be falsified by the event. Again, supposing that under the influence of the pressure which these muscles have to sustain, the reflex action of the spinal marrow is unable to produce their contraction in the efforts, involuntary though they be; supposing, we repeat, that they are paralyzed in the etherized female, it is not to be credited that the entire resistance of the perineum is on that account ever suspended. The fact is, that the resistance is ordinarily due quite as much to the aponeurotic planes of the pelvic floor, and to the sometimes very large amount of fatty tissue situated between the different layers, as to the muscular fibres themselves. In those who have borne children, and in whom the perineum presents but slight resistance, the muscles of this region are at least quite as fully developed and as strong as in primiparous females. To what, then, can be due the facility with which the foetus is expelled, if not to the greater elasticity of the aponeurotic planes, which, having suffered distension in previous labors, have their suppleness increased thereby? Since the chloroform can have no effect upon them, it is no cause for astonishment that after its administration the resistance of the perineum should continue. Hence we may conclude that: 1. When properly administered and in mode- rate doses, anaesthetic agents do not interfere with the regular course of the uterine contractions; and that whenever their administration is followed by the cessation or weakening of the efforts, the effect ought not to be attributed to the agent, but to the abuse which has been made of it; 2. That it is not yet suffi- ciently shown that during the anaesthetic slumber, the abdominal muscles con- 1 Rupture of the perineum does not prove, however, that the resistance may not have been lessened by the use of chloroform. In two cases, indeed, it seemed to me that the great rapidity with which the distension and thinning took place facilitated the rupture. This stretching, resembling precisely -what a piece of India rubber would undergo, was effected so quickly by the very strong pains, that there occurred, first, a sort of fraying followed by extensive rupture of the perineum. ANESTHETICS IN LABOR. 953 tinue to aid, by their contraction, the expulsive efforts of the womb; 3. That fresh observations are necessary to settle definitely the influence of chloroform upon the resistance of the perineum. Before determining what cases indicate or contra-indicate the use of chloro- form, it remains for us to state what is proved by experience regarding the influence of chloroform upon the health of both mother and child. 1. Effect upon the mother's health.—Accoucheurs who have often used chloro- form, are almost unanimous in the declaration that it has never had the least mischievous effect upon the mother's health, whilst in all cases it has spared them the sufferings of the last expulsive pains. None of my patients, says Dr. Simpson, has been conscious of them; and several, through their confidence in etherization, have been spared the fears which they usually suffered toward the end of their preceding pregnancies, in anticipation of the coming labor. By exempting women from the terminal sufferings, the anaesthesia husbands their strength, and avoids the nervous exhaustion which follows a painful labor. Some, who were already mothers, declared in grateful terms their condition to be in- comparably better than after their previous labors. Their recovery, continues the same author, is more rapid, and consecutive inflammations are much rarer or less serious than usual. I am not yet convinced, so far at least as regards natural labor, that this last proposition is fairly demonstrated; and nothing in the facts yet known, those even of Dr. Simpson included, appear to me of a character to prove its exactness. In natural labor the fatigue is moderate, and the remembrance of it soon abolished by the happiness of maternity. The lying-in demands always the same precau- tions, whether chloroform be used or not, and the time of getting up is nearly always the same. Finally, in an epidemic of puerperal fever at Edinburgh, the women who had used inhalations were not more exempt from the disease than those who had not. I would even add, that in tedious labors the gravity of consecutive acci- dents has not been sensibly diminished by the use of chloroform. Its only incontestable effect is to abolish pain, and prevent the considerable nervous dis- turbance sometimes consequent thereto. This result is, doubtless, of importance, but, except in some very exceptional cases, the pain is not fatal of itself, and the nervous shock is generally avoided. Metritis, deep-seated suppurations, inflam- mations, and gangrenous eschars of the soft parts of the pelvis, are consequences of the violent uterine efforts. Now, as Montgomery has shown, the only effect of chloroform is to remove the pain, leaving intact all the other consequences of difficult labors. Another incontestable advantage of chloroform is that of facilitating certain obstetrical operations. The uncontrollable and disordered movements of the agonized female hinder the operator greatly; but the sleep which she enjoys during the inhalation, and the complete insensibility of all the organs, enable her quietly to bear the most painful operations. The annihilation of pain in all cases, the prevention of the nervous shock which is sometimes the consequence of too painful or too prolonged a labor, and the facilitation of obstetrical manoeuvres, are, therefore, the only indisputable advantages to be derived from the use of chloroform 954 APPENDIX. Are not these advantages counterbalanced by serious inconveniences? Such is the opinion of some accoucheurs, though they have, in my opinion, exagge- rated both their frequency and gravity. We are now able to estimate its power of suppressing the pains of labor: prudently administered, it in no respect alters the regularity and power of the contractions; but is it altogether the same as regards the contractility of the tissue, and may not the retraction of the womb after labor be in some degree modified by the previous use of anaesthetics? 1 confess the want of an entire assurance upon this point, and am inclined to believe that they have not, in some cases at least, been altogether without in- fluence in the production of subsequent inertia and hemorrhage. Two cases of slight hemorrhage are quoted by Duncan, one of which, it is true, occurring in a twin labor with extreme distension of the uterus, is thereby sufficiently accounted for; but the other took place six hours after delivery, without any appreciable cause. Dr. Channing has met with 4 cases of hemorrhage in 78 of anaesthesia. In one case it was internal, and happened one hour after delivery; in another, the woman half fainted immediately upon the termination of labor, and he found the uterus much enlarged and filled with clots, upon the removal of which, the organ contracted, and there was no further loss. In a third case, a serious hemorrhage occurred immediately after delivery. The fourth observation is less conclusive, on account of the patient having experienced losses after previous labors, and because the delivery of the placenta was made difficult by adhesion. Dr. 31ontgomery declares, as his personal experience, that when the influence of the chloroform is kept up until the labor is ended, the patient is more or less exposed to hemorrhage from inertia and to retention of the placenta. The expe- rience of several of my brother practitioners, he adds, has been similar to my own. I am well aware that in all these instances the hemorrhage may have been due to various circumstances, and there is uothing to show that chloroform was necessarily the cause; still, it is well to be aware of them, were it only to excite prudence in the use of the agent; for, since by too large a dose the exercise of the organic contractility has sometimes been suspended, why may not the same dose diminish the contractility of the tissue ? In practice, these facts ought not to be lost sight of, and I think that, immediately after delivery, it would be prudent to administer some ergot. In certain surgical operations, death has resulted immediately from the admi- nistration of chloroform. Is not the supposition both probable and reasonable, says Dr. 3Iontgomery, that a similar misfortune might happen to a woman in labor? Doubtless it is possible; but happily, although a great number of women have used inhalation, not a case can be mentioned in which sudden death can be reasonably attributed thereto; for I cannot accept as such the following related by Gream. A young woman had just been delivered of one child, and chloro- form was administered before the expulsion of the second; death ensued in half an hour. No further detail is given. In two other cases mentioned by the same author, death occurred at a still later period after delivery. The patients whom the surgeons have had the misfortune to lose, did not die in this manner; for, in their cases, it was during the administration of the agent that life became extinct; it is, therefore, because in the observations of Gream a ANESTHETICS IN LABOR. 955 longer or shorter time had elapsed between the cessation of inhalation and death, that I cannot regard the chloroform as chargeable with the fatal result. With still less reason has it been reproached with the production of eclampsia. by increasing the cerebral congestion, which the exertions of labor have of them- selves a tendency to produce. For, although Wood has quoted a case of convul- sions occurring in an etherized woman in the last stage of labor, we are now in possession of enough facts to prove that the administration of chloroform during convulsive attacks, lessens their frequency, and sometimes puts an end to them altogether. Inhalation has also been accused of the production of insanity; of which, says Channing, there is not a single well-established case. In reference to this point, he cites the following observation by one of his countrymen. An insane woman had in a preceding labor suffered from extreme agitation, whieh was the occasion of serious difficulty. In her last labor, ether was administered, thanks to which, the patient was perfectly quiet, and all passed over admirably. 2. Effect of Chloroform upon the Life and Health of the Fcetus.—Whatever difference of opinion may still remain respecting the influence of chloroform upon the health of the mother, no one doubts its entire innocence as regards the fcetus. In the immense majority of cases, the new-born child presents its usual appear- ance; its cries are neither weaker, nor heard less promptly, nor does its viability appear to be in any way injured. Thus have the gloomy previsions of certain physiologists been falsified by experience. The conclusions which 31. Amussat thought himself entitled to draw from his experiments were contradicted by the ulterior researches of M. Renault. Indications.—In what cases is the accoucheur justified in the employment of chloroform ? This question is variously answered in different countries. Dr. Simpson, and with him quite a large number of his countrymen, recommend it unhesitatingly in all labors, whether natural or difficult. In France, on the con- trary, it is confined almost exclusively to cases of difficult parturition. We adopt unhesitatingly the latter position, and a few words will suffice to explain the motives of our preference. Whilst regarding the use of chloroform as devoid of danger in the majority of cases, we cannot entirely forget the misfortunes of certain surgeons, who had, nevertheless, taken the best precautions to avoid them. Now, though it be allowable to subject a patient to some danger, in order to spare him the intense suffering of an amputation or any other bloody operation, are we sufficiently au- thorized to do so when the regular accomplishment of a function is concerned ? And, after all, is the suffering of childbirth, in simple cases, so grave and ter- rible ? Do we not see women delivered almost without pain ? To speak only of what is most common, do they not often preserve their calmness and gaiety to the end of the labor ? Do they not often complain of the repose afibrded by the intervals between the pains, and ardently desire their return, in the conviction that each is a step toward delivery? Why, therefore, with the simple object of sparing them some suffering, which, after all, they endure courageously, deprive them of the caresses of the husband, the condolence of their relatives, and deaden the imagi- nation, already teeming with the joys of maternity? Why, especially, should they be deprived of the ineffable happiness of hearing the first cry of the new- 956 APPENDIX. born child ? Instead of the pleasant chatting in which women so often indulge, instead of those maternal aspirations and dreams of the future which soothe the young mother, what do we observe after the anaesthetic inhalations ? A deep sleep, resembling more or less the coma of inebriation, or concussion of the brain, a complete annihilation of the sensorial and intellectual faculties, is the lot of the mother; an always increasing solicitude that of her attendants. Finally, we may add, that supposing the physician to be devoid of all fear, he is obliged to remain constantly by the side of his patient to administer the agent personally, and to watch attentively the state of the pulse, of the breathing, and of the heart. As a justification of the use of anaesthetics in ordinary labors, it has been said that they favor the dilatation of the mouth of the womb, and by lessening the resistance of the perineum also shorten the period of expulsion. We have already seen that the diminution of the resistance of the perineum is not sufficiently proved; and the same may be said, I believe, of the rapidity with which the dilatation of the orifice is effected. However it may be, upon consulting the published observations, it is not discoverable that, in the cases in which chloro- form has been employed, the duration of the labors, as compared with preceding ones, has been sensibly shortened. Besides, the duration of a labor becomes dangerous for either mother or child only as it exceeds the natural limits, and of the latter case only are we speaking at present. Indeed, the more I reflect upon it, the more determined do I feel to exclude anaesthetics from simple labor entirely. The case is different when some unfortunate complication disturbs or inter- feres with the course of nature. It will have been seen, on reading this work, that we very often have spoken in favor of the use of chloroform, and we shall now proceed to recapitulate the different cases in which we feel justified in re- commending it. It may be especially useful: 1. In calming the extreme agitation and mental excitement which labor often produces in very nervous women (see page 388). 2. In those cases in which labor appears to be suspended or much retarded by the pain occasioned by previous disease, or such as may supervene during labor (vomiting, cramps, colic, compression of the sciatic nerve, page 508.) Dr. Montgomery, who certainly is no enthusiast, states that he had witnessed a case, in which he certainly would have used chloroform had he been acquainted with it at the time : the sphincter ani muscle was affected with so violent a spasmodic pain as almost to deprive the patient of reason. 3. It seems to us particularly indicated by those irregular or partial contractions, which, notwithstanding the intense and almost constant pain which they occasion, have no effect to advance the labor (page 509). We might even think, with M. Bele, that chloroform, which must be exhibited in very large doses to suspend the normal and rhythmi- cal contractions of the uterus, would act much more promptly in stopping the irregular contractions. 4. Spasmodic contraction and rigidity of the cervix uteri have sometimes been favorably affected by inhalation (page 60:]). As this part of the uterus receives some spinal nerves, it. becomes, to a certain extent, a por- tion of the muscular apparatus of animal life. Facts are, however, as yet too few to enable us to determine the question. ANESTHETICS IN LABOR. 957 When the last edition of this work was published, I was not sufficiently in- formed in respect to the usefulness of anaesthetics in the treatment of eclampsia. Besides having had no personal experience, the cases I had read of, those quoted so abundantly by Channing included, still left me in doubt as to their utility. This being the case, I came to no definite conclusion, leaving the question for decision in the future. Since then, the publication of further observations, as well as my own experience, lead me to advise the use of chloroform (see page 728). It has seemed to me especially useful when the convulsions begin during pregnancy, or at an early period of labor, when blood-letting, purgation, revulsives to the skin, &c, have all been tried and the attacks continue as severe as ever. The same remark applies to their occurrence only after delivery, or when having be- gun during labor, they persist after the child is born. Under the latter circum- stances, however, I think it important not to stop the inhalations too soon after the attacks have ceased. At any rate, it were prudent to stand prepared to recommence them should the convulsions be renewed. Obstetrical Operations.—Not only does chloroform abolish the great pain pro- duced by various obstetrical operations and relieve the'patient from the dread which they inspire, but by rendering her motionless, greatly facilitate the ma- noeuvre. It is, therefore, no despicable auxiliary, provided the nature of the services required of it be well understood. Turning, for example, would cer- tainly be facilitated by the immobility and insensibility of the patient, but not at all by any fancied suspension of the physiological contractions; only the sensi- bility and irritability of the organ being destroyed, it is not irritated by the pre- sence of the hand, and the usual spasmodic contraction does not occur. To expect other assistance from the chloroform, to propose, for example, overcoming by its aid the difficulties sometimes presented by a long and strongly-contracted uterus, would be, as we have said (see page 768), exposing ourselves to the danger of carrying the anaesthesia to the third degree,—a circumstance to be dreaded on account of the terrible accidents which some surgeons have had to deplore. When instruments are employed, it is very often useful to interrogate the sen- sations of the female, in order to be sure that no part of the uterus or vagina is caught between the branches of the instrument. Now, during the anaes- thetic slumber, the patient can reply to no question, and thus is the surgeon deprived of a source of useful information. Whatever may be the process em- ployed, it is impossible to render the patient too secure, therefore, as the intro- duction of the blades of the forceps or of the cephalotribe is generally attended with but moderate pain, I would recommend that the patient be not etherized until this first stage of the operation is over. The extraction of the child may then be effected without causing any pain. If ever symphyseotomy or the Caesarean operation be decided upon, I should think the administration of chloroform as likely to be useful as in any other great surgical operation. Finally, the difficulties attendant upon the delivery of the placenta from its abnormal adhesions, and from irregular contraction of the uterus, sometimes require proceedings which are very painful to the female. Anaesthe- tics may here render the same services as in version. It is, however, necessary not to administer them too freely, for, independently of the dangers of which we 958 APPENDIX. have spoken, it might be feared lest by paralyzing the contractile powers of the womb, they should expose the patient to inertia and consecutive hemorrhage. Before finishing the study of the indications for the use of chloroform, we add a few remarks on its administration to pregnant women and nurses. During Pregnancy.—Is the somewhat free use of anaesthetics during preg- nancy capable of exciting premature contraction of the womb, or of exerting any deleterious influence upon the health or life of the child ? Iu reference to this question, 31. Blot mentions in his thesis, three cases, two of which came from M. Uhassaignac : In the first case the woman had, three days after the inhalation, uterine and lumbar pains which yielded readily to opiates ; the pregnancy, how- ever, pursuing its regular course. Another patient, five months advanced, presented nothing unusual. The third observation, borrowed from Robinson, had reference to a young woman who, in tbe fifth month of her third pregnancy, breathed chloroform for the relief of toothache, remaining in a state of demi- stupor for half an hour. Shortly after, abdominal pains came on, which in- creased, and in a few days ended in abortion. This last case is the only one to which I attribute some importance, and if it should recur in other instances, would show the importance of great caution in the use of inhalations during pregnancy. Whilst Nursing.—M. Blot also mentions in his thesis two facts tending to prove that the chloroform inhaled may pass into the secretions, and that occurring in a nurse, for example, might have a bad effect upon the child if sufficient time were not allowed to elapse between the period of inhalation and that of suckling. A mother put her child to the breast three hours after breathing chloroform, and in a few moments it fell into a profound sleep which lasted for eight hours. After the sleep, came on a state of excitement which continued for two days (Scanzoni). An analogous case is reported by 31. Chas- saignac. It would seem prudent, therefore, to delay nursing in such cases for seven, eight, or ten hours. Mode of Administration.—The plan described by Dr. Simpson is the one usually followed. It consists, as is well known, in placing near the nostrils and mouth, a concave sponge, or a handkerchief folded into a cone, after having poured into the concavity a drachm or two of chloroform. The handkerchief ought to be held rather above the opening of the nostrils, for the weight of the chloroform being rather greater than that of the air, it would otherwise fall, and not enter the mouth or the nostrils. The sponge should be held at some dis- tance from the face, so as to allow a free passage to air, and prevent contact of the fluid with the skin and mucous membrane. If this precaution be not taken, little vesicles, and even small superficial eschars will be formed. Durin«- the interval of the inhalations, the evaporation of the chloroform is prevented by closing the hollow of the handkerchief by the corners or with the hand. Dr. Simpson recommends beginning with a strong inhalation, and at the out- set, to cause enough to be breathed to produce complete somnolence. He attri- butes the loquacity, delirium, spasms, and extreme agitation observed in certain subjects, to beginning with too small a dose. This advice, which is very proper if ether be employed, is not of equal value if chloroform be used. The latter generally produces much less excitement, and throws the patient at once into a ANESTHETICS IN LABOR. 959 tranquil sleep. The cough and pulmonary irritation which they sometimes occasion, depend either upon the bad quality of the agent, or the holding of the sponge too near the nostrils at the outset, thus causing too much of the vapor to be respired at a time. When an operation to last but a few minutes is to be performed, it is proper, as in surgical practice, to induce profound slumber, and to continue inhalation whilst the operation is going on. But if it be intended merely to moderate the general excitability of the female, to abolish a pain which is foreign to the labor, or to modify partial, irregular, or tetanic contractions, it is necessary, after quiet- ness is obtained, to remove the sponge in order to allow of free respiration, and to be content with a few slight inhalations at the beginning of every contraction. Three or four pains may sometimes be allowed to pass without applying the sponge, having recourse to it only when the patient complains of suffering. These repeated inhalations are sufficient to keep the patient in a state in which self-consciousness is lost, and which may thus be prolonged for several hours without inconvenience. What we have to avoid, adds Dr. Simpson, is either too much or too little. By too large a dose, the contractions may be suspended; by too feeble a one, much excitement is produced. To calm the latter, increase the dose; to remedy the suspension of the pains, withhold the chloroform for some time. It is a singular fact, that large inhalations are less likely to suspend the con- tractions in the second than iu the first stage of labor, and, consequently, there is then less inconvenience in administering them to a smaller extent. Let it not be imagined, however, that in order to produce complete anaesthesia, it is neces- sary to carry the inhalations so far as to produce noisy respiration, as in surgical practice. It is rarely needful to go so far The amounts required to produce sleep and immobility also vary greatly in different individuals. The patients are calm during the intervals between the pains; at the return of the contractions they indicate to the accoucheur by more or less motion and « by slight groaning, that sensation is not completely abolished, and that it is proper to repeat the inhalation. So long as the etherization is continued, the greatest silence should be main- tained about the bed of the patient, for the general excitement and loquacity produced by the first doses are sometimes augmented by noise. INDEX. A. Abdomen, enlargement of, in pregnancy, 129. palpation of, 139. Abdominal pains during pregnancy, 306. Abnormal pregnancies, 236. Abortion, 321. causes of, 322. symptoms, 327. diagnosis, 331. prognosis, 335. delivery of after-birth in, 336. production of, 827. Abscesses in lips of cervix uteri, 609. Adhesion of the labia, 571. After-pains, 477. After-birth, natural delivery of, 858. Affective faculties, lesions of, during preg- nancy, 303. Agglutination of external orifice of uterus, 607. Agalactia, 929. Allantoid, of the, 170. Albuminuria during pregnancy, 281. symptoms, 285. progress, duration, and termi- nation, 286. mode of detecting, 287. as a cause of puerperal convul- sions, 697. Alimentation of children, 902. Amnion, of the, 168, 186. dropsy of the, 295. Amniotic fluid, 168. amount of, and composition, 187. Anorexia in pregnancy, 255. Animal diet in functional disorders of preg- nancy, 275. Anteversion of the uterus, 319. Anchylosis of fcetal articulations, 626. Anomalies in the mechanism of labor, 645. Aneurism complicating labor, 747. Aorta, compression of, to arrest hemorrhage, 887. Apparent death of the child, 491. treatment, 496. insufflation for, 498. Appendages, fetal, 183. 61 Appendix. On the use of ana?sthetics in obstetrical practice, 947. Apoplexy and asphyxia of the child, 490. placental, 674. Articulations of the pelvis, 22. Articulation, sacro-vertebral, 25. Arm, presentation of, 776. Ascites during pregnancy, 296. treatment of, 297. of fcetus, 624. Asphyxia of the child, 490. Asthma complicating labor, 748 Attentions to the woman during labor, 454. child during labor, 464. woman immediately a-lter delivery, 471. lying in woman, 486. child immediately after birth, 487. Auscultation, applied to pregnancy, 146. mode of performance of, 159. determination of position of child by, 149. determination ot twin preg- nancy by, 148. determination of child's health by, 150. j^ B. Bag of waters, 383. Ballottement, 143. Battledoor placenta, 204. Baudelocque's cephalotribe forceps, 851. Bellows murmur, 152. Bile, secretion of, in fcetus, 225. Bladder, tumors of the, 597. Blastodermic membrane, 166. Blindness, caused by hemorrhage, 682. Blood, composition of, in pregnancy, 270. alteration of, as cause of secondary hemorrhage, 895. Bodies of Rosenmuller, 62. Blunt hook, 774. Blot's perforator, 849. Botal, foramen of, 206, 226. Bony tumors of pelvis resulting from defor- mities, 579. Breasts, changes in, from pregnancy, 125. 962 INDEX. Breech presentations, 432. Broad ligaments, 61. cysts of, 62. C. Cavity of the pelvis, 33. dimensions of, 33. diameters of, 33. general arrangement of, 33. axis of, 34. Carunculae myrtiformes, 44. Catheter, mode of introduction of, 42. Canal of Nuck, 63. Cauliflower tumors of the uterus, 593. Callipers, Baudelocque's, 551. Cancer of neck of uterus, 609. Caesarean operation, 839. mode of operating, 845. vaginal, 847. Cervix uteri, induration with hypertrophy of, 609. obliteration of, 611. Cephalalgia, caused by hemorrhage, 682. Cephalic version, 751. Chorion, 188. villi of, 197. Chlorosis in pregnancy, 273, 354. Child, healthy, management of, 488. diseased or feeble, management of, 490. attentions to, immediately after birth, 488. apparent death of, 491 apoplexy of, 490. asphyxia of, 490. lesions of respiration of, 493. circulation, 495. nervous centres, 495,. debility of, 501. Chloroform, used to facilitate version, 768. Circulation of filCtus, 225. changes in, after birth, 22B. lesions of, during pregnancy, 268. Clitoris, 41. Coccyx, 19, Coxal bone, 20. Corpora lutea, 75. discrimination between, in pregnancy or otherwise, 77. Conception, 93. opposing causes of, 97. Constipation in pregnancy, 267. Congestion, uterine, in pregnancy, 276. as cause of hemorrhage after delivery, 894. Cough and dyspnoea during pregnancy, 267. Colostrum, 483, 903. Congenital luxation of the femur, 535. Convulsions, puerperal, 694. statistical table of, 696. causes of, 697. Convulsions, proportional occurrence in pri- miparas, 699. local causes of, 700. symptoms, 702. phenomena of attack, 703. suppression of urinary secre- tion in, 705. terminations of, 707. ruptures of uterus from, 708. meningitis from, 708. intestinal inflammation from, 709. diagnosis, 709. prognosis, 711. dangers to foetus from, 713. pathological anatomy of, 714. nature of, 715. treatment, 718. tartar emetic for, 719. bleeding for, 720. chloroform for, 719, 728. general measures for, 720. use of Junod's apparatus for, 722. special measures for, 723. treatment of, during gestation, 724. during labor, 725. after delivery, 728. Complicated positions, 652. Cord, prolapsus of, 634. shortness of, 639. constriction of neck of child by, 639. rupture of one of its vessels, 667. hemorrhage from, 896. Cramps during labor, 508. Craniotomy, 848. Cystocele, 601. D. Decidua, of the, 172. reflex, 173. external or uterine, 173. serotina or inter-utero-placental, 174. theory of, 175. Death, sudden, during or after labor, 389. of fcetus from hemorrhage, 679. Debility of the child, 501. Deformities of the pelvis, 517. pathological anatomy of, 520. causes and mode of production, 530. dependent on previous deformity of another part of the skele- ton, 534. influence of, upon pregnancy and parturition, 540. rational signs of, 547. sensible signs of, 550. indications presented by, 565. indications presented by, when the smallest diameter is at least three and three-quarter inches, 565. INDEX. 963 Deformities, indications presented by, when the largest diameter is three and three-quarter inches, and the smallest two and a half inches, 568. indications presented by, when the diameters are less than two and a half inches, 569. of the fcetus, 627. Decapitation of foetus in trunk presentations, 856. Delivery of the after-birth, 859. Dentition, 920. Diameters of the foetal head at term, 213. of foetal head from the 32d to the 37th week, 816. of the pelvis, 29, 32. Diseases of pregnancy, 253. of the ovum, as a cause of abortion, 323. of the womb and its appendages, as causes of abortion, 324. occurring during pregnancy, 346. and accidents that may complicate pregnancy and require the inter- vention of art, 656. that may complicate labor, 747. of the fcetus, 620. Digestion, lesions of, during pregnancy, 255. Diarrhoea during pregnancy, 267. Disposition to falling, 302. Displacements of the uterus, in relation to the accidents they may cause during preg- nancy, 309. Distension of bladder, effect of, upon labor, 508. Dropsy of cellular tissue during pregnancy, 289. progress and symp- toms of, 290. terminations, 291. prognosis, 291. treatment, 291. of the amnion, 295. the foetus, 297. Duct of Gartner, 67. Ductus arteriosus, 226. venosus, 226. Dyspnoea during pregnancy, 267. Dystocia, 502. E. Eclampsia, 694. Effect of bleeding and debilitating regimen upon the development of the child, 831. Embryonic spot, 167. Emphysema occurring during labor, 389. Emphysematous condition of fcetus, 625. Embryotomy, 848. forceps, Baudelocque's, 851. Cazeaux's modifica- tion of, 852. Endochorion, 189. Epilepsy during pregnancy, 354. Eruptive fevers during pregnancy, 349. Ergot, natural history of, 510. therapeutical action of, 511. External parts of generation, 38. secretory apparatus of, 44. Examination, anal, 145. Exochorion, 189. Extra-uterine pregnancy, 236. Exhaustion in labor, symptoms of, 504. from disease, as complicating labor, 749. Excavation, tumors in, 577. Exostosis in cavity of pelvis, 578. F. Fallopian tubes, 63. structure of, 64. fimbriated extremities, su- pernumerary, 65. changes of, during gesta- tion, 65. tumors of, 596. False kidneys, 206. waters, 299. pains, 454. labor, 456. Falling, disposition to, 302. of the womb, 309. of the cord, 634. prognosis of, 636. treatment, 638. Face presentations, 420. inclined positions of, 647. Fecundations, place of occurrence, 93. Fevers during pregnancy, typhoid, 348. eruptive, 349. intermittent, 351. Flooding, external, 673. internal, 673. seat of effusion in, 673. Fossa navicular!^ 44. Foetal openings, period of obliteration of after-birth, 228. mode of obliteration of, 228. appendages, 183. head at term, 211. diameter of, 213. circumference of, 214. Fcetus, of the, 204. dimensions and weight of, at differ- ent periods of intra-uterine life, 205. position and attitude in the uterus, 216. functions of, 219. respiration of, 223. nutrition of, 219. secretions of, 225. circulation of, 225. dropsy of, 297, 624. diseases of, 620. emphysematous condition of, 625. 964 INDEX. Foetus, tumors of, 625. deformities of, 627. excess of volume of, 627. malpositions of, 643. Fcetuses, multiple and adherent, 628. multiple and independent, 629. Foramen of Botal, 206, 226. Fontanelles, 211. anterior and posterior, 212. Forceps of the, 779. Smellie's, 780. Levret's, 780. Simpson's, 781. use of, preliminary precautions, 782. general rules of application, 783. Hatin's method of applying, 784. special rules of application, 789. application of, in vertex positions, at the inferior strait, 789. application of, in vertex positions, when the head is merely en- gaged at the superior strait, 794. application of, when the head is movable above the superior strait, 795. application of, in face positions, 797. when the head re- mains after the body is expell- ed, 800. general considerations on the em- ployment of, 802. use of, in inclined vertex, or face positions, 802. use of, in contracted pelves, 803. use of, in case of accident re- quiring immediate delivery, 807. use of, on account of resistance of mujiies of the perineum, 807. ^^^V. statistics of use of, and general views of the operation, 809. dangers to the fcetus from use of, 810. Fourchette, 39. G. Gartner, duct of, 67. Galactorrhoea, 930. Generation, external organs, 39. internal organs, 48. Generation, 93. Germinal vesicle, 70. spot, 71. Gestation, 99. displacement of bladder during, 124. vesical tenesmus during, 124. pathology of, 253. Giddiness during pregnancy, 304. Glans clitoridis, 41. Gland, vulvo-vaginal, 45. Glairy discharges during labor, 382. Graafian vesicle, 68. Granular vaginitis, 289. H. Hand or arm presentations, 776. Hernia, congenital, 201. intestinal or omental, 599. vaginal, 599. vagino-labial 599. vulvar or perineal, 600. vesical or cystocele, 601. of the womb, 617. complicating labor, 748. Head of foetus at term, 211. presentation, cause of, 217. Hemorrhoids during pregnancy, 278. Hemorrhage, puerperal, 657. causes, 657. predisposing causes, 657. determining causes, 662. special causes, 663. symptoms, 672. general symptoms, 672. local symptoms, 672. diagnosis, 674. internal, diagnosis of, 673. prognosis, 678. treatment, 683. general treatment, 684. special treatment, 684. moderate, occurring in the last three months, 684. profuse, occurring in the last three months, 685. rupture of membranes as a remedy for, 688. internal treatment of, 690. moderate, during labor, 69.1. profuse, during labor, 691. table showing treatment of be- fore and after labor, 693. complicating delivery of the after-birth, 880. causes, 880. symptoms, 881. diagnosis, 883. treatment, 884. .tampon for, 886. compression of aorta for, 887. ergot for, 890. transfusion for, 890. secondary, 893. from congestion of uterus, 894. from alteration of the blood, 895. from the umbilical cord, 896. Hemoptysis complicating labor, 747. Hematemesis complicating labor, 747. Heart, chronic diseases of, complicating la- bor, 748. INDEX. 965 Hour-glass contraction of the uterus, 867. Hymen, 43. varieties of, 43. persistence of, 571. Hydrorrhcea, 298. Hysteria during pregnancy, 354. Hygiene of the lying-in woman, 486. of children from birth to time of weaning, 902. Hydrocephalus, 620. Hydrothorax and ascites of the fcetus, 624. Hysterotomy, 839. Icterus during pregnancy, 351. Ilium, 21. Iron, use of, in functional disorders of preg- nancy, 275. Inferior strait, 30. plane of, 31. variations in plane of, 31. axis of, 32. variations in axis of, 32. diameters of, 32. extremities, lesions of, 539. Innervation, lesions of, during pregnancy, 303. Intellectual faculties, lesions of, during preg- nancy, 303. Inguinal pains during pregnancy, 306. Intermittent fever during pregnancy, 351. Inflammations of the pelvic articulations dur- ing pregnancy, 302. Inflammations caused by hemorrhage, 682. Inspiration, cause of the first act of, 491. Inclined positions of the vertex, 644. of the pelvis, 647. of the face, 647. Insertion of the placenta upon the lower seg- ment of the uterus, 664. Induction of premature labor, 813. Inertia of the womb, 865. , secondary, 893. Inversion of the uterus, 896. spontaneous reduc- tion of, 900. Infants, hygiene of, 902. feeding of, 902. nursing of, 909. clothing of, 944. bathing of, 944. aeration of, 945. sleep of, 946. exercise of, 946. Ischium, 22. Itching of the skin during pregnancy, 305. Junod's apparatus, 722. application of, for convul- sions, 722. K. Kidneys, false, 206. Kiwisch's method of inducing premature la- bor by use of injections, 825. Kluge's method of dilating the os uteri for inducing premature labor, 822. Kyesteine, 132. Labia majora, structure of, 39. peculiar pouch in, 39. interna, 40. adhesion of, 571. externa, oedema of, 580. Labor, in general, 361. premature, 361. retarded, 363. natural, at term, 366. causes of, 366. duration of, 385. physiological phenomena of, 374. pain or contraction, 378. glairy discharges during, 382. effect of, on mother and child, 388. mechanical phenomena of, 391. false, 456. pains, true, characters of, 455. preternatural and painful, 503. tedious, 505. rendered difficult, impossible, or dangerous, by deficiency or excess of action of the expulsive forces, 503. extreme slowness of, 503. exhaustion in, symptoms of, 504. too rapid, 514. rendered difficult, impossible, or dangerous, by obstacles opposing the readv expulsion of the fcetus, 517. anomalies in the mechanism of, 645. premature, inducHhn of, 813. Lactation, 903. j Leucorrhcea during pregnancy, 288. Levret's forceps, 780. Ligaments, pubic, 23. sacro-sciatic, 23. sacro-iliac, 24. sacro-coccygeal, 24. softening of, 25. broad, 61. round, 62. vesico-uterine, 63. utero-sacral, 63. Line traversed by fcetus, 38. Locomotion, lesions of, 300. Lochia, of the, 479. absence of, 483. effect of lactation upon, 481. substituted by hematemesis, 482. long continued, 482. profuse and purulent, 483. Lumbar pains during pregnancy, 306. Luxation of the femur, congenital, 535. non-congenital, 539. 966 INDEX. M. Manimse, changes in, from pregnancy, 125, 130. changes of, as a sign of pregnancy, 130. Malacia, 256. Malformations of the vulva and vagina, 570. of the vagina, 574. Malpositions of the fcetus, 643. Maternal nursing, 909. Meatus urinarius, 43. Menstruation, 81. time of beginning, 83. premature, 83. duration of, 85. amount of, 85. seat of, 85. from vagina, case of, 86. cause of, 88. cessation of, 90. effect of, upon the quality of the milk, 907. Menses, suppression of, in pregnancy, 127. continuation in pregnancy, 128. Membrane, blastodermic, 166. intermediate or utero-epichorial, 178. epichorial, 178. anhistous, 182. Meconium, 225. Measles during pregnancy, 350. Mental diseases during pregnancy, 354. Milk fever, 483. cause of, 485. suppression or prevention of the secre- tion of, 485. qualities of, 903. induced secretion of, 904. quantity of, 905. influence of health of mother upon, 906. JR^ral affections upon, 906. genlf&munctions upon, 907. alimentUfcy or medicinal substances upon, 908. affected by general health of the mo- ther, 906, 950. alterations in the quality of, 906, 950. poor, effects of, 930. over-rich, effects of, 931. altered by colostrum, 931. altered by pus, 932. Mons veneris, 38. Monstrosity by inclusion, 236. Monstrosities, 627. Movements of the child in utero, 141. passive, of child, in utero, 143. Muco'us membrane of uterus, hypertrophied, 177. utero-epichorial, 198. Multiple and adherent foetuses, 628. independent fcetuses, 629. N. Nipple, affections of, 924. Nuck, canal of, 63. Nutrition of fcetus, 219. Nursing of children, 909. maternal, 909. obstacles to, 913. rules to be observed dur- ing, 911. accidents liable to inter- fere with, 923. mixed, 932. by wet nurses, 935. by a female animal, 942. artificial, 942. children, food for, 918. mothers, regimen of, 922. Nurses, selection of, 935. regulation of nursing by, 939. regimen of, 941. Nymphae, 40. O. Obturator membrane, 26. Obliquities of the uterus, 320. Oblique-oval pelvis, 524. Obliquity of uterine orifice, 605. of the uterus, 611. anterior, 612. posterior, 613. lateral, 616. Obliteration of neck of uterus, 611. Obstacles to delivery dependent on the body of the womb, 611. dependent on the fcetus or its appendages, 619. maternal nursing, 909. Obstetrical operations, 750. CEdema of labia externa, 580. Omphalo-mesenteric vessels, 170. Operations for producing premature labor, 819. Outrepont's and Ritgen's method, 820. Dr. Hamilton's method, 820. Dr. Cohen's method, 820. by puncture of mem- branes, 820. Meissner's plan, 821. Kluge's method, 822. Schceller's method, 824. Kiwisch's method, 825. Os tincae, 55. Osteo-sarcoma of pelvis, 579. Ovula Nabothi, 58. Ovaries, the, 65. ligaments of, 66. structure of, 67. Ovarian vesicles, 68. modifications of, 71. Ovule, 69. size of the, 69. Ovulation, spontaneous, 79. Ovum, human, after fecundation, 163. INDEX. 967 Ovum, human, development of, 164. changes of, in the tube, 164. modifications of, in the womb, until after the de- velopment of the allantoid, 166. modifications of, from de- velopment of the allantoid, until end of gestation, 183. diseases of, as a cause of abortion, 323. Ovary, tumors of, 594. P. Padjeras, 89. Pathology of gestation, 253. Pains during pregnancy, abdominal, 306. inguinal, 306. lumbar, 306. uterine, 307. of labor, 378. slowness or feebleness of, 505. relaxation or suspension of, 507. irregularity of, 509. Paralysis, facial, of new-born children, from use of forceps, 810. Pelvis, 17. in general, 26. external surface of, 26. internal surface of, 26. greater, 27. lesser, 27. inclined planes of, 28. straits of, 28, 30. cavity of, 33. base of, 34. differences of, according to age and sex, 34. uses of 35. covered by soft parts, 35. deformities of, 517. deformed, by excess of amplitude, 518. retraction, 519. simple contracted, without curvature or malformation of the bones, 520. contracted by curvature and malfor- mation of the bones, 521. oblique-oval, 524. degrees of contraction of, 529. variations in depth of, 529. causes and mode of production of deformities of, 530. deformed by rachitis or mollities os- sium, 530. deformity of, dependent on previous deformity in another part of the skeleton, 534. deformed by absolute narrowness, 540. influence of deformities of, upon pregnancy and parturition, 540. Pelvis, having at least three and three- quarter inches in its contracted part, 543. having at least two and a half inches in its contracted part, 545. in which the contracted diameter is less than two and a half inches, 545. deformities of, diagnosis, 547. indications presented by deformities of, 565. exostosis of excavation, 578. osteo-sarcoma of, 579. bony tumors of, resulting from defor- mities, 579. inclined position of the, 647. Pelvic canal, outlet of, 37. articulations, relaxation of, 300. inflammation of, 302. version, necessary conditions for, 759. general rules of the opera- tion, 760. introduction of the hand, 760. evolution of the foetus, 762. extraction of the foetus, 763. difficulties that may be met with in its performance, 765. smallness of the vulva, 766. resistance of the uterine ori- fice, 766. insertion of the placenta on the neck of the uterus, 767. Pelvimetry, 550. by the finger, 561. Pelvimeter, internal, 553. Baudelocque's, 551. Coutouly's, 553. Stein's, 553. Wellenberg's, 554. Van Huevel's, 554. Perineum, extent of37r- rigidityroFresiStance of, 573. Perforator, Blottd; 849. Phthisis, during pregnancy, 353. Phenomena appertaining to the lying-in state, 472. Pica or malacia, 256. Placental murmur, 152. apoplexy, 674. adhesions, 872. Placenta, 189. battledoor, 189, 204. multiple, 190. structure of, 191. arteries of, 193. veins of, 193. insertion of, upon lower segment of uterus, 664. perforation of, by head of the fcetus, 679. expulsion of, before birth of child, 680. natural delivery of, 859. mode of extracting, 862. 968 INDEX, Placenta, delivery of, in twin labor, 864. artificial delivery of, 865. excessive volume of, 866. encystment of, 869. encasement of, 869. abnormal adhesions of, 872. partial or complete retention of, 875. putrid absorption of, 876. late expulsion of, 877. complete absorption of, 878. accidents that may complicate its delivery—hemorrhage, 880. Pneumonia during pregnancy, 350. Positions of fcetus, determined by ausculta- tion, 149. of the trunk, 651. complicated, 652. Position, left anterior occipito-iliac—mechan- ism of natural labor in, 404. right anterior occipito-iliac—me- chanism of natural labor in, 412. Polypus of the body and neck of the uterus, 592. Pregnancy, diagnosis of, 127. rational signs of, 127. sensible signs of, 136. abnormal, 230. multiple, statistics of, 231. causes of, 231. extra-uterine, 236. varieties of, 236. pathological changes in, 241. progress of, 244. causes of, 248. terminations of, 245. treatment of, 251. diseases of, 253. lesions of respiration during, 267. circulation, 268. composijijinof the blood during, 270.--*^^*» chlorosis during, mistaken for plethora as producing func- tional disorders, 273. plethora during, 275. uterine congestion during, 276. - varices during, 278. hemorrhoids during, 278. lesions of secretion and excretion during, 279. ptyalism during, 279. secretion and excretion of urine during, 280. albuminuria during, 281. uraemia during, 284. leucorrhcea during, 288. dropsy of cellular tissue during, 289. ascites during, 292. lesions of locomotion during, 300. relaxation of pelvic articulations during, 300. Pregnancy, disposition to falling during, 302. lesions of innervation during, 303. lesions of sensorial faculties during, 303. lesions of affective facuties dur- ing, 303. lesions of intellectual faculties during, 303. vertigo during, 304. giddiness during, 304. syncope during, 304. pruritus of vulva during, 305. itching of skin during, 305. abdominal pains during, 306. lumbar pains during, 306. inguinal pains during, 306. uterine pains during, 307. displacements of the uterus, in relation to the accidents they may occasion during, 309. diseases occurring during, 346. epidemic diseases during, 347. sporadic diseases during, 348. chronic diseases during, 351. surgical diseases during, 355. typhoid fever during, 348. eruptive fevers during, 349. intermittent fever during, 351. pneumonia during, 350. icterus during, 351. syphilis during, 352. phthisis during, 353. hysteria during, 354. epilepsy during, 354. mental diseases during, 354. chlorosis during, 354. tumors in the abdomen and pel- vis during, 356. ulceration of neck of uterus dur- ing, 356. effect of, upon the lacteal secre- tion, 908. Presentations and positions, classification of, by various authors, 391, 401. Presentation of the face, 420. frequency of, 420. causes, 421. ( diagnosis, 422. inclined or irregu- lar, 429. prognosis of, 430. pelvic extremity, 432. causes of, 433. diagnosis, 434. mechanism, 436. prognosis, 440. trunk, 444. causes of, 445. diagnosis, 446. mechanism, 449. prognosis, 453. Preternatural and painful labor, 502. Premature labor, cases requiring it. 814. on account of abdominal tumors, 817. INDEX. 969 Premature labor, on account of smallness of abdominal cavity, 818. on account of nervous dis- orders, 818. on account of intercurrent acute diseases, 819. on account of death of fcetus in preceding preg- nancies, 819. operations for inducing, 819. Precautions to be observed by nursing wo- men, 910. Pruritus of the vulva during pregnancy, 305. Prolapsus uteri, 309, 618. of the cord, 634. Production of abortion, 827. modes of operating for, 829. Ptyalism, 279. Pubis, 22. arch of, 31. symphysis of, 22. Pubic ligaments, 23. Puerperal hemorrhage, 657. convulsions, 694. R. Rapid contraction of the uterus as a cause of hemorrhage, 672. Respiration of fcetus, 223. lesions of, during pregnancy, 267. Relaxation of-the pelvic articulations, 300. Retroversion of the uterus, 313. treatment of, 316. Regimen of the woman in labor, 468. the nursing mother, 922. Rectum, tumors of the, 596. scirrhus of, 597. Rheumatism of the uterus, 456, 743. causes, 743. symptoms, 743. influence of, upon the pro- gress of gestation, 745. influence of, upon the labor, 745. influence of, upon the puer- peral functions, 746. prognosis, 746. treatment, 747. Rigidity or resistance of the perineum, 573. of the neck of the uterus, 602. Rosenmuller, bodies of, 62. Round ligaments, 62. Rotation of the head, 407, 410, 412. Rupture of the respiratory organs during labor, 389. uterus, 729. causes, 729. predisposing causes, 730. determining causes, 731. external or traumatic causes, 731. internal causes, 732. 62 Rupture of the uterus, symptoms, 734. prognosis and termi- nations 735. pathological anato- my, 737. treatment, 739. Rupture of the vagina, 741. cord or of one of its vessels 667. S. Sacrum, 18. Saw forceps, Van Huevel's, 854. Sanguineous tumors or thrombus, 580. Scarlatina during pregnancy, 349. Scirrhus of the rectum, 597. Secretions of fcetus, 225. Secretion and excretion, lesions of, during, pregnancy, 279. Sensorial faculties, lesions of, during preg- nancy, 303. Secale cornutum, 510. Secondary hemorrhage, 893. Sexual intercourse, effect of, upon the qual- ity of the milk, 908. Shoulder presentation, 444. Shortness of the cord, 639. labor delayed by, 640, Signs of life or death of the child during labor, 457. Simpson's, Prof., plan of removing placenta for arresting hemorrhage in placental presenta- tions, 691. substitute for forceps, 781. Skin, itching of, during pregnancy, 305. Smellie's scissors, 848. forceps, 780. Sound of the fcetal heart, L4J5. Souffle, abdominal, Ijjft. ^^ uterine, 152. seat and mode of production, 154. Soft parts, tumors appertaining to, 580. Spontaneous ovulation, 79. version, 449. evolution, 450. Spermatozoa, 94. office of, 96. Spermatic granules, 94. fluid, characters of, 93. Spasmodic contraction of the neck of the uterus, 603. Superior strait, 28. plane and axis of, 29. inclination of, 29. diameters of, 30. Sutures, 211. Suckling, when to be commenced, 912. means of facilitating, 913. obstruction to, from shortness of the fraenum linguae, sublingual tumors, hare-lip, facial hemi- plegia, debility of child, 913,914. 970 INDEX. Suckling, regulation of, 915. regular times for, 915. Swelling and elongation of anterior lip of cervix, 608. Symphysis pubis, 22. sacro-iliac, 23. sacro-coccygeal, 24. Syncope, during pregnancy, 304. complicating- labor, 749. Syphilis during pregnancy, 352. Symphyseotomy, 834. effects of, 835. indication for, 836. operation, 838. Stoltz's method, 839. Imbert's method, 838. Table of the signs of pregnancy at various periods, 160. showing treatment of external hemor- rhage before and after labor, 693. statistical, of convulsions, 696. Tampon, 686. Thrombus, 580. treatment of, 584. of lips of the neck of the uterus, 588. Touch, of the, 136. vaginal, 137. Tongue-tie, operation for, 913. Trunk presentation, 444. positions of the, 651. Transfusion for hemorrhage, 890. Tumor of the scalp, as means of determin- ing the life or death of the child, 457. Tumors in the excavation, 577. abdomen and pelvis during pregnancy, 356. appertaining to the soft parts, 580. sanguineous, 580. various, 589. >v appertaining to the neck or body of the uterus, 589. fibrous, of the cervix uteri, 589. fungous, or cauliflower of the uterus, 593. of parts adjacent to the uterus, 593. of the ovary, 594. of the Fallopian tube, 596. of the rectum, 596. of the bladder, 597. in cellular tissue of pelvis, 598. hernial, 599. of the fcetus, 625. Twin pregnancy, 230. pregnancies, table of presentations in, 630. delayed delivery of the second child, 631. difficulties of delivery in, 632. Typhoid fever during pregnancy, 348. U. Ulceration of the neck of the uterus during pregnancy, 356. Umbilical vesicle, 169, 184. arteries and vein, 169. cord, 201. length of, 202. nerves and lymphatics of, 202. prolapsus of, 634. weakness of, 867. hemorrhage from, 896. Urethra, 42. dilatation of, 43. Urine, alterations of, during pregnancy, 131. secretion and excretion of, during pregnancy, 280. alteration of, in Bright's disease, 283. mode of detecting albumen in, 288. secretion of, in fcetus, 225. Urachus, 184. Uraemia, as cause of convulsions, 715. Uterus, the, 52. cavity of body of, 57. anteflexion of, 53. cavity of the neck of, 57. external surface of, 54. structure of, 58. neck of, 55. internal surface of, 57. internal or mucous membrane of, 59. structure of mucous membrane of, 60. development of, 61. ligaments of, 61. vessels of, 61. nerves of, 61. changes in body of, by pregnancy, 100. in neck of, by pregnancy, 105. in texture and properties of, by pregnancy, 111. serous coat of, 111. mucous coat of, 111. middle or muscular coat of, 112. vessels of, 115. nerves of, 117. properties of, 118. organic contractility of, 119. contractility of tissue of, 121. relations of, at term, 122. changes in neighboring parts, 122. hypertrophied mucous membrane of, 177. displacements of, 309. prolapsus of, 309, 618. faulty directions of, 313. retroversion of, 313. anteversion of, 319. obliquities of, 320, 611. ulceration of neck of, during preg- nancy, 356. changes in, after delivery, 476. INDEX. 971 Uterus, sanguineous tumors, or thrombus of lips of neck, 588. tumors appertaining to neck or body of, 589. fibrous tumors of cervix, 589. polypus of body or neck, 592. fungous or cauliflower tumors of, 593. tumors of parts adjacent, 593. obstacles presented by neck and body of, 602. rigidity of neck of, 602. spasmodic contraction of neck, 603. obliquity of orifice, 605. agglutination of external orifice, 607. swelling and elongation of anterior lip, 608. abscesses in the lips of the cervix, 609. indurated and hypertrophied cervix of, 609. cancer of neck of, 609. complete obliteration of cervix, 611. hernia of, 617. rapid contraction of, as cause of he- morrhage, 672. rupture of, 729, 900. rheumatism of, 743. inertia of, 865, 893. spasmodic contraction of internal orifice of, 868. hour-glass contraction, 868. spasmodic contraction of whole organ, 871. congestions of, as cause of secondary hemorrhage, 894. inversion of, 896. Uterine congestion, during pregnancy, 276. as cause of secondary hemorrhage, 894. pains during pregnancy, 307. rheumatism, 456. obliquity, 611. hemorrhage, 657. Utero-epichorial mucous membrane, 178. V. Vagina, 48. length of, 48. mode of attachment to uterus, 50. congenital shortening of, 49. structure of, 51. malformations of, 574. inversion of, 577. rupture of, 741. Vaginal pulse, 123. Caesarean operation, 847. Vaginitis, granular, 289. Van Huevel's new pelvimeter, 557. saw forceps, 854. Varices, during pregnancy, 278. Variola, during pregnancy, 349. Vesicle, allantoid, 170, 183. Vesicle, umbilical, 169, 184. ovarian, 68. Vertigo, during pregnancy, 304. Vertex presentation, 401. causes of, 402. diagnosis of, 402. mechanism of expul- sion in, 404. inclined or irregular, 416, 644. prognosis of, 417. inclined positions of, 644. Vestibule, 42. Version, 750. general considerations upon, 750. cephalic, 751. pelvic, 757. difficulties of, from mobility of body of uterus, 769. from shortness of cord, 769. from volume of shoul- ders, 769. from crossing of arms behind the neck, 769. from arrest of the head, 770. appreciation of, in vertex presenta- tions, 773. in face presenta- tions, 774. in pelvic presenta- tions, 774. in trunk presenta- tions, 775. Vectis, of the, 811. Villi, of chorion, 197. Vomiting, during pregnancy, 256. treatment of, 260. induction of premature labor for, 264.^- "* Vulva, 39. / pruritus of, during pregnancy, 305. and vagina, malformations of, 570. contraction and rigidity of, 571. Vulva-vaginal gland, 45. excretory duct of, 46. organization of, 47. uses and functions of, 47. W. Weaning, 920. Wharton's gelatine, 203. Wolffian bodies, 206. Womb, and appendages, diseases of, as causes of abortion, 324. hernia of the, 617. inertia of, 865, 893. hour-glass contraction of, 868. irregular contraction of the body of, 869. 'VL*V\ *%;■ NLM031903516