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CRAIGHEAD, Printer, Slereocyper, ami Kicctroljrper, Carton Utilising, 81. S3, and 85 Centre Street. $ To THE ALUMNI AND STUDENTS, WHO HAVE ATTENDED THE AUTHOR'S LECTURES OX OBSTETRICS IN THE UNIVERSITY OF NEW YORX, AND TO WHOSE UNIFORM COURTESY AND KINDNESS HE IS SO GREATLY INDEBTED, STIris $oIunu is ^fftciioiraitlg .vltbitnteb. PREFACE. In writing a work on the " Principles and Practice of Obstetrics " I have had constantly before me one' cardinal object—to be useful. I have endeavored to present to the Profession a practi- cal Book, one which will develop the phenomena of parturition in their various phases as they occur in the Lying-in room. The anatomy of the Pelvis and Genitalia, and their special bear- ings on Parturition, have been dwelt upon with a minuteness to which they have a just claim. Abortion, the subject of Labor, its Divisions, its Mechanism and Management, its deter- mining cause, together with the forces engaged in the expulsion of the child, the treatment of the puerperal woman and her new-born infant, Flooding both ante-partum and post-partum, Placenta Prasvia, Puerperal Fever, Puerperal Mania, Anaesthe- tics, have all been considered with the fulness their importance demanded. Nor have I neglected the physiological disquisitions necessarily involved in the consideration of the numerous ques- tions connected with Menstruation, Keproduction, Pregnancy, Foetal Nutrition, Puerperal Convulsions, and other kindred topics. Manual, Instrumental, and Premature Artificial Delivery have received their share of attention ; they have been discussed freely and at length. On the subject of Instruments, I have spoken without reserve, and have not failed to raise my voice, in the most emphatic manner, in rebuke of what I believe to be oftentimes their unnecessary and reckless employment. If what I have said on this point shall exercise an influence in vi PREFACE. behalf of suffering woman, in the hour of her need, I shall indeed be happy. Touching the grave questions of Embryo- tomy and the Caesarean section I have suffered my mind to be governed by no predilection, but have examined, with the singh purpose of reaching the truth, the substantial evidence both for and against these alternatives; my deductions are the results of what I believe to be a thorough and impartial analysis of this evidence. The arrangement of the work is rigidly systematic, the vari- ous subjects following each other in what I conceive to be the proper order of their dependence. In one word, I have had in view the wants of the obstetric student; I have endeavored to aggregate facts, and dispense as far as possible with theoretical discussions. Throughout the work I have maintained strictly a Conservative Midwifery, as I have always done—and shall con- tinue to do—in my oral teachings in the University. It has also been my endeavor to inculcate upon the accoucheur a due reverence for the resources of nature, so that he may not thoughtlessly lapse into that too common error—" Meddlesome Midwifery." Among other things, it has been my special aim to bring the work fully up to the existing state of Obstetric Science in all its varied relations. For this purpose I have dili- gently consulted the ablest and most recent authors; at the same time, I have not been unmindful of the obligations of our science to the early Fathers. May I presume to hope that the Book, both in its matter and arrangement, will not be unaccep- table to the general practitioner, or to the Professor of Obstetrics himself? In reference to the Illustrations, I have consulted quality rather than quantity, and have in every case endeavored to make them explanatory of some important practical lesson. With this view, I have not hesitated, where it could be done with advantage, to avail myself of the graphic delineations by Maygrier, Moreau, Montgomery, and others. The engravings, representing Forceps delivery, are. the Daguerreotypes of my instnictions on this subject in the University, and I trust they may convey accurate rules for guidance on this important and interesting part of the Accoucheur's duties. PREFACE. vii In order to facilitate the object of the reader, and place promptly within his reach the numerous subjects discussed in the volume, a Table of Contents, and, in addition, a full and carefully prepared Alphabetical Index have been provided. I have also added a list of authors to whom reference has been made, and this will give some indication of the labor expended on the work. The Book itself embodies ample internal evidence of failure or success in the accomplishment of the objects proposed. If that evidence, under a fair examination, shall lead to the decision that the design has not been carried out, it will be to me a source of the deepest regret. If, on the contrary, it shall be my good fortune to have my efforts approved by the Profession, then I shall be abundantly repaid for my labor, and may, with- out arrogance, exclaim—" Nee Egofrustra." In conclusion, I cannot but cherish the hope that if this Volume should fall into the hands of some of my numerous pupils, residing in various portions of this and other countries, it may serve to awaken old associations, and bring back to memory the many happy hours we have spent together in the lecture-hall; and may these words be accepted as proof that their preceptor continues to entertain for them feelings of deep interest and afrection. New York, 06 Fifth Aventtb, Oct. \, 1861. PREFACE TO THE SECOND EDITION. An Author can covet no richer compensation for his labors than the endorsement of his Peers. It would, therefore, be affectation in me to attempt to conceal the pleasure I experience in being thus early called upon for a Preface to the Second Edition of the "Principles and Practice of Obstetrics.'1'' But a little over four months has elapsed since the book was first issued from the Press. In view of the unhappy and disturbed condition of the country, and the consequent derangement of commercial as well as of scientific pursuits, I have, indeed, good cause for self-congratulation ; and I'avail myself of this occasion to return my cordial thanks to the Profession for the counte- nance, which they have so promptly extended to my efforts. The eulogistic notices of the Medical Press—both home and foreign—have imposed upon me an obligation not soon to be forgotten—an obligation I can cancel in no other way than by the pledge, that it shall be my earnest care to endeavor to render myself still more worthy of its good opinion. The present edition has undergone a thorough revision ; numerous verbal and typographical errors, more or less incident to a first issue, have been corrected. I again submit the work to the Profession, not without hope that it may continue to have awarded to it the seal of their approbation. March, 1862. CONTENTS. LECTURE I. POSITION AND BONES OF THE PELVIS. Midwifery an Exact Science—The Passage of the Child through the Maternal Organs is fouuded on the Principle of Adjustment—The Pelvis; the Position it occupies in the Human Skeleton—Importance of its Position in Childbirth—The Direction of the Pelvis; its Variations—Bones of the Pelvis in the Adult and Foetus—Sacrum, Coccyx, and the Two Innominata—Anterior Sacral Plexus of Nerves; its Influence in the Production of Numerous Pathological Phenomena— The Os Coccyx; its Importance in Childbirth—Dislocation of the Coccyx— Fracture of the Coccyx—The Spinous Process of the Ischium—How, when mal- formed, it may interfere with the Process of Delivery.........1 LECTURE II. USES, ARTICULATIONS, AXES, AND DIVISIONS OF THE PELVIS. Uses of the Pelvis—Articulations, or Joints of the Pelvis—Do these Articulations during Pregnancy become Relaxed ?—Is their separation necessary, at the time of Labor, for the passage of the Child ?—Objections to the Theory of Separation —Pathological Changes in these Articulations— Form of the Pelvis—The Greater and Lesser Pelvis—Straits of the Pelvis—The Pelvis is a Crooked Canal; Proof —Axes—Varieties of the Human Pelvis—Influence of Sex and Age—Contrast between the Male and Female Pelvis—Pelvis of the newborn Infant—The Pelvis in Connexion with the Soft Parts—Its Measurements. . .•......12 LECTURE III. DIVISIONS AND PRESENTATIONS OF FCETAL HEAD. Foetal Head; its Regions, Diameters, Circumferences, Extremities, Sutures, Fonta- nelles__Sutures of the Adult and Foetal Head contrasted—Arch and Base of Foetal Head—The former undergoes Diminution during Childbirth, the latter does not; Reasons for—Contrast between Diameters of Foetal Head and those of Maternal Pelvis—Deductions—Articulations of Foetal Head—Two Movements, Extension and Flexion—Rotation. Presentation of, Foetal Head r its relative Frequency—Presentation of Vertex—Circumstances which modify the Frequency of Head Presentations—Causes of the Frequency of Head Presentations—Differ- ence between Presentation and Position—Six Positions of the Vertex by Baude- locque—Relative Frequency of these Positions—Naegele's Division. ... 37 X CONTENTS. LECTTIIE IV. MECHANISM OF LABOR IN VERTEX PRESENTATIONS. Mechanism of Labor—Its Importance—Mechanism in the first Vertex Position— Left Occipito-acetabular—Position of the Foetus—Relations of the Head to the Pelvis—Necessity for a Change in these Relations—Movements imposed upon" the Head—Flexion, Descent, Rotation, Extension, and External Rotation—Object and Causes of these Movements—Proof that these Movements occur—Gerdy's Explanation of External Rotation—Mechanism in the Second Position—Right Occipito-acetabular—Mechanism in the Third Position—Right Posterior Occipito- iliac, the Second in Frequency, according to Naegele—Conversion of the Poste- rior Occipital into Anterior Occipital Positions—How this Conversion is accom- plished—Mechanism in the Fourth Position—Left Posterior Occipito-iliac—Ne- cessity of an accurate Knowledge of the Principles on which the Mechanism of Parturition is founded—The practical application of this 'Knowledge at the Bedside........................44 LECTURE V. DEFORMITIES OF THE PELVIS. Pelvic Deformities, how divided—Evils of Increased Capacity—Case in Illustration —Dangers of Increased Capacity during Pregnancy and Labor—Diminished Capacity—Dangers of—Varieties of Pelvic Deformities — Causes of—Rachitis, Mollities Ossium—Distortion of Spinal Column does not necessarily cause Distor- tion of Pelvis. Obstructed Labor from Polypus—Removal of Polypus, and subse- quent Delivery of Child by Forceps—Pubic Arcade—Congenital Deformity of— Craniotomy—The Space through which a Living Child can pass—Experiments of the Author—Discrepancy of Opinion among "Writers—The Space through which a Child may be extracted by Embryotomy. How to ascertain that Defor- mities exist—In the young Girl—In the married Woman. Measurements of the Pelvis—Baudelocque's Pelvimeter—How employed—Its reliabilities—Objections answered. The best Pelvimeter, the Finger of the well educated Accoucheur— The " Toucher"—How conducted. . •............57 LECTURE VI. ORGANS OF GENERATION. Organs of Generation—External Organs—The Mons Veneris, Labia Externa, Clitoris, Labia Interna, Vestibulum, Meatus Urinarius, and Urethra—Secretory Apparatus of the External Organs—Sebaceous and Muciparous Follicles—Vulvo-vaginal Gland—The Internal Organs—The Vagina, its Anterior and Posterior Relations —The Urethro-vaginal, Vesico-vaginal, and Recto-vaginal Septa—Vesico-vaginal and Recto-vaginal Fistula;—How produced—Orifice and Superior Extremity of Vagina—The Hymen, its Absence no Test of Loss of Virginity—Its Presence no Evidence that Sexual Congress has not occurred—Retention of Menses mistaken for Pregnancy—Blood-vessels and Nerves of Vagina—Uterus, LTses and Situation of—How divided—The Structure of Uterus composite—External and Internal Coat—Intermediate Tissue is Muscular—Is the Uterus an Erectile Organ ?— Rough's Researches—Blood-vessels, Nerves, and Lymphatics of Uterus—Recto- CONTENTS. XI uterine Fossa, Importance of—Ligaments of Uterus—The Cervix, its Peculiarities before and after Puberty—Os Tincse, Cicatrices upon, not always reliable as evi- dences of Childbirth—The Fallopian Tubes—The Ovaries, the Essential Organs of Generation—Structure and Uses of the Ovaries. .... ,11 LECTURE VII. MENSTRUATION. Functions of t&e Uterus and its Annexse—Essential to Health, but not to Life- Forces in the Female Economy two-fold—Proof—Uterine Organs before and after Puberty—Indications of Puberty—Menstruation—Meaning of the Term—Age at which First Menstruation occurs—Influences which Promote and Retard it—Girls in the Country contrasted with those in the City—Influence of Race on the Men- strual Function—Menstruation in young Children—Tardy Menstruation__Cause of Menstruation—Conflicting Opinions—The Menstrual Function dependent on Organic Development—Menstruation does not consist in the Discharge of Blood. but in the Maturity of the Ovules—Ovular Theory—Dr. John Powers's Claim__ Periodicity of Menstruation—How explained—Is the Menstrual Fluid an Exuda- tion, or Secretion ?—Is it Blood ?—Does it escape by Endosmosis ?—The Source of the Menstrual Discharge, and its true mode of escape—Menstrual Blood in the Uterus and Vagina—Difference between—On what the Difference is depen- dent—Duration of each Menstrual Period, and Quantity Lost—Is Menstruation peculiar to the Human Female?—General Properties of the Menstrual Dis- charge—Period of Final Cessation—Why called the Critical Period—Aptitude in the Female for Impregnation—Case of Catherine de' Medici—Early Marriages in India........................92 LECTURE VIII. REPRODUCTION. Reproduction—Its Importance and Necessity—Early Opinions concerning—Meaning of the term Fecundation ; in what it consists—Reproduction the Joint Act of both Sexes—The Female furnishes the " Germ-cell"—The Ovisac or Graafian Vesicle— Membrana Granulosa—Discus Proligerus—Zona Pellucida—Germinal Vesicle— Germinal Spot—Modifications in the Ovisac previous to its Rupture—Corpus Luteum—" Coagulum"' does not contribute to its Formation—Corpus Luteum not a Permanent Structure—True and False Corpora Lutea—Former connected with Pregnancy, Latter with Menstruation—Characteristics of each—True Corpus Luteum an Evidence of Gestation, but not of Childbirth—Can two " Germ-cells" bo contained in one Ovisac?—The Male Vivifies the " Germ-cell"—Spermatozoon, the True Fertilizing Element—What are the Spermatozoa ?—Contact between " Sperm- cell" and "Germ-cell" necessary for Fecundation—How accomplished—Opinions concerning—Aura Seminalis—Electrical and Magnetic Influence—Doctrine of the Animalculists—Chemical Hypothesis—Mr. Newport's Experiments on the Frog— Deductions—Where does this Contact take Place ?—Experiments of Bischoff and Valentin—Theory of Pouchet—Movements of Spermatozoa—Deductions from Analogy—Experiments of Nuck and Haighton—Fimbriated Extremity of Fallo- pian Tubes—Peculiarities of.................109 Xll CONTENTS. LECTURE IX. DEFINITION AND DIVISIONS OF PREGNANCY. Pregnancy; Definition and Divisions of—Is Pregnancy a Pathological Condition ?— The Uterus and Annexse before and after Fecundation—Two Orders of Pheno- mena following Impregnation; Physiological and Mechanical—How the Uterus Enlarges—Microscope and its Proofs—Development of the Muscular Tissue of the Uterus; how accomplished—Solid Bulk of Uterus at Full Term—Meckel's Esti- mate—Increase of Blood-vessels, Lymphatics, Nerves, and other Tissues of Uterus —Nausea and Vomiting; how produced—Influence of Nausea and Vomiting on Healthy Gestation ; the Explanation of this Influence—Blood—how Modified by Pregnancy—Is Plethora characteristic of Gestation ?—Cause of this Hypothesis— Treatment of Acute Diseases in Pregnancy—Aphorism of Hippocrates on this Question—Increase of Fibrin in Inflammation—Deductions—" Buffy Coat" not always the Product of Inflammatory Action—" Buffy Coat " in Chlorosis, Preg- nancy, etc.—Kiestine; what its Presence indicates—Blot's Experiments—Sugar in the Urine of the Puerperal Woman—Deductions—How are we to know that Pregnancy exists? Importance of the Question; its Medico-legal bearings; Illus- tration—The Proof of Pregnancy altogether a Question of Evidence; how this Evidence should be examined................121 LECTURE X. SIGNS OF PREGNANCY. Evidences of Gestation; how divided; their Relative and Positive Value—Suppres- sion of the Catamenia—Can a Pregnant Woman Menstruate ?—Nausea and Vomiting material to a Healthy Gestation—Depraved Longings—Salivation of Pregnancy; how distinguished from Mercurial Salivation—Salivary Glands in Connexion with the Mamm:e in the Female, and the Testes in the Male—Sym- pathy between ; Illustration—Parotitis—Mammary Changes—Secretion of Milk not always dependent upon Pregnancy—Milk in the Breast of the Virgin, and in the Male—Mammary Metastasis—-Illustration—The Areola; its Value—Color not its Essential Attribute—Deposit of Black Pigment and Excitement of the Sexual Organs—Connexion between—The True Areola; its Value—Areola around the Umbilicus—Discoloration of Integument between Umbilicus and Pubes—Dr. Montgomery's View of Areola—Can Pregnancy exist without the Areola ?—Changes in Uterus and Abdomen—First two Months of Gestation, Uterus descends into Pelvic Excavation—Consequences—Vesical Irritation— Pain and Depression of Umbilicus; how Explained—Impregnated Uterus at end of third Month —Gradual Ascent of the Organ—Right Lateral Obliquity—Pain in Right Side; how Explained—Uterus at end of eighth Month—Cough and Oppressed Breathing; Reasons for—Projection of Umbilicus; its Value as a Sign of Pregnancy—Uterus at end of ninth Month—Contrast with eighth Month —Ascent of Organ in Primipara and Multipara; Difference Explained—Bladder and Urethra; Change in Position—Thrombus of Vagina and Vulva—ffidema of Lower Extremities; how accounted for.............143 LECTURE XI. SIGNS OF PREGNANCY, CONTINUED. Evidences of Pregnancy continued—The Effect of Fecundation on Development of Uterus—Order of Development—Fundus enlarges first three Months—Body from CONTENTS. Xlll third to sixth Month—Wisdom of this Arrangement—Shape of Impregnated Uterus—Modifications of Cervix in Pregnancy—Error of certain Authors— Uterine and Vaginal Extremities of Cervix—Cervical Canal—Relaxation of Tissues of Cervix—Cervix does not Lengthen—Error of Madame Boivin—Promi- nence of Os Tineas—Softening and Moisture—Mucous Follicles—Development of —Increased Mucous Secretion not a Pathological State—Uses of this Secretion— Cervix begins to shorten at its Uterine, and not at the Vaginal Extremity— Proof—Opinions of Stoltz and Cazeaux—Placenta Praevia and Shortening of Cer- vix—Modifications of Cervix in Primipara and Multipara—Increased Development of Uterine Appendages in Pregnancy—How does the Cavity of the Uterus enlarge?—Ancient Theory—Increased Nutrition the true Cause—Thickness of Uterine Walls: Opinions respecting—Os Uteri at Time of Labor—Discoloration of Vagina as a sign of Pregnancy—Is this Discoloration peculiar to Preg- nancy? .......................163 LECTURE XII. QUICKENING, BALLOTTEMENT, AND PLACENTAL SOUFFLE. Evidences of Pregnancy continued—Quickening—Ancient Theory—Law of England in regard to Quickening—What is Quickening ?—Opinions of Authors—Nervous and Muscular Development—Muscular Contractions of the Foetus—Sensible and Insensible Muscular Contractions—Quickening not a Psychical Act, but the result of Excito-motory Influence—Spinal System—Its Physiological Importance— When does Quickening take Place ?—Does not always Occur—Delusive Quickening —Illustration—Contraction of Abdominal Walls mistaken for—Final Cessation of Menses and Supposed Quickening—Attempted Imposition—Queen Mary of Eng- land—Manipulations to Detect Quickening—Influence of Cold on Movements of Foetus—Illustration—Ballottement or Passive Movement of Foetus—Rules for Detecting—Positions of Foetus and Ballottement—Pulsations of Foetal Heart— Auscultation—Mayor of Geneva—Average Beats of Foetal Heart—Not Synchro- nous with Maternal Pulse—Auscultation, how Applied—Auscultation and Position of Foetus—Twin and Extra-uterine Pregnancies—How ascertained—Placental Souffle—Uterine Murmur—Kergaradec—Conflict of Opinions—Souffle not always Dependent upon Pregnancy—Uterine and Abdominal Tumors; Cause of—Souffle no Evidence of Life of Foetus—Pulsations of Umbilical Cord—Dr. Evory Ken- nedy.........................175 LECTURE XIII EXAMINATION OF THE FEMALE. Examination of the Female to Ascertain the Existence of Pregnancy—The Three Senses, Feeling, Seeing, and Hearing, to be employed—The "Toucher;" what is it?__External Abdominal Examination; its Objects; how to be conducted—Va- rious Causes of Uterine Enlargement; how to be distinguished—Examination per Va<*inam; Rules for—The Vagina; its Position and Relations—Position of the Female__Relation of the Vagina to the Cervix Uteri—Examination per Anum ; when indicated—Retro-Version of Uterus—Prolapsion of Ovary into Triangular Fossa—Vaginal Ovariotomy—Auscultation—The Metroscope; its Uses. . 192 XIV CONTENTS. LECTURE XIV. EXTRA-UTERINE PREGNANCY. Extra-uterine Pregnancy; its Varieties—Ovarian, Fallopian, Abdominal, and Interstitial—Characteristics of each Variety—Causes of Extra-uterine Pregnan- cy—Opinion of Astruc—Objections—Progress and Phenomena of Extra-uterine Pregnancy—Placenta and Membranes; the Germ inclosed in a Cyst—Exponent of the Uterus ; Cyst; how formed—Cyst affords no Outlet for Foetus—Rupture of Cyst from Increased Growth of Foetus—Hemorrhage; how Produced—Enlarge- ment of Uterus—Extra-uterine Fcetation rarely extends to the Fifth Month— Exceptional Cases—Secondary Cyst; how Formed—Signs of Extra-uterine Fcetation—Areola and Tumefactiou of Breasts—Illustration—Active Movement of Foetus; Cardiac Pulsations—Malpositions of Uterus from Position of Cyst;— Intermittent Pain in Extra-uterine Gestation—Dangers of this Variety of Gesta- tion—Hemorrhage from Rupture of Cyst—Peritoneal Inflammation—Termina- tions of Extra-uterine Pregnancy; Treatment—Gastrotomy; when Performed— Gastrotomy and Caesarean Section—Fearful Hemorrhage in the Former; why— Section of Vagina—Elimination of Foetus; how aided........203 LECTURE XV. THE OCCASIONAL DERANGEMENTS ACCOMPANYING PREGNANCY. Pregnancy, although not a Pathological State, is occasionally subject to Derange- ments—These Derangements are both Physiological and Mechanical; Illustration— Dogmatical Doctrines of the Ancients in regard to the Therapeutics of Pregnancy— Bloodletting in Pregnancy; when Indicated—Cathartics and Emetics; are they admissible?—Nausea and Vomiting; how Treated—When Excessive—Ptyalism— Constipation—How Constipation is caused in the Pregnant Female; in part through Morbid Nervous Influence; in part from Mechanical Pressure—Diarrhoea; its Dangers—Palpitation of the Heart and Syncope—Larcher's Opinion respecting Hypertrophy of the Heart—Pain in the Abdomiual Muscles ; how Treated—Pain- ful Mammae—Pain in the Right Hypochondrium—Pruritus of the Vulva; Hemor- rhoids; how Produced—Varicose Veins—Cough and Oppressed Breathing. . 216 LECTURE XVI. DISPLACEMENTS OF UTERUS IN PREGNANCY. Complications of Pregnancy from Displacements of the Uterus—Prolapsion, Ante- version and Retro-version of the Organ—Three Varieties of Prolapsion—Evils and Treatment of these Varieties—How Direction of the Urethra is Modified—Rules for Introduction of Catheter—Ante-version, Symptoms and Treatment of—Retro- version more frequent than Ante-version—Complete Retro-version occurs only during earlier Months of Gestation—Occasional Serious Consequences of this Form of Displacement—Premature Labor sometimes the Result of Retro-version__Diag- nosis of Retro-version—How determined—Symptoms—Retention of Urine__Punc- ture of Bladder, first proposed by Sabatier—Treatment of Retro-version—Plan of Evrat, Halpin, and Gariel—Retro-version often mistaken for other Pathological Conditions—Prolapsion of Ovary in Triangular Fossa, and Faeces in the Rectum__ How distinguished from Retro-version—Hernia of Gravid Uterus.....2.32 CONTENTS. XV LECTURE XVII. PLACENTA AND ANNEX.E OF FOETCS. The Annexaa of the Foetus; The Decidua—Hunter's Theory of its Formation; The Decidua, an Hypertrophied Condition of the Uterine Mucous Membrane—The Reflexa; how formed—Coste's Views—Uses of the Decidua—The Chorion and its Villi—The Uses of each—Nourishment of the Embryo through the Villi— Professor Goodsir—The Amnion; its Uses—The Liquor Amnii: Origin of—Is it derived from Mother or Foetus?—Casts of the Uriniferous Tubes found in Liquor Amnii—Uses of Liquor Amnii—Various—Does it contribute to Nourish- ment of Foetus?—The Placenta—Peculiar to the Mammiferous Class—How Divided, and Dimensions of—Two Circulations in Placenta—Distinct and Inde- pendent—Red Corpuscles—Difference in Size of in Foetal and Maternal Blood— When does Placenta begin to Form ?—What is the Connexion between Placenta and Uterus ?—Do the Blood-vessels of the Mother penetrate the Placenta ?— Hunter's Opinion confirmed by Dr. Rcid and Professor Goodsir—Professor Dalton, his Injection of the Utero-Placental Vessels by Air—Fatty Degeneration of the Placenta/—Is it Normal or Pathological?—The Umbilical Cord ; how Composed— Its Uses—Nomenclature of the Anatomist and Physiologist—Difference between— Variations in Volume and Length of the Cord—Twisting of the Cord around the Foetus—Dr. Weidemann's Statistics of—Does the Cord possess any Trace of Nervous Tissue—Dr. Simpson on Contractility of the Cord—Scanzoni's Opinion— Virchow........ ...............241 LECTURE XVIII. NUTRITION, GROWTH, AND DEVELOPMENT OF FCETUS. Nutrition, a fundamental law of life—Objects of Nutrition; Growth and Develop- ment—Development physiologically considered—Nutrition of Embryo; various Opinions concerning—Yolk Nutrition—Nutrition through Villous Tufts—Liquor Amnii; has it nutrient properties?—Does it enter the System of the Foetus by Cutaneous Absorption or Deglutition?—The Placenta and Foetal Circulation— Adult Circulation ; how it differs from that of the Foetus—How is the Impure Blood, returned by the Umbilical Arteries, decarbonized in the Placenta?—Endos- mose Action—Albumen cannot pass by Endosmosis; Opinion of Mjalhe—Albu- minose—Influence of Parent upon Progeny—Transmission of Hereditary Disease— Change in the Circulation as soon as Respiration is established—Puer Ca?ruleus— Does the Foetus Breathe in Utero?—Intra-uteririe Respiration not Essential to Development or Life of Foetus................254 LECTURE XIX. ABORTION. Abortion—Its frequency—Loss occasioned by it to the Human Family—Dr. White- head's Statistics—The Various Divisions of Abortion—Viability of the Foetus— The Case of Fortunio Liceti—At what Period of Gestation is a Female most likely to Abort?—The Opinion of Madame La Chapelle—Not sustained by general Facts—Abortion more frequent in the Primipara—Why ?—Reflex Action —Whylt—Reid—Prochaska—Marshall Hall—Concentric and Eccentric Nervous XVI CONTENTS. Influence—What does it mean ?—Eccentric Causes of Abortion—Hemorrhoids, Strangury, Tenesmus, Sea-bathing, etc.—How do they Produce Abortion ?—Irrita- tion of the Mammae and Premature Action of the Uterus—Cause and Effect— How explained—Lactation, its influence on early Contractions of the Uterus- Centric Causes of Abortion—Anaemia and Abortion—Exsanguification and Con- vulsions—Experiments of Sir Charles Bell and Marshall Hall—Experiments and" Deductions of Dr. E. Brown-Sequard—Mental Emotions, Syphilitic Taint, Death of the Foetus, all Causes of Abortiou—Disease of the Placenta and Abortion- Abortion sometimes the Result of Habit—Phenomena of Expulsion in Abortion —The Pain and Hemorrhage of Abortion—How distinguished—Treatment- How divided—The Application of Cold—Its Mode of Action in Arresting Hemorrhage—Tampon and Ergot—When to be Employed—Two-fold Action of Tampon.—Extracting Placenta in Abortion—Exhaustion from Hemorrhage— How Treated—Laudanum, its Efficacy in Exhaustion........266 LECTURE XX. MOLAR PREGNANCY. Moles—Importance of the Subject—Moles variously Classified—Mauriceau's Defini- tion—The Opinion of Fernel—Practical Division of Moles—The True Mole always a Proof of Previous Gestation—Distinction between True and False Mole first made by Cruveilhier—Mettenheimer and Paget on True Mole—Dr. Graily Hewitt —Case in Illustration of a True Mole—Can a Married Woman, if separated from her Husband since the Birth of her Child, or can a Widow, Discharge a True Mole from the Uterus consistently with her Fidelity?—False Moles, what are they ?—Substances expelled from the Womb of the Young Virgin—Fibrinous Clots—The Membrane of Congestive Dysmenorrhcea—The Hen lays an Egg without the Tread of the Cock—Does the Membrana Decidua pass off at each Menstrual Period, or is it simply the Epithelial Covering?—The Testimony of Lamsweerde, Ruysch, and Van Swieten as to the False Mole—The True Hyda- tids—Can they be produced in the Virgin Uterus?—The Case cited by Rokitan- sky—Importance of the Question—How are the True Hydatids to be distin- guished from the Hydatiform Vesicle ?.............283 LECTURE XXI. LABOR AND DURATION OF PREGNANCY. Labor—Multiplied and Unprofitable Divisions of; Classification of the Author into Natural and Preternatural; Labor consists of a series of acts—Important Practi- cal Deduction connected with this Succession of Phenomena; Duration of Preg- nancy—When does it Terminate ?—The Original Mode of Calculating Time; Calen- dar and Lunar Months—Has Pregnancy a Fixed Duration?__The Gardner Peerage Case—Conflicting Opinions; Testimony of Desormeaux__The Code Na- poleon in reference to Tardy and Premature Births; Experiments of Tessier ■ Tropical Heat and Vegetation—How is the Period of Pregnancy to be ascer- tained ?—The various Modes of Calculation—Dr. Reid's Experiments in reference to a Single Coitus ; Naegele's Opinion ; Dr. Clay, of Manchester—Influence of the Age of the Parent on the Duration of Pregnancy—Can a Female be Fecundated during her Menstrual Period ?—Case in Illustration.........2lJ6 CONTENTS. XVII LECTURE XXII. DETERMINING CAUSE OF LABOR. Determining Cause of Labor—Meaning of the Term ; The Expulsive Forces—pri- mary and secondary; Determining Cause referred by some to the Foetus, by others to the Uterus; Opinion of Buffon with regard to the agency of the Foetus; Ancient Doctrines; Uterus the true Seat of the Determining Cause of Parturi- tion ; Antagonism between Muscular Fibres of Body and Neck of Uterus ; Change in Structure of Decidua and Placenta, as alleged by Prof. Simpson; Haller's Theory of the Decadence of the Placenta; Objections to the Theory; Dr. Brown- SSquard's Theory—Carbonic Acid the Stimulant to Muscular Contraction ; The Doctrine of Ovarian Nisus, as propounded by Carus, Mende, and Dr. Tyler Smith; Objections to the Doctrine; Is Menstruation Peculiar to the Human Female? The Theory of Dr. John Power, adopted by Paul Dubois, of Paris; Objections to the Theory; Explanation of the Author as to the Determining Cause of Labor; Modifications in Structure of Uterus at Close of Gestation ; Peristaltic Movement of Uterine Muscular Fibre; Inherent Contractions; These Inherent Contractions independent of Nervous Force—Proof; Connexion between Inherent Contractions and Matured Development of Muscular Structure of Uterus; Irritability of Muscular Tissue of Uterus increases as Pregnancy advances— Deductions from this Fact; Modifications' in Structure of Uterus after Child-birth; Diminution of Musculo-fibre Cells; Flatty Degeneration, a Natural Change in certain Structures after they have completed their Functional Activity—sometimes a Pathological Result...................309 LECTURE XXIII. EXPULSIVE FORCES IN PARTURITION. Seat and Origin of the Expulsive Forces in Parturition—How these Forces are Modified—Spinal Cord—Its Influence—Parturition in part an Excito-motory Act— Excitors of Reflex Action in the Uterus—What are they ?—Difference in Uterine Contraction due to Inherent Irritability and Nervous Force—What is it that causes the Diaphragm and Abdominal Muscles to Contract as a Secondary Aid in La- bor?—The Contraction of these Muscles is not always an Act of Volition ; it is sometimes Reflex—Signs of Labor—Importance of—The Signs of Labor divided into Preliminary and Essential, or Characteristic—What are the Preliminary ?— What the Essential Signs?—Labor Pain; how Divided?—Is Pain the Necessary Accompaniment of Parturition ?—What is the true Explanation of Labor Pain ?— Is it identical with Uterine Contraction, or is it the Result of Contraction ?— Change in the Physical Condition of the Uterine Muscular Fibre under Contrac- tion ; Deduction—True and False Labor Pain ; how Discriminated—Dilatation of Os Uteri; how Produced—Rigors and Vomiting during Dilatation; What do they Portend?—The Muco-Sanguineous Discharge during Labor; how Pro- duced—Formation and Rupture of the "Bag of Waters;" how the Formation is Accomplished—Uses of the " Bag of Waters " during Childbirth—Caution against its Premature Rupture—The "Caul or Hood;" What does it mean? . . . 321 LECTURE XXIV. NATURAL LABOR. Natural Labor: Conditions for—What is required on the part of the Mother; what on the part of the Foetus—Hippocrates and Head Presentations in Natural Labor; B xviii CONTENTS. Fallacy of his Opinion—Face Presentations in Natural Labor; Mechanism of— Diagnosis of Face Presentations ; may be Confounded with Presentations of the Breech-Face Presentations in Dublin Lying-in Hospital-Error of Wnters with regard to Version and Forceps Delivery m Face Presentations-Presentation ot the Pelvic Extremities; the Breech, Feet, and Knees-Opinion of Hippocrates; his Direction for bringing down the Head in these Presentations-The Practice of A. Petit, Bounder, and others—Presentation of the Pelvic Extremities and .Natu- ral Labor-Dr. Churchill's Statistics-Statistics of Dr. Collins; Deduction-Dr. Hunter on Management of Breech Presentations-Diagnosis of these Presenta- tions; may be Confounded with those of the Shoulder; Prognosis—Are Breech Presentations necessarily Destructive to the Child?—Do they in any way Com- promise the Safety of the Mother?—Mechanism of Breech Presentations—Pre- sentation of the Feet; Diagnosis and Mechanism of—Presentation of the Knees; Diagnosis and Mechanism of.................33" LECTURE XXV. DUTIES OF THE ACCOUCHEUR IN NATURAL LABOR. The young Accoucheur's Debut in the Lying-in Chamber—What he is to do, and what he is not to do; his Chat with the Nurse—The Examination per Vaginam ; how it is conducted, and what it should reveal—Is the Patient Pregnant?—Is she actually in Labor ?—Are the Pelvis and Soft Parts Normal or otherwise ? A Woman may imagine herself in Labor, and yet not be Pregnant; Illustration— What is the Presentation of the Foetus?—Is it Natural or Preternatural?—What will be the Duration of the Labor ?—How this question is to be answered— When Labor has commenced, the Bowels and Bladder to be attended to—Quietude of the Lying-in Woman important; Loquacity of the Nurse—The Stages of Labor; what are they?—Conduct of the Accoucheur during each of these Stages —After the Escape of the Head, Rule to be followed—When the entire Expul- sion of the Foetus is completed, important rule to be observed—How many Liga- tures are to be applied to the Cord ?—The Author recommends but one—Reasons for—Trismus Nascentium, and Inflammation of the Umbilical Vessels ; Scholer's Opinion—When the Child is separated from the Mother, what is to be done ?— Respiration of the Infant; Causes which Impede it—Asphyxia; Causes of— Treatment of Asphyxia—Marshall Hall's Method—Ability to resist Asphyxia greater in the New-Born Infant than in the Adult—The Opinion of Bracliet, of Lyons, Josat, and others, as to the Restoration of Life some time after the Pulsa- tions of the Heart have ceased—Death of the Mother not necessarily Fatal to Foetus in Utero; Why?—Brown-Sequard's Experiments.......351 LECTURE XXVI. MANAGEMENT OF THE PLACENTA. The Third Stage of Lulior; Expulsion of tli.». Placenta—Mismanagement of Pla- centa—Dangers of—Function of Placenta, limited to a Certain Period—Natural Detachment of Placenta; HoW effected—What are the Evidences that the Detachment is going on? What that it is Accomplished?—The Mode of Extract- ing the Mass after its Separation from the Uterus—Rule to be observed after its Removal—Retained Coagulum and Puerperal Convulsions ; Case in Illustration__ After Extraction of Placenta, it should be carefully Examined—Retained Frag- CONTENTS. Xix ments of After-birth and Irritative Fever—Tractions on Umbilical Cord before Separation of the Placenta—Dangers of—How Detachment of Placenta is to be Aided when Uterus is Lethargic—Circumstances rendering it necessary to ex- tract After-Birth—Its excessive Volume—Spasm of the Os Uteri—Hour-glass Contraction—Morbid Adhesion—Convulsions—Hemorrhage—Opium and Bella- donna ; Difference in their Therapeutic Effects—How long after Delivery of the Child should the Extraction of the After-Birth be Delayed when there is no Com- plication ?—Permanent Retention of the Placenta, and Decomposition of the Mass —Does the Retained Placenta ever become Absorbed ?—Convulsions supervening on Retained Placenta; The Indication to be Fulfilled—Convulsions in this Case are Traceable to Irritation of the Uterus, and are of Eccentric Origin. . . 372 LECTURE XXVII. POST-PARTUM HEMORRHAGE. Management of Placenta in Flooding after the Birth of Child—Frequency and Morta- lity of Flooding—Statistics—Dangers of Post-partum Hemorrhage—What is Post- partum Hemorrhage, and how produced ?—How is this form of Flooding divided? —External and Internal Flooding—Causes and Diagnosis of External Hemor- rhage ; how distinguished from Internal—Duty of the Accoucheur the instant the Child has escaped through the Vulva—Treatment of External Hemorrhage; the entire object is to produce Uterine Contraction—How is this to be accom- plished ?—Ergot not to be relied on as a Heroic Remedy in Perilous Flooding— Why ?—The Tampon; objection to its use in Post-partum Hemorrhage—Pressure and Cold the two Reliable Remedies in Uterine Hemorrhage—the Cold Dash; action of—A small piece of Ice introduced into the Vagina; its reflex influence— Mammae and Uterus—Sympathy between and Deductions from—Pressure of the Abdominal Aorta—Electricity as a Remedy in Hemorrhage; Objections to— Injections of Vinegar, Lemon-juice, etc., into Vagina, bad practice—Internal Ute- rine Hemorrhage; how treated—Cephalalgia from Profuse Losses of Blood; how treated; how distinguished from Phrenitis—Transfusion as an Alternative after Excessive Hemorrhage—Dr. Blundell first to resort to it in the Puerperal Woman —Average Success of the Operation—Prof. Edward Martin, of Berlin—How does Transfusion accomplish Reaction ?—Is it by the Quantity of Blood transfused, or by stimulating the Walls of the Vessels and Heart ?—Brown-Sequard's Expe- riments ; Deductions from—Secondary Post-partum Hemorrhage; what does it - mean ?—Treatment of Secondary Hemorrhage...........388 LECTURE XXVIII. TREATMENT OF THE PUERPERAL WOMAN, AND NEW-BORN INFANT. Management of the Puerperal Woman and her infant, during the Month—Applica- tion of the Binder; rules for—Object of the Binder; napkin to the vulva—Stimu- lants not to be administered to the newly delivered Woman; why?—Ablution of the infant: rules for—Dressing of the Umbilical Cord—Examination of Infant to ascertain Existence or not of Deformity—Toilet of the Child; pins not to be used —After-pains; how managed—Anodynes and Individual Idiosyncrasies—Bed. pan; motives for its use—Physicking and Cramming the Infant; Objections to— Argument from Analogy—When should the Child be put to the Breast ?—Colos- trum ; uses of Meconium—A Flat Nipple; how remedied—First Visit after deli- XX CONTENTS. very ; when to be made—What the Accoucheur is to do at this Visit—Retention of Urine; how managed—Retention and Suppression ; difference between—The Catheter; mode of introduction—Obstacles to Passage of the Catheter; what are they?—Incontinence of Urine; causes of—Vesico-vaginal, and Urethro-vaginal Fistulas—the Lochial Discharge; what it is; derangement of—When Infant can- not take the breast, how to be Nourished—Substitute for the Colostrum—Reten- tion of Urine in Infant; causes of; Milk in Breasts of new-born Infants—Gubler's Observations—Milk Fever—Blot's Researches on Diminution of Pulse in Milk Fever —Constipation of Infant; causes of—Occlusion of Anus; how managed—Puru- lent Ophthalmia; causes of—Sore Nipples—Mammary Abscess—Paraplegia; causes of in recently delivered women—Sloughing of Umbilical Cord—Pain in Uterus when Child is put to the Breast; Explanation of........404 LECTURE XXIX. MULTIPLE PREGNANCY, AND SUPERFCETATION. Multiple Pregnancy; relative frequency of; mortality of—Hypothesis in Explana- tion of Multiple Gestation—Plural Births apt to occur in certain Families—Sign8 of a Twin Pregnancy; their value—Twin labor not necessarily Preternatural; how managed—Presentation of the Foetuses—When one Child is born, should the Mother be told there is another in Utero ?—Delivery of the Placenta after the Birth of the first Child—Rules for Delivery of Second Child—Discre- pancy of Opinion among Authors—Interesting Twin Case; exhibiting extraordi- nary peculiarities—Can a Twin Gestation exist with only one Amnion ?—Super- foetation ; meaning of the term—The Possibility of Super-foetation generally con- ceded by the early Writers; not so with the men of our own times—The Case cited by Buffon—The Case in the Brazils, by Dr. Lopez—Is Super-fcetation possible in Animals; Illustration—Can a Woman simultaneously carry a Uterine and Extra- uterine Foetus ?—Super-foetation in a Double Uterus; the instance recorded in the Encyclographie Medicale—Objections to Super-foetation examined—the Mucous Plug; is it an obstacle to a second fecundation ?—The Mucous Plug in Cervical Canal of the Pregnant and Unimpregnated Female; is there any difference between ?—Demonstrations of the Microscope—The Membrana Decidua; does it prevent the entrance of the Spermatozoon into the impregnated uterus ?—Moral Considerations involved in the Question of Super-foetation.......431 LECTURE XXX. INVERSION OF THE UTERUS. Inversion of the Uterus—Often connected with Mismanagement of Placenta__Can Inversion occur in the Unimpregnated Woman ?—Causes of Inversion__What are they ?—Inversion most frequently the result of Carelessness or Ignorance__Dublin Lying-in Hospital Statistics—Inversion Complete or Incomplete__Diagnosis of each—Chronic Inversion, confounded with Prolapsus, Procidentia, and Polypus__ How to be Distinguished—Treatment of Inversion when either Complete or In- complete—Does an Inverted Womb ever become Spontaneously Restored ?__The case of Spontaneous Restoration cited by Baudelocque—In Chronic Inversion when the Organ cannot be replaced, is Extirpation of the Uterus Justifiable ?__ Importance of the Question—The Records of Successful Extirpation—Case of Mal- practice in which an Inverted Uterus was forcibly torn from the Person of the Patient, having been mistaken for the Placenta...........446 CONTENTS. XXI LECTURE XXXI. PRETERNATURAL LABOR, PLACENTA PREVIA, UNAVOIDABLE HE- MORRHAGE. Preternatural Labor, divided into Manual and Instrumental—Causes of Manual Labor—Malposition of the Foetus—How may the Foetus be Malposed?—Exhaus- tion, how Divided—Positive and Relative Exhaustion—Importance of the Dis- tinction—Diagnosis of the two kinds of Exhaustion—Hernia, as a cause of Manual Labor—Prolapsion of the Umbilical Cord; Relative Frequency of—Extremely Destructive to the Child, but not to the Mother—Predisposing Causes of Prolap- sion—Diagnosis of Prolapsion—How is the Death of the Child occasioned in Pro- lapsion ?—Is it the Coagulation of the Blood in the Descended Portion of the Cord ?—Is the Arrest of the Circulation in the Cord a positive Proof of the Child's Death?—Dr. Arneth, of Vienna; his Cases—At what period of Labor does Pro- lapsion occur ?—Treatment of Prolapsion; on what it depends—Various Contri- vances for Reposition of the Cord; their Value—Mode of replacing Cord in Vienna Hospital—Postural Treatment, as recommended by Dr. Thomas. Hemor- rhage, as a Cause of Manual Labor—Placenta Praevia and Ante-partum Hemor- rhage—The Earlier Writers; their views of Placenta Praevia—Connexion between Placenta Praevia and Hemorrhage—Unavoidable Hemorrhage. Placenta Praevia; Symptoms of—Diagnosis—Treatment of Placenta Praevia before and at the time of Labor—The Tampon; when to be employed—Benefits and Dangers of the Tampon—Version in Placenta Praevia; Rules for—Dr. Simpson and Entire Arti- ficial Detachment of Placenta; Objections to—Dr. Barnes and Partial Artificial Detachment.—Ergot in Placenta Praevia; Abuse of; when to be employed—Rup- ture of the Membranous Sac in Placenta Praevia; is it useful or otherwise ?— Accidental Hemorrhage; how it differs from Unavoidable Hemorrhage—The Pathology and Causes of Accidental Hemorrhage—Dr. Robert Lee, and a Short Cord as a Cause—Treatment of Accidental Hemorrhage during Pregnancy, and at the time of Labor.....................457 LECTURE XXXII. PUERPERAL CONVULSIONS—ECCENTRIC. Puerperal Convulsions, the different periods of their Occurrence—Muscular Action, on what is it dependent ?—Nervous Disturbance, Centric and Eccentric—Causes of Eccentric Disturbance—Modus Operandi of these Causes—Treatment of Eccen- tric Convulsions oftentimes empirical—Cases in Illustration—Irritation of Uterus as a Cause of Puerperal Convulsions during Pregnancy, at Time of Labor, and sub- sequent to Deliver}'—Convulsions during Pregnancy more frequent in the Primi- para; why ?—Period of Life at which Convulsions are most apt to occur—Blood- letting and Opium oftentimes routine in Treatment of Convulsions; just Distinc- tions essential—Opium, when a Stimulant, and when a Sedative—Fatality of Stereotyped Practice—Excessive Blood-letting; how it produces Convulsions- Treatment of Convulsions based upon their special Cause—Sulphuric Ether as a Therapeutic Agent—Convulsions and Head Presentations; relation of—Artificial Delivery, when indicated in Convulsions—Divisions of Convulsive Diseases; Epi- leptic, Hysteric, Cataleptic, Tetanic, etc.; how distinguished—Hysteria much more frequent in earlier months of Pregnancy—Symptoms, Diagnosis, and Prognosis of Puerperal Convulsions...................485 XXU CONTENTS. LECTURE XXXIII. TUERPERAL CONVULSIONS—CENTRIC. Puerperal Convulsions continued—Their Centric Causes; divided into Psychical and Physical; how distinguished. Toxemia, or Blood-poisoning—Albuminuria, its Re- lations to Convulsions—Causes of Albuminuria—Ed. Robin's Theory not sustained —A Change in the Composition of the Blood a Cause—Illustrations and Proofs- Secretion, its Objects—A Change in the Kidney, Structural or Dynamic, a Cause of Albuminuria; Proofs—Pressure on the Renal Veins a Cause—Illustration—Albu- minuria more frequent in the Primipara; why?—Is Albuminuria a necessary Result of Diseased Kidney ?—Does it always exist in Pregnancy ?—Uraemia, what is it?—Dr. CarlBraun and Urasmic Intoxication— Is Albuminuria always followed by Uraemia ?—Is Urea a Poison?—Carbonate of Ammonia and Urea—Frerichs's Theory—Orfila's Experiments with Carbonate of Ammonia on Animals; Result- Treatment of Uraemia, on what it should be based—Therapeutic Indications—Col- chicum Autumnale and Guaiacum as Remedial Agents—Dr. Imbert Goubeyre and Bright's Disease in connexion with Albuminuria—Anaesthetics in Uraemia. . 504 LECTURE XXXIV. MANUAL LABOR--DIVISIONS OF VERSION. Manual Labor—Version, divided into Cephalic, Podalic, Pelvic, and Version by Ex- ternal Manipulation—Diagnosis of Manual Labor; important that it should be made early—Prognosis, how it varies—Indications of Manual Delivery; in what they consist—Time most suitable for Termination of Manual Delivery—Undilated Os Uteri, means of overcoming—Mode of Terminating Manual Delivery; the various Rules to be observed—Divisions of Manual Delivery—Rules for correcting Malpositions of the Head—What are these Malpositions, and how do they Ob- struct the Mechanism of Labor?...............516 LECTURE XXXV. RULES FOR PODALIC, PELVIC, AND CEPHALIC VERSION. Manual Labor continued—Certain Complications of Labor rendering Manual Inter- ference necessary—What are these Complications?—Podalic Version, or Turning by the Feet—Rules for Podalic Version—Should one or both Feet be seized ?— Manner of Delivering the Child after the Feet have been brought to the Superior Strait—Rules for Extracting the Shoulders—Rules for Extracting the Head- Appalling Consequences of Ignorance—Case in Illustration—Pelvic Version— Cephalic Version by Internal Manipulation—Cephalic Version by External Manipulation—Prerequisites for its Performance—Mattei and his Views • Objec- tions to—Version in Cases of Pelvic Deformity, recommended by Denman__Prof. Simpson's advocacy of Version in Deformed Pelvis—Examination of his Opinion- Objections to Version in these Cases..............530 LECTURE XXXVI. MANUAL LABOR IN BREECH, KNEES, AND FEET PRESENTATIONS. Manual Delivery continued—Presentation of the Breech, Knees, and Feet; Manual Delivery in—The Indications in these Pelvic Presentations—Malpositions of the CONTENTS. XXU1 Pelvic Extremities—Excessive Size of the Breech ; how managed—Presentation of the Pelvic Extremities complicated with Hemorrhage, Exhaustion, Convul- sions—The Management of Pelvic Presentations in Inertia of the Womb—Iner- tia, how divided—Inertia from Constitutional and Local Causes—Importance of ., the Distinction in a Therapeutical Sense—Blood-letting in Inertia, when to be employed—Ergot, when indicated...............547 LECTURE XXXVII. MANUAL LABOR IN TRUNK PRESENTATIONS ; SPONTANEOUS EVO- LUTION. ' Manual Delivery continued—Trunk or Transverse Presentations, including the Abdomen, Chest, Back, and Sides of the Foetus—Presentation of the Abdomen : its Diagnosis and Treatment—Presentation of the Chest, Back, and Sides; how Managed—Shoulder Presentation with or without Protrusion of the Arm—Treat- ment of—Management of these Cases by the Ancients, barbarous and destructive to the Child, because founded upon Ignorance of the Mechanism of Labor—Their Management, Philosophic and Conservative in our Times—Spontaneous Evolu- tion—Meaning of the Term—Divided into Cephalic and Pelvic—Comparative Rarity of Spontaneous Evolution—Statistics by Dr. Riecke—Statistics of Dublin Lying-in Hospital—Fearful Fatality to the Child in Spontaneous Evolution—Dr. Denman's Exposition of the Manner in which the Evolution is performed, shown to be Erroneous by Dr. Douglass, of Dublin—Spontaneous Evolution not to be relied upon when Artificial Delivery is indicated..........555 LECTURE XXXVIII. INSTRUMENTAL DELIVERY--BLUNT INSTRUMENTS, FORCEPS. Instrumental Delivery—Instruments divided into Blunt and Cutting—Blunt Instru- ments—What are they?—The Fillet and its Uses—The Blunt Hook and Vectis; their Uses—The Forceps—The Abuse of Instruments in Midwifery—Their too General and Indiscriminate Employment—Tlie Object of the Forceps—The For- ceps an Instrument for both Mother and Child—Abuse of the Forceps—Case in Illustration—The Forceps a Precious Resource when employed with Judgment— Statistics of Forceps Delivery—What is the true Power of the Forceps?—Is it a Tractor or Compressor?—The Forceps a Substitute for, or an Aid to, Uterine Effort—To what Part of the Child should the Instrument be applied?—The Advantages and Evils of the Forceps—How is the Head of the Child to be Grasped by the Instrument ?—Modification of the Forceps—Its Cranial and Pelvic Curves—The Author's Forceps—Indications for the Use of the Forceps—Time of Employing the Instrument—The Opinions of Denman, Merriman, and others— Objections to—The Justification of Forceps Delivery, a Question of Evidence to be Determined by the sound Judgment of the Accoucheur......565 LECTURE XXXIX. FORCEPS DELIVERY, CONTINUED. Forceps Delivery continued—Rules for the Application of the Forceps—Tlie instru- ment may be employed when the Head is at the Inferior Strait, in the Pelvic XXIV CONTENTS. Cavity, or at the Superior Strait—The Head at the Outlet, with the Occiput toward the Pubes, and the Face in the Concavity of the Sacrum—The Head at the Outlet in a Reverse t'o-ition— The Head in the Pelvic Cavity diagonally, the Occiput regarding the Left Lateral Portion of the Pelvis, the Face at tlie opposite Sacro-iliac Symphysis—The Head in the Pelvic Cavity diagonally, with the Occi- put at the Right Lateral Portion of the Pelvis, and the Face at the opposite Sacro iliac Symphysis—The Head in the Pelvic Cavity in Positions the reverse of the two preceding—Application of the Forceps, the Head being at the Superior Strait —Positions of the Head at this Strait—Difficulties of Forceps Delivery when the Head is at the Upper Strait—Version, in such case, preferable—Case in Illustra- tion—Rules for Forceps Delivery, the Head being at the Superior Strait—Locked- Head—What does it mean ?—Want of Concurrence among Authors as to what Locked-Head is—Is Locked-Head of Frequent Occurrence ?—Campers Opinion— Dangers of Locked-Head to the Child and Mother—Under what Circumstan- ces may Locked-Head occur?—Application of the Forceps in Locked-Head— Rules for.......................585 LECTURE XL. FORCEPS DELIVERY, CONTINUED. Forceps Delivery continued—Use of the Instrument when the Head is retained after the Expulsion of the Body—Circumstances justifying the Forceps in these Cases—Application of the Instrument, the Head at the Inferior Strait, with the Occiput at the Symphysis Pubis, the Face in the Concavity of the Sacrum— Application in a reverse Position—When the Occiput is at the Left and Front of the Pelvis—The Occiput at the Right and Front of the Pelvis—Use of the Instru- ment, the Head resting at the Superior Strait—The Forceps in Face Presenta- tions—Under what Circumstances indicated—Practice of the Old Schoolmen in Face Presentations—Objections to—When Version is to be Preferred to Forceps Delivery in Face Presentations—The Manner in which the F'aee usually presents at the Superior Strait—Right Mento-iliac Position—Left Mento-iliac Position— Mode of Descent in these Positions—Manner and Difficulty of applying the For- ceps in Face Presentations at the Superior Strait—Use of the Instrument when the Face is at the Inferior Strait—Mento-anterior Position—Mento-posterior Posi- tion—Comparative Rarity of the latter Position—The Oblique Positions of the Face at the Inferior Strait—How managed—Face Presentation and Convulsions—Case in Illustration......................607 LECTURE XLI. CUTTING INSTRUMENTS—SYMPHYSEOTOMY---CESAREAN SECTION. Cutting Instruments—What they Involve—Importance of the Question__What is the Smallest Pelvic Capacity through which a Living Child can be made to pass, and what the Capacity through which a Child maybe extracted piecemeal?__Dis- crepancy of Opinion on these Questions—Symphyseotomy, in what it consists__ Sigault its Originator—The true claims of the Operation—The Question exa- mined—Comparison instituted between Symphyseotomy and the Cesarean Section —Statistics of each—Deduction—The Caesarean Section—The Opiuions in Great Britain and on the Continent gf^ Europe as to the Merits of the Operation—Reasons for the marked Difference of Opinion—Analysis of the Views of Authors touching CONTENTS. XXV the Caesarean Section—Statistics of the Operation—How its Fatality may be Modified—Opinion of the Author as to the Advantages of the Caesarean Section over Craniotomy—What are the Dangers of the Operation?—The Benefits of Anaesthesia in controlling the Shock to the Nervous System—Post-mortem Caesar- ean Section, when resorted to—The Case of the Princess of Schwartzenberg—The Roman Law on the Subject of the Post-mortem Operation—Method of Performing the Caesarean Section; the Vertical Incision through the Linea Alba preferred— Why ?—Should the Operation be Performed before or after the Rupture of the Membranous Sac?—How is the Child to be Extracted through the Opening in the Uterus ?—Rules for Removing the Placenta—Dressing the Wound, and sub- sequent Treatment—The Operation of Elytrotomy, as a Substitute for the Incision into the Uterus, proposed by Jorg and others—Merits of the Operation—Dr. Christoforis and the Resectio-subperiostea of the Pubic Bones......618 LECTURE XLII. VAGINAL HYSTEROTOMY—EMBRYOTOMY---CEPHALOTRIPSY. Vaginal Caesarean Operation, or Vaginal-Hysterotomy—Indications for this Opera- tion—Two Cases in Illustration by the Author—Embryotomy—Meaning of the Term—Amount of Pelvic Contraction justifyhsg Embryotomy—Dangers and Fatality of the Operation—Difference of Opinion among Authors as to the Circum- stances indicating Embryotomy—The Case of Elizabeth Sherwood, as reported by Dr. Osborn—The Dangerous Precedent growing out of that Case—Evidences of the Child's Death in Utero—What are these Evidences?—Conflict of Sentiment among Writers on this Question—Great Caution necessary in forming a Judgment —Analysis of the Evidence—Too General Use of the Perforator and Crotchet— Melancholy Results of this Fondness for Embryotomy—Case in Illustration—Mode of Performing the Operation of Embryotomy—In Hydrocephalus, what is to be done?—Decollation—When to be resorted to—Evisceration—When indicated— Cephaiotripsy—Meaning of the Term—When to be employed......644 LECTURE XLIII. PREMATURE ARTIFICIAL DELIVERY. The Induction of Premature Artificial Delivery—Premature Artificial Delivery— How divided—When is the Foetus viable ?—The Period of inducing Artificial Delivery with the hope of saving the Child—What was it that first suggested a Recourse to it ?—The History of the Operation—First performed in Great Britain —Statistical Tables showing the Diameters of the Foetal Head at Different Periods of Development—The Opinion of Dr. Merriman and others, that Premature Deli- very should not be attempted in the Primipara—Objections to—The Causes of Artificial Delivery—What are they ?—Deformity of the Soft Parts sometimes a cause—Case in Illustration—Excessive vomiting in Pregnancy and Artificial Deli- very—Examination of the Question—Statistics of Premature Artificial Delivery contrasted with those of the Caesarean Section and Embryotomy—The various modes of inducing Artificial Delivery—Perforation of the Membranes—Ergot, Dilatation of Os Uteri by prepared Sponge, according to the method of Klugeand Bruninghausen—Meissner's mode of Rupturing the Membranes—The Method of Kiwisch, or Water-douche—The Method of Cohen—Injection of Carbonic Acid into the Vagina as proposed by Dr. E. Brown-Sequaiji; its influence on contraction of non-striated muscular fibres—Induction of Abortion—Is it ever justifiable ?. 665 XXVI CONTENTS. LECTURE XLIV. TUERPERAL FEVER. Puerperal Fever—Synonyms; its Fatality most Fearful—What is Puerperal Fever 7 —Is it a Local Phlegmasia?—Objections to the Hypothesis—Is it in its Nature a Toxaemia, or Blood Poisoning?—Proofs in Demonstration of this Opinion. Humo- ral Pathology—Puerperal Fever not conEned to the Parturient Woman; it may attack Young Women, Pregnant and Non-Pregnant Women, New-born Children, and the Foetus in Utero. The true Meaning of the Term Puerperal State—Divi- sions, of Puerperal Fever—Epidemic and Sporadic —Is it contagious ? Discrepant Views; Proofs that it is a Zymotic Disease; Contagion accomplished only through an Animal Poison—Prof. Arneth's Account of Puerperal Fever in Vienna Hospi- tal—Its Propagation through Dissections. The Question of Transmissibility through Decomposed Matter. Causes of Puerperal Fever. Symptoms—How Divided—Their Value—Anatomical Lesions—Not Uniform—Sometimes the only appreciable Change is in the Blood. Diagnosis—With what Affections Puerperal Fever may possibly be Confounded. Prognosis—in the Epidemic Form generally unfavorable; the usual Preludes to a Fatal Termination readily detected by the observant Physician. Treatment—Divided into Prophylactic and Remedial—Pro- phylactic—in what it Consists. Dr. Collins's Sanitary Measures in Dublin Lying- in Hospital—Results. Epidemic Puerperal Fever not always confined to Lying-in Hospitals; its occasional Ravages in large Cities and Villages. Remedial Treat- ment—Depletory Remedies—When employed—Stimulants ; when indicated. Opium Treatment; the Veratrum Viride.............680 LECTURE XLV. PUERPERAL MANIA. Puerperal Mania; its Pathology—Is it a Phrenitis, or is it essentially a Disease of Exhaustion and Irritation?—Opinions divided; Necroscopical Researches—At what Period of the Puerperal State is Mania most apt to Occur?—Esquirol's Sta- tistics—Frequency of the Disease—Is Puerperal Mania liable to recur in a Subse- quent Birth?—The Opinion of Dr. Gooch and others on this Point—Causes of Puerperal Mania—Predisposing and Exciting; Hereditary Influence—Symptoms —Rapid Pulse and Continued Restlessness—What do they Portend ?- Diagnosis- Puerperal Mania and Phrenitis, Distinction between—Prognosis-Records of Hospitals for the Insane; Records of Private Practice-Duration of Puerperal Mania—Is Permanent Aberration of Mind Probable in this Disease?—Treatment —Marshall Hall and Blood-letting—Opiates—Their Importance—Moral Treat- LECTURE XLV I. ANAESTHETICS. Etherization—Its Importance; Anaesthesia—meaning of the Term—Anaesthetics in Midwifery of Recent Discovery—in Surgery, of Ancient Date; The Anaesthetic Agents now in use—Sulphuric Ether, Chloroform, and Amylene—Sulphuric Ether first employed as an Anaesthetic by Dr. Morton; in Parturition, by Prof CONTENTS. XXV11 Simpson; its first trial in America, in Labor, by Dr. Keep, of Boston—Chloroform, its Introduction by Prof. Simpson; Amylene; Dr. Snow—Comparative Safety of Sulphuric Ether, Chloroform, and Amylene—Cardiac Syncope and Paralysis of the Heart from Chloroform—Indications for the use of Anaesthetics in Parturition— Should they be employed in Natural Labor?—Their value in Instrumental and Manual Delivery—Anaesthetics in Infancy—Influence of Etherization on Contrac- tions of the Uterus; on Mother and Child—Flourens on the Nervous System in Etherization—Time and Mode of resorting to Anaesthetics in Parturition—The Pulse; how affected by Etherization—Relaxing Effects of Etherization—Case in Illustration..................... "^8 LTS^" OF ILLUSTRATIONS................xxix CATALOGUE OF AUTHORS REFERRED TO AND QUOTED . . . xxxi ALPHABETICAL INDEX................ 711 LIST OF ILLUSTRATIONS. LITHOGRAPHIC PLATES. Plates 1, 2, 3, 4, representing the Areola in Pregnancy, as delineated by Dr. Montgomery..................................... 145, 149, 153, 161 WOOD ENGRAVINGS. fig. PAOB 1. The bones of the trunk........................................... 2 2. The anterior surface of the os sacrum............................... 4 3. The posterior surface of the sacrum................................. 5 4. The lateral surfaces of the sacrum.................................. 5 5. The coccyx..................................................... 6 6. The posterior surface of the coccyx................................. 6 7. The os innominatum................'.............................. 8 8. The external surface of the os innominatum.......................... 9 9. The adult female pelvis........................................... 14 10. The adult male pelvis............................................ 16 11. The foetal pelvis................................................ 17 12. Tlie planes and axes of the pelvis.................................. 18 13. The central curved line, or axis of excavation........................ 21 14. The course pursued by the foetus in its exit.......................... 22 15. Diameters of the upper strait of the pelvis........................... 25 ] 6. Diameters of the lower strait of the pelvis........................... 26 17. The occipito-mental. occipito-frontal, and vertical diameters ef the foetal head 29 18. The transverse or bi-parietal^diameter, and fontanelles................. 29 19. The coronal suture.............................................. 30 20, 21, 22, 23. Vertex presentations, as classified by the author............40, 4] 24. Flexion of the head.............................................. 46 25. Rotation of foetal head............................................ 48 26. Extension of foetal head.................................... ..... 50 27. External rotation of foetal head.................................... 51 28. A peculiar deformed pelvis in the author's collection.................. 62 29. Oblique distortion of the pelvis..................................... 65 30. The pelvimeter.................................................. 68 31. Method of vaginal exammation to detect deformity.................... 70 32. The uterus, as situated in the pelvic cavity.......................... 80 33. The uterus and its annexae........................................ 81 34. The arrangement of the external coat of the uterus................... 82 35. Double uterus and vagina......................................... 8S XXX LIST OF ILLUSTRATIONS. nr„ rAGH 36. Continuity of the fallopian tube with tlie cavity of the uterus........... 90 37, 38. The muscular structure of tho uterus............................ 12? 39. The uterus in its natural state..................................... '"' 40. The uterus at the third month of gestation.......................... 1°7 41. The uterus at the sixth month of gestation.............................. I-**9 42. The uterus at the ninth month of gestation........................... 159 43. The disposition of the hand for a vaginal examination................. 198 44. The amnios inclosing the foetus.................................... ~'*4 45. The foetal surface of the placenta................................... 247 46. The maternal surface of the placenta................................ 217 17. The knotted cord................................................ 2^'2 48. Presentation of the face, first position.............................. 341 49. Descent of the face............................................... 342 10. Presentation of the face, second position............................. 342 51. First position of the breech........................................ 346 52, 53. Descent of the breech......................................... 347 54. Examination per vaginam—commencement of dilatation of os uteri...... 353 55. The os uteri fully dilated—membranous sac unruptured................ 359 5G, 57. Manner of supporting the perineum............................. 364 58. 59. Removal of the placenta........................................ 375 60. Hour-glass contraction of the uterus................................ 381 61. Introduction of the hand in hour-glass contraction..................... 382 62. Detachment of the placenta in morbid adhesion to the uterus........... 385 63. Placentae in twin pregnancy....................................... 432 64. Presentation in twin pregnancy.................................... 435 65. Presentation of the left side of the head............................. 525 6ing the mechanism by which the child effects its exit through the maternal organs. LECTURE III. Foetal Head; its Regions, Diameters, Circumferences, Extremities, Sutures, Fonta- nelles—Sutures of the Adult and Foetal Head contrasted—Arch and Base of Foetal Head—The former undergoes Diminution during Childbirth, the latter does not; Reasons for—Contrast between Diameters of Foetal Head and those of Maternal Pelvis—Deductions—Articulations of Foetal Head—Two Movements, Extension and Flexion—Rotation. Presentation of Fcetal Head; its relative Frequency—Presentation of Vertex—Circumstances which modify the Frequency of Head Presentations—Causes of the Frequency of Head Presentations—Differ- ence between Presentation and Position—Six Positions of the Vertex by Baude- locque—Relative Frequency of these Positions—Naegele's Division. Gentlemen—Having described the normal pelvis, in relation to its bearings on childbirth, and called your attention especially to the measurements of this canal, which, you know, constitutes the space or passage through which the foetus makes its exit, the subject next in order is a description of the fcetal head, with its various divisions, positions, etc.; and when this is completed, I shall proceed to show you the mechanism, which nature has contrived, according to the laws of adjustment, for the safe transmission of the child through the organs of the parent. The head being the most voluminous portion of the foetus, I shall limit myself for the present to a descrip- tion of it alone; for, unless some deformity should exist, whenever the size of the head offers no impediment to its expulsion there will be found no obstruction in any other portion of the fcetal body. This remark you may at first think strange; bat the shoulders, chest, and pelvis of the foetus are so soft and compressible, that they readily find egress, when the head has preceded them. Picisions of Fceted Head.—The head of the foetus, for obstetric purposes, is divided into regions, diameters, circumferences, extremi- ties, sutures, and fontanelles; and these divisions have, to a greater or less extent, a practical bearing on its passage through the pelvic canal.* The general shape of the head is that of an ovoid. * Dr. Clarke of Dublin, was, I believe, the first to point out that the male foetus is in size and weight, in every way larger than the female: with this proposition, now universally conceded, he attempted to show that the disproportion is the cause of a more protracted labor and a greater number of still-Mrths in the case of male children. His paper, which will well repay perusal, under the title "Observations on some causes of the excess of the mortality of males above that of females," will be found in the Philosophical Transactions of 1786, vol. lxxvi. p. 352. Prof. Simp- son has elaborated this fact, first propounded by Dr. Clarke, in a very interesting 28 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Regions.—They are five in number: 1. The vertex or summit; 2. The face; 3. The two lateral regions; 4. The occiput; 5. The base. These various surfaces may present at the superior strait at memoir on the " Sex of the Child," published in the Edinburgh Medical and Surgi- cal Journal for October. 1844. The following is an analysis of the results at which Prof Simpson has arrived:— 1. A greater proportion of deaths occurs in women who have brought forth male children; 2. There are more male still-born children than female; 3. Of the children born alive and which suffer from disease or injuries consequent on parturition, there is a greater proportion among the males than females; 4. The number of children which die in utero prior to labor, is about equal among the male and female; 5. First labors are more dangerous both to mother and child than subsequent ones; 6. The complications of labor are more frequent in the birth of male than female children : 7. For the very marked differences between the difficulties and perils of male as compared with female births, there is no other traceable cause in the mechanism of parturition than the larger size of the head of the male child. It may not be out of place to remark here, that the founh deduction, viz. " the number of children which die in utero prior to labor is about equal among the male and female," if true, is opposed to the general belief on the subject; and it is to be regretted that the learned professor had not more ample data for the opinion expressed on this point. He is in direct opposition both to Drs. Clarke and Quete- let; the former, in the paper already alluded to, observes, " As the stamina of the male are naturally constituted to grow of a greater size, a greater supply of nourish- ment in utero will be necessary to his growth than to that of the female. Defects, therefore, of nourishment proceeding from delicacy of constitution or diseases of the mother, must, of course, be more injurious to the male sex." Quetelet, in his admi- rable treatise on man, says, " It appears beyond doubt that there is a particular cause of mortality which attacks male children by preference before and immediately after their birth." It should be stated in this connexion that the bills of mortality in the city of Hamburg [British and Foreign Medical Review, No. xxxviii.] give the proportion of the sexes in the cases of premature still-born children as 52 ^ males to 47$ females. In regard to the seventh deduction, arrived at by Prof. Simpson, it does seem to me that, while admitting the influence of the size of the head as a cause of the increased mortality among male children, yet it should not be forgotten that preternatural pre- sentations are much more frequent among male than female offspring. Conceding tnis to be so—and statistics sustain the fact—it is, in my judgment, right to refer to this character of presentation some portion of the acknowledged greater fatality of male births. Dr. Veit, of Prussia [British and Foreign Medico-Chirurgical Review, Jan. 1856 p. 268], has recently presented some interesting facts touching this very subject. In his examination of Dr. Clarke's opinion, that the increased mortality of male infants is due to their greater size and weight, and consequently to the greater pressure upon the head, he attempts to show that this circumstance is not alone sufficient to account for the difference in mortality. He agrees with Casper, that the longer life-duration of the female sex has a deeper relation to this question; and he remarks that the difference in development between the sexes is too inconsiderable to exercise so marked an influence on the life of the child. In 2550 children, he found the differ- ence of weight between boys and girls, whether first-born or otherwise, to be only 0.22 of a civil pound, while the difference in the circumference of the head was but six lines. Dr. Clarke on the contrary fixed tlie difference of measurement at 0.366 inch. Dr. Veit says that, even when the development is the same, more boys than girls are always still-bon. In his analysis of the proportion of deaths in the male THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 29 the time of labor ; and I need not state that the only circumstances under which the last re- gion or base is found there, will be when, either through an operation per- formed by the accoucheur, or through brutal manage- ment, the head has been separated from the trunk. The region, which pre- sents the most commonly at the superior strait, is the vertex; and, when discussing the relative frequency of presenta- tions, your attention shall be particularly drawn to this interesting fact. Diameters.—The diameters of the fcetal head, which have a direct bearing on its exit through the pelvis, are four in number: 1. The occipito-mental (Fig. 17), some- times called the oblique, because in position it is oblique to the axis of the body, is the longest diame- ter of the head, and measures five inches and a quarter; it extends from the central portion or prominence of the occiput to the chin; 2. The occipito-frontal diameter, known as the direct, measures four inches and a quar- ter, and extends from the anterior portion of the frontal bone to the occiput; 3. The transverse or bi-parietal diameter (Fig. 18), measures three inches and a half, reaching from the protuberance of one parietal bone to the corresponding protuberance on the other; 4. The perpendicular or vertical diameter, which intersects the bi-parietal at right angles, and measures also three inches and and female infant, as connected with the duration of labor, either in first or subse. quent pregnancies, he presents the following conclusions: 1. The danger to the child when the birth is completed in twelve hours, is only half as great as when the labor is protracted to twenty-four hours; and that further protraction is still more danger ou3; 2. The danger is much increased when the second stage of labor exceeds two hours: 3. When the duration of the entire labor, and the duration especially of the second stage, are equal, the male sex is more endangered than the female. 30 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. a half; it extends from the centre of the vertex perpendicularly to the base of the head.* (Fig. 17.) Circumferences.—The two circumferences of the fcetal head are : 1. The larger circumference, which separates the head into two equilateral portions, and measures from thirteen to fifteen inches; it commences at the symphysis of the chin, proceeds directly upward along the sagittal suture, and then down the central line of the occiput back to the chin; 2. The lesser circumference, which divides the head into an anterior and posterior portion, and measures from ten to twelve inches. It passes transversely across the head, commencing at one of the protuberances of the parietal bone. Extremities.—The two -extremities are : 1. Posteriorly and above, the prominence of the occiput; 2. In front and below, the chin. Sutures.—The sutures may be said, for our purpose, to be three : 1. The coronal; 2. The sagittal; 3. The lambdoidal. The coro- nal suture (Fig. 19) is between the posterior edge of the frontal, and the two anterior edges of the parietal bones. The sagittal suture (Fig. 18) extends from the frontal to the occipital bones, and runs along the internal and superior borders of the two ossa parietalia. The lambdoidal su- ture, on the contrary, unites the posterior borders of the parietal with the anterior borders of the occiput. Fontanelles.—The fontanelles Fig. 19. are two in number: 1. The an- terior (Fig. 18), which is found at the junction of the coronal and sagittal sutures; it is quadri- * Authors differ in their estimate of the diameters of the foetal head. It is not easy to do more than approximate a true average of these measurements, and this we think we have done in the text. Prof. Meigs, after an examination of one hun- dred and fifty heads, gives the following as the result of his observation: occipito- mental 5£ inches; occipito-frontal 4}|; bi-parietal 3fi. In the Amer. Jour, of Med. Sciences for Jan., 1860, Joseph K. J. Van Pelt M D gives measurements made by himself of seven hundred fcetal heads at term. For this purpose he employed the cephalometre of Stein. In 646, the occipito-mental diameter averaged 5\l inches; the occipito-frontal measured 4f| inches- the bi-parietal diameter measured 3f| inches. Of 166 crania measured by Addinell Hewson, M.D., the average occipito-mental was 5.25; occipito-frontal, 4.68; bi-parietal, 3.60. It would, therefore, seem, for some reason yet unexplained, that authentic mea- surements in this country give larger diameters for the most part, especially the occipito-frontal and bi-parietal, than foreign measurements. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 31 lateral in shape, membranous, and smooth. This fontanelle is what the old women call the " opening of the head." There is felt at this point a pulsation, which the ignorant oftentimes imagine to be the result of disease, but which is nothing more than an arterial throbbing. As ossification advances, this membranous expansion becomes consolidated into bone. 2. The posterior fontanelle (Fig. 18), which is at the junction of the sagittal and lambdoidal sutures. It is usually, at birth, ossified—it is triangular in shape, and more or less rough. It is important to recollect the characteristic differences between these two fontanelles, for they, as well as the sagittal suture, con- stitute the guides by which you are to distinguish the individual positions of the vertex. For example, the respective positions of the fontanelles will indicate whether the occiput regards one of the anterior or posterior points of the pelvis ; while the direction of the sagittal suture will disclose whether the head rests obliquely or otherwise.* Sutures of Fcetal and Adult Head.—Although I have employed the term suture, yet you will at once perceive a striking contrast between the sutures of the fcetal and those of the adult head. In the latter, they are serrated, and perfect in their organization, giving to the bones of the cranium a consolidation and immobility essential for the due protection of the brain. In the former, on the contrary, you observe a very different construction ; the sutures, instead of uniting the bones by a species of dovetailing, present an arrangement by which these bones—and this is more remarkable in the two ossa parietalia—are permitted to overlap each other. In this difference of arrangement in the adult and foetal head is exhibited another of those numerous evidences of design so con- stantly presenting themselves to the attention of the student of medicine; evidences which, while they demonstrate the great truth that a supreme intelligence has directed the architecture of the human fabric, disclose the provident care which has been exer- cised in its adaptation to the special wants of the individual. When treating of that subject, we shall show you that the arch of the foetal cranium, during the passage of the head through the pelvis, oftentimes becomes diminished in its transverse diameter ; and this especially occurs in cases in which the head is a little larger than usual; this diminution is accomplished, without detriment to the * An interesting fact has recently been communicated, touching the occlusion and ossification of the anterior fontanelle, by Dr. Roger, physician to the Hopital des Enfans, in Paris. He is positive, as the result of his researches on this subject, that the cephalic souffle can be recognised only when there is no bony obstacle between the ear and the brain; in the examination of nearly three hundred infants, the fon- tanelle was never closed before fifteen months, and never found open after the age of three years—[L'Union Medicale in 1859.] 32 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. child or mother, by the overlapping of the two parietal bones. You see, therefore, that the lessening of the size of the head could not be accomplished, if the sutures in the foetus were constructed similarly to those in the adult. There is also another interesting point connected with the differ- ence in the construction of the arch and base of the fcetal head. The former becomes, I have just stated, diminished, and there is no inconvenience from it, for the upper portion of the brain is not essential to the maintenance of life ; the base of the fcetal skull is firm in its construction, sufficiently so, at least, to resist pressure, and, therefore, does not, like the arch, undergo diminution. If you inquire why this is so, the answer is found in the important circum- stance that the base of the brain, especially the medulla oblongata, is so directly connected with life that it cannot be disturbed without more or less hazard ; and hence this peculiarity of construction. There is an essential practical fact, much insisted upon by Capuron, directly deducible from what has just been said touching the difference in the compressibility of the arch and base of the fcetal head ; and it is this—the difference in the width of the arch and base points out the exact amount of diminution which it is possible for the former to undergo, in order to facilitate delivery; for should the disproportion between the maternal pelvis and base of the cranium be such as to prevent the passage of the base, the compression of the arch would result in no benefit, so far as the delivery of the child is concerned. Diameters of Fcetal Head and Pelvis.— Contrast.—In describ- ing the respective diameters of the fcetal head and adult female pelvis, you will have noticed a very interesting point, namely, that the former presents one diameter, the occipito-mental, measuring five inches and a quarter, which is larger than any diameter of the pelvis; and again, it has another diameter, the occipito-frontal, yielding four inches and a quarter, which is also larger than the transverse and bis-ischiatic diameters of the upper and lower straits, each of which measures only four inches. Here, then, is the head of the foetus possessing certain larger dimensions than the maternal pelvis, the space through which it has to pass. This at once involves apparently the physical difficulty—of a larger body traversing a smaller space ; nature, however, appreciates this diffi- culty, and has most eftectually—as will be shown in the succeeding lecture—removed it by the institution of a mechanism, not only perfect, but worthy of your profound admiration. Articulations and Movements of Fcetal Head.—Before pro- ceeding further, it is important that your attention should be directed to the articulations of the foetal head. It, like the adult head, enjoys two movements: 1. That of flexion and extension* 2. That of rotation, or the lateral movement. In both the adult THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 33 anil foetus, these movements are respectively the result of the same kind of articulation. The condyloid processes, on either side of the foramen magnum of the occipital bone, are received on the superior articulating surfaces of the atlas, or first cervical vertebra; this junction constitutes the articulation known as the occipito-atloidien, and it is through it that the head is enabled to perform the move- ment of flexion and extension. The second movement, that of rotation, results from the articulation subsisting between the odon- toid process of the second cervical vertebra—the vertebra dentata —and the internal surface of the atlas. This movement enjoys a much greater degree of latitude in the foetus than in the adult. It oftentimes extends beyond the fourth of a circle, but, in these cases, the excess of rotation is undoubtedly enhanced by the par- ticipation of the spinal column, which possesses much greater mobility in the foetus than in more advanced life, for the reason of its cartilaginous structure.* The importance of these two move- ments you will more readily appreciate, when describing the manner of the head's exit through the pelvis. Frequency of Head Presentations.—In the Maternite of Paris, among 84,395 births, at full term, the head presented 82,164 times ; and that you may appreciate the comparative frequency of the vertex or summit presentations, contrasted with the other regions of the head, in these 82,104 cases the vertex was found at the superior strait—81,806 times.f Dr. Churchill J says, in 327,802 cases collected by him, the head presented 321,502 times. In 219,253, reported by Uiecke, the vertex presented 214,134 times. You observe, therefore, from these statistics, which, in the main, agree with those derived from other sources, that the head, out of all proportion to any other part of the foetus, presents most frequently at the superior strait. It is, however, a fact worthy of note that this extraordinary proportion refers only to the full period of utero-gestation; for Dubois, in his researches on this subject, has found that of one hundred and twenty-one children, born before the seventh month, sixty-five presented the vertex, fifty-one the pelvic extremity, and five the shoulder. Thus, previous to the seventh month, the pre. sentation of the pelvic extremity is to that of the head as four to five, while, at the completion of pregnancy, it is as one to twenty. It has also been shown, that the life or death of the foetus exercises respectively a decided influence on the kind of presentation. In ninety-six children, born dead in the latter months of gestation, * It is stated by Madame La Chapelle and M. Dubois, that they have observed several instances in which the face was turned almost directly backward, such was the latitude of the rotary movement, without at all compromising the safety of the child. f Moreau, p. 146. \ Churchill's Midwifery, p. 190. 3 3-4 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. seventy-two presented the head, twenty-two the pelvic extremity, and two the shoulder; so that the presentations of the pelvic extremity relatively to those of the head, were as one to three and a quarter. In forty-six, dead and delivered at the seventh month, twenty-one came by the head, twenty-one by the pelvic extremity. and four by the shoulder. In seventy-three living children, born at the seventh month, sixty-one presented the head, ten the pelvic extremity, and two the shoulder. It would, therefore, appear that, at the seventh month, in foetuses born alive, the presentation of the head compared with that of the pelvic extremity, was as six to one, and when the foetuses were dead, one to one. Again: according to Scanzoni,* there were, in the Lying-in Hospital at Prague, during a period of six years, 12,539 deliveries, of which twenty-one occurred previously to the seventh month; of these twenty-one, only six presented the head, while there were fifteen pelvic presentations. In twenty-four cases of abortion, noted by Scanzoni in his private practice, fourteen presented the pelvic extremities. He also observed that, in premature births, at a later period of pregnancy, pelvic presentations were frequent, and more especially when the foetus was born dead. Cause of the Frequency of Head Presentations.—Various theo- ries have been suggested in explanation of the remarkable relative preponderance of this form of presentation; and some of the cleverest minds in the profession have, within comparatively a few years, been engaged in the discussion of the question. The old theory, which, for a long time, was accepted as the true exposition, inculcated that the foetus, until a certain period of gestation, say the seventh month, remained in the uterus with its head upward ; at this time, it made a somerset, which resulted in bringing the head to the os uteri, and placing the breech at the fundus of the organ. Such was the teaching of Hippocrates, Galen, and others. In the sixteenth and seventeenth centuries, a new hypothesis was advanced, giving to the foetus a certain instinctive or voluntary power, which caused it at the latter period of pregnancy to turn its head downward. One of the principal supporters of this view was Alauriceau. He maintained that the foetus, toward the close of gestation, places its head in correspondence with the mouth of the womb, in order that it may the more readily effect its eo-ress.f Without enumerating other conjectures in the attempted explana- tion of the general fact as to the frequency of head presentations it may be stated that, in our day, there are three principal theories. which have more or less occupied the professional mind on the sub * Lehrbuch der Geburtshilfe. 1855. p. 92. \ L'enfant tourne done de cette mantere sa tete vers les derniers mois de la gros- Besse, afin seulement d^tre dispose etre plus facilement mis hors de la matrice au temps de l'accouehement.—Traite des Maladies des Femmes Grosses, t. 1, p. 266. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 35 ject, viz. Physical gravitation, voluntary or instinctive action of the fatus, and, lastly, reflex or excito-motory movements of the latter. These various hypotheses have been discussed with much ability by their respective advocates. The theory of physical gravitation has had many supporters, and a very interesting paper sustaining this view has recently appeared from the pen of Dr. Matthews Duncan, who, within the last few years, has made several important contributions to obstetric science. Professor Paul Dubois, in revival, as it were, of the notion entertained by Mauri- ceau and his school, published, in 1832, an essay* referring the fre- quency of head presentations to an instinctive or psychical influence exercised by the foetus. This essay has deservedly attracted much attention. Finally, we have the theory of reflex or excito-motory movements as the cause of the attitude of the foetus in utero, ably advocated by Prof. Simpson.f If I may be permitted to express an opinion on this controverted question, I should say that, in lieu of any one of these influences being per se sufficient to explain the position of the foetus in the womb, the fact is due to a combination of circumstances not yet, perhaps, properly comprehended.;]; The cardinal point, however, for you to remember is, that usually the head is found at the time of labor at the superior strait of the pelvis, and whatever may be the true explanation of the cause, whether vital or mechanical, you cannot fail to perceive in this arrangement another evidence of the wise provisions of nature. You have been told that, cmteris paribus, the head is the most voluminous portion of the foetus, and hence the advantage of its preceding in childbirth the other parts of the fcetal body; it is, moreover, true that, in the presentation of the pelvic extremity at the time of parturition, as a general rule, whenever difficulty occurs in the delivery, it is not until the entire body has been expelled, the obstacle being due to the passage of the head. This will be shown more fully, when describing the mechanism of labor in pelvic pre- sentations. Presentation and Position.—It is not only important that you should appreciate the frequency of head presentations, but it is also necessary to understand in what manner the head may present itself at the upper strait. This brings me, for a moment, to the consideration of the difference between & presentation and position of the foetus. In obstetric language, presentation signifies the par- ticular portion of the foetus found at the upper strait at the time * Memoire sur la Cause des Presentations de la Tete pendant l'Accouchement et sur les Determinations instinctives et volontiers du Foetus Humain. f Simpson's Obstetric Works, vol. ii., p. 102. \ I should not omit to mention that Scanzoni refers the frequent presentation of the head to the shape of the uterus, and the mode of its development during preg- nancy. 36 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of labor, whether it be the head, feet, shoulder, or any other part- The position, on the contrary, is meant to define the particular situation of the presenting part. The distinction, you perceive, is obvious, and should be borne in memory, in order that what we shall now have to say touching the various positions of the vertex may become intelligible. I shall, for the present, limit myself to the positions of the vertex, reserving the other regions of the head for future consideration. Positions of the Vertex.—There is not only a remarkable dis- crepancy among authors as to the number of vertex positions, but also as to the order of their frequency. If, for example, we are to be guided by some of these writers, we shall find the vertex situ- ated at the superior strait, according to one of them in eight, to another in twelve, and to a third in sixteen different positions. All this is well enough, perhaps, for the closet, but it cannot, in my opinion, subserve any practical interest. It does seem to me, that our great object should be to simplify, and not complicate science by fictitious and useless classifications; they only tend to burden the mind, and confuse thought. The accoucheur, in the lying-in room, is in need of substantial facts and wholesome principles; he cares not for barren hypothesis, for he knows that it cannot aid him in the hour of peril. His mind should be stored with lessons of truth, which will constitute so many guides to point out the course to be pursued, when embarrassed and circumvented by difficulty. Hence, I shall not weary you with an array of the numerous divisions which different writers have made of vertex positions, together with their varieties. My object is to econo- mize your time, without, however, restricting your knowledge ; and it shall be my aim, in these lectures, to lay before you princi- ples, which you will recognise at the bedside of your patient, and not idle away the hour in the vain and unprofitable agitation of crude and unsupported theory. I shall, therefore, limit myself to the positions of the vertex with the relative frequency of each, as defined by what may be termed, touching this question, the two great obstetric schools__ the one represented by Baudelgcque, the other by Naegele, Paul Dubois, and Stoltz. Were I to continue the history of the divi- sions, as suggested by some other writers, it would, I am quite sure not only be without profit, but would, I think, afford satisfactory evidence that these very writers had fallen into a species of tran- scendentalism, which, for the healthy progress of science and the benefit of the sick-room, had, in my opinion, better have been avoided. Transcendentalism in our profession, like transcendental- ism in religion, commerce, or government, is not only an absurdity but is oftentimes fraught with danger. The Schqol of Baudelocque.—According to Baudelocque, there THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 37 are six different positions of the vertex at the superior strait; and in order that you may clearly comprehend them, I shall ask you, in the first place, to recall to memory what we have already stated as to the anterior and posterior divisions of the pelvis, and the six cardinal points found in these two divisions of the pelvic canal. In drawing a line transversely across the superior strait, you divide the pelvis into an anterior and posterior portion ; you have, on the former, the right and left acetabula, and the symphysis pubis ; while on the latter, are observed the three posterior points, namely, the right and left sacro-iliac symphyses, and the sacro-vertebral prominence; now these six points, taken in connexion with the occiput and os frontis of the foetal head, will give the six vertex presentations as follows : In the first, the occiput corresponds with the left acetabulum, and the os frontis with the opposite sacro-iliac symphysis. In the second, the occiput is at the right acetabulum, the os frontis at the left sacro-iliac symphysis. In the third, the occiput is at the symphysis pubis, the os frontis at the sacro-vertebral prominence. In the fourth, the os frontis is at the left acetabulum, and the occiput at the right sacro-iliac symphysis. In the fifth, the os frontis is at the right acetabulum, and the occiput at the left sacro-iliac symphysis. In the sixth, the os frontis is at the symphysis pubis, the occiput at the sacro-vertebral prominence. You cannot have failed to notice, from what I have just said, that the fourth, fifth, and sixth presentations are the direct opposites of the first, second, and third, and that, while the three latter are obtained by placing the occiput respectively at the three anterior points of the pelvis, you find the three former, by placing at these same points the os frontis. Let us next consider the relative frequency of these vertex posi- tions, in accordance with the statistics as recorded by Baudelocque himself, and some of his disciples. In 10,322 vertex presentations, 8,522 occupied the first position, 1,754 the second, two the third, twenty-five the fourth, nineteen th*fifth, and one the sixth.* With Madame La Chapelle, in 20,698 vertex cases, 15,809 were' in the first position, 4,059 in the second, 164 in the fourth, and sixty. six in the fifth.f Madame Boivin states that, in 19,585 vertex presentations, the occiput was found at the left acetabulum (first position), 15,693 times; at the right acetabulum (second position), 3,682 times; at the symphyses pubis (third position), six times; at the right sacro- iliac symphysis (fourth position), 109 times; at the left sacro-iliac * L'Art des Accouchemens. Par I. L. Baudelocque. Tome L, p. 305. f Pratique des Accouchemens. Par Madame La Chapelle. Tome'ii.. p. 508. 38 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. symphysis (fifth position), ninety-four times; at the sacro-vertebral prominence (sixth position), but twice. If these statistics prove anything, they unequivocally establish that, in vertex presentations, the very general rule is that the occi- put is either at the left or right acetabulum (first or second posi- tion), and that when it is either at the symphysis pubis, the right or left sacro-iliac symphysis, or at the sacro-vertebral prominence, it is so, comparatively at least, as a rare exception. The authori- ties, which I have cited in support of these data, are both eminent and reliable, and yet, when their deductions are cunt lasted with the statistics of the opposite school—equally eminent and reliable— we shall be struck with the extraordinary, and apparently irrecon- cilable discrepancy in their conclusions ; and as illogical as it may at first sight seem, that tAvo results, directly contradictory the one to the other, can both be right, yet I am disposed to think that the fact can be demonstrated. Before, however, attempting to recon- cile the conflicting statements, it is proper that the testimony of the other side should be presented. The School of Naegelh.—The opinion advanced by Baudelocque with regard to the relative frequency of the positions of the vertex had received the very general concurrence of obstetric writers, until contested by Naegele, who, in 1818, published his views on the mechanism of parturition. While Naegel6 agreed with Baude- locque as to the positive frequency of the first position of the ver- tex—the occiput in correspondence with the left acetabulum—yet he maintained that the second most frequent position was not with the occiput to the right acetabulum, but to the right sacro-iliac symphysis. Here, then, was a remarkable discrepancy of senti- ment, and it was not long before it attracted the consideration of the learned in obstetric science. The distinguished Professor of Heidelberg, after a rigorous examination of the subject at the bed- side, arrived at the following results: In one thousand instances of vertex presentation, for example, he found the occiput at the left acetabulum (first position) six hundred and ninety-eight times; at the right acetabulum (second position of Baudelocque) once ; at the right sacro-iliac symphysis (fourth position of Baudelocque) two hundred and ninety-eight times; at the left sacro-iliac symphy- sis (fifth of Baudelocque) three times. Dubois and Stoltz, who were among the first to examine practi- cally the new view as propounded by Naegele, have given the results of their investigation, which are radically in confirmation of those of the German Professor. Dubois, in 1913 presentations of the vertex, observed the occiput at the left acetabulum (first position) 1339 times ; at the right acetabulum (second position) fifty- five times; at the right sacro-iliac symphysis (fourth position) four hundred and ninety-one times; at the left sacro-iliac symphysis THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 39 (fifth position) twelve times. The material difference between Dubois and Naegele, it will be seen, is in the position of the occi- put at the right acetabulum, the latter making it but one in 1000, while with the former it was fifty-five in 1913. This, however, does not affect the main proposition, with regard to which there is an entire concurrence, viz. that the second most frequent position of the vertex is, when the occiput is turned toward the right sacro- iliac symp>hysis (the fourth of Baudelocque). So much for France, in agreement with the opinion of Naegele ; and to the names of Stoltz and Dubois, may be added those of Cazeaux, Jacquemier, and others. Next, let us turn to Great Britain, and see whether this revolu- tion of opinion—originated by the eminent German accoucheur— has enlisted any supporters in that commonwealth. Prof. Simp- son, in 1846, in a clinical lecture* on head-presentations, sustains, with his usual ability, the views of Naegele. He says, very em- phatically, " I find that in one out of every three or four cases among my private patients, I meet with this position of the head— the occiput to the right sacro-iliac symphysis. It is so very fre- quent, that I have repeatedly seen two or three instances of it occur in succession." The statistics gathered by Dr. Martin Barry, House-Surgeon to the Edinburgh Maternity Hospital, present the following results : In three hundred and twenty-five cases of cranial presentations, carefully observed by him in that institution, the occiput was directed to the left acetabulum two hundred and fifty- six times ; to the right acetabulum once; to the right sacro-iliac symphysis seventy-six times; to the left sacro-iliac symphysis twice. It may also be stated that Naegele's opinion is concurred in by Drs. Kigby, Murphy, and Tyler Smith. Dr. Ramsbothamf admits that " the right posterior occipito-iliac positions are far more com- mon than before supposed." Lastly, Dr. Churchill,J the distin- guished representative of the Dublin School of Midwifery, observes, " The more closely the opinion of Naegele has been tested by expe- rience and careful observation, the more clear does its correctness appear." Now, with the deductions of the two schools before you, differ- ing, as they do, so widely, the inference naturally is, that if one be right, the other is wrong. I think, however, that the discrepancy is due altogether to the time of labor at which these results were respectively reached. Baudelocque, for instance, judged of the relative frequency of the occipito-anterior positions, from the posi- tion the head occupied after its descent to the vulva. Naegele, on the contrary, began his investigations at the very moment of par- * Northern Journal of Medicine, April, 1846, p. 216. \ Ramsbotham's System of Obstetrics, p. 206. % Churchill's System of Midwifery, p. 203. 10 THE PRINCIPLES AND PRACTICE OF OBSl'ETRICS. Fio. 21 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 41 Fig. 22. Fig. 23. 42 THE PRINCIPLES AND PRACTICE OF OHSTETHICS. turition, when the head had undergone little or no departure from its original position. But the question arises—admitting this differ- ence of time as to the period of their respective investigations how does it happen that one school should find, at the commence- ment of labor, the occiput, second in frequency, in correspondence with the right sacro-iliac symphysis; and the other school, after the descent of the head, should recognise the occiput to be in accord- ance with the anterior section of the pelvis ? The solution of this inquiry is a key to the problem, and will, I think, satisfactorily explain it. Naegele, while maintaining that the right occipito-sacro-iliac position is second in frequency, admits that it is so only as a primi- tive position ; and he shows that, as labor advances, the descent of the head is such that, as a very general rule, both the right and left posterior occipito-sacro-iliac positions become converted into one or other of the anterior-occipital. For example, the posterior right is converted into the anterior right, while the posterior left is changed into the anterior left; in other words, the head undergoes a move- ment of rotation, which turns the occiput from the posterior to the anterior section of the pelvic canal. The following statistics, in proof of this conversion, are not with- out interest: In 1254 occipito-posterior positions mentioned by Naegele, in only seventeen instances did the occiput disengage along the posterior wall of the pelvis; and, in each of these, the exception could be explained by the greater capacity of the pelvis, numerous previous labors, or rupture of the perineum. In twenty- six occipito-posterior positions, observed by Stoltz, the occiput underwent the anterior conversion in all. In five hundred and three, recorded by Dubois, the occiput was expelled posteriorly in thirty- nine. In the seventy-six cases as recorded by Dr. Martin Barry, in two only did the occiput fail to rotate forward. The general senti- ment of obstetricians, at the present day, appears to be in concur- rence with the views of Naegele* and his school, viz. that the right posterior occipital position is the second in the order of frequency only as a primitive position ; and with this concurrence I heartily accord. Author's Classification.—In order to simplify the positions of •he vertex, we shall reject the third and sixth of Baudelocque, for the reason of their extreme rarity, and because, on this account, they should be regarded as altogether exceptional, and shall adopt the following classification : *A late writer, however, R. U. West, M.D., in an exceedingly interesting memoir, contests the truth of Naegele's views. Dr. West's opinion is founded on observations made by him in four hundred and eighty-one deliveries. He agrees with the old school as to the vertex positions.— Cranial Presentations and Cranial Positions, etc. By R. U. West, M.D. London, 1857. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 43 First Position—The occiput in correspondence with the left acetabulum, and the os frontis at the opposite sacro-iliac symphy- sis. (Fig. 20.) Seroud Position*—The occiput at the right acetabulum, the os frontis to the left sacro-iliac symphysis. (Fig. 21.) Third Position.—The os frontis at the left acetabulum, and the occiput at the right sacro-iliac symphysis. (Fig. 22.) Fourth Position.—The os frontis at the right acetabulum, and the occiput at the left sacro-iliac symphysis. (Fig. 23.) In the succeeding lecture, I shall describe the mechanism by which, in the four positions of the vertex, is insured the safe passage of the child through the maternal organs. * It must be distinctly borne in mind that this is the second position, not in the order of frequency, for it has already been shown that the third position (the right posterior occipito-iliac) is next to the first in frequency, but this classification ot first, second, third, and fourth, is made merely to avoid confusion. For example, thb occiput is placed first at the two acetabula, and afterwards at the two sacro-iliac symphyses, without reference to the relative frequency of its apposition with these various points of the pelvis, always excepting, however, the left occipito-acetabular, which, out of all comparison, is the most frequent of tlie four vertex positions. LECTURE IV. Mechanism of Labor—Its Importance—Mechanism in the first Vertex Position— Left Occipito-acetabular—Position of the Foetus—Relations of the Head to the Pelvis—Necessity for a Change in these Relations—Movements imposed upon the Head—Flexion, Descent, Rotation, Extension, and External Rotation—Object and Causes of these Movements—Proof that these Movements occur—Gerdy's Explanation of External Rotation—Mechanism in the Second Position—Right Occipito-acetabular—Mechanism in the Third Position—Right Posterior Occipito- iliac, the Second in Frequency, according to Naiigele—Conversion of the Poste- rior Occipital into Anterior Occipital Positions—How this Conversion is accom- plished—Mechanism in the Fourth Position—Left Posterior Occipito-iliac—Ne- cessity of an accurate Knowledge of the Principles on which the Mechanism of Parturition is founded—The practical application of this Knowledge at the Bedside. Gextlicjiex—You are now prepared to appreciate the interest- ing mechanism by which the transmission of the child, through the bony and soft structures of the parent, is accomplished. The me- chanism of labor maybe defined to be a combination of movements founded upon the principle of adaptation, and intended, through the proper adjustment of the respective diameters of the foetus to those of the pelvis, to facilitate the passage of the former into the world. In the whole range of obstetric science there is no topic more worthy of profound study—none certainly which involves more deeply the lives of both mother and child. One defective link in the chain of movements necessary to the perfection of this mechanism—unless promptly supplied by judicious interposition— and the saddest results may ensue. Therefore, I ask your attention while I endeavor to present to you, in the simplest possible man- ner, the various stages of this adaptation, a knowledge of which is as necessary to the obstetrician as is the compass to the navigator. I shall, for the present, limit myself to a description of the me- chanism of labor as connected with the four positions of the vertex reserving the other positions of the foetus to a future and more appropriate period of the course. Mechanism in the First Vertex Position—Left Occipito-aceta- bular.—\\\ this position (Fig. 20), you will remember, the occi- put or posterior fontanelle corresponds with the left acetabulum, while the os frontis or anterior fontanelle regards the opposite or right sacro-iliac symphysis. The general relations of the foetus are such, that its dorsal surface is to the left and in front; its anterior THE PK1NCIFLES AND PRACTICE OF OBSTETRICS. 45 plane to the right and posteriorly; its right lateral surface to the right and forward ; its left lateral surface to the left and backward, with the pelvic extremities toward the fundus of the womb. For the proper understanding of what we shall presently say, it is abso- lutely essential that you should be under no error as to the exact relations, in this first vertex position, Avhich the head of the foetus bears to the pelvis of the mother at the superior strait. In the first place, the sagittal suture occupies the left oblique diameter of the pelvis; the occipito-mental diameter is oblique to the axis of the superior strait, and, at the same time, the perpendicular or ver- tical diameter is in correspondence or parallel with this same axis; the occipito-frontal and transverse diameters of the head accord respectively with the two oblique diameters of the strait. If, now, you attentively consider these relations of the foetus to the pelvis, it will at once become manifest that, for the head to pass through the pelvic cavity, some change in its position is necessary, and for the following reasons :—1. The occipito-frontal diameter of the head measures four inches and a quarter, and to this is to be added the thickness of the scalp, hair, and walls of the uterus, which, together, will make up nearly, if not quite, a quarter of an inch—this increase, therefore, will give to the occipito-frontal dia- meter four inches and a half, or within a fraction of it; as a conse- quence, this diameter would have, without alteration in the position of the head, to pass through the oblique diameter of the brim, which, it is not to be forgotten, measures only four inches and a half. This, then, would necessarily involve the physical objection of a body of four inches and a half traversing a space of precisely the same dimensions. 2. The occipito-mental diameter of the head, giving five inches and a quarter, is, in this first position of the ver- tex, oblique to the axis of the superior strait; and as it exceeds any diameter of the pelvis, its descent into the pelvic cavity is impos*- sible, unless through a change in its relations, which change, we shall show you, will be such as to bring it in parallelism with the axis of the upper strait, thus affording every facility for its passage into tlie excavation. Such, therefore, is usually the condition of things relatively to the fcetal head and maternal pelvis at the commencement of labor ; and you plainly perceive the necessity for a modification in these relations.* Nature, cognizant of the difficulties just enumerated, * It sometimes occurs that the chin will be in more or less approximation with the sternum before the commencement of labor—but that this is the general rule, as is maintained by some writers, is, I think, altogether erroneous. The flexion of the head, as I shall endeavor to prove, is the result of certain mechanical forces—and these are wisely brought into operation for the purpose of overcoming the physical disproportions between the head of the foetus and maternal pelvis, as they ordinarily exist before the commencement of the parturient effort. It is stated by Jacquemier, that, so far from the head undergoing the movement of flexion, it frequently descends 46 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. imposes upon the head of the child a succession of movements, which, when completed, exhibit the mechanism of labor in all its perfection. These movements are—-flexion, descent, rotation^ extension, and, lastly, what is now denominated external rotation, as a substitute for the term formerly employed—restitution. Flexion.—Responsive to the contractions of the uterus, the position of the head becomes changed; the chin is brought in close approximation with the sternum, constituting the movement of flexion,* and it is interesting to contemplate how immediately the relations of the pelvis and head become modified. As soon as the chin is thrown upon the sternum, the occipito- mental diameter is made parallel to the axis of the superior strait (Fig. 24), the occipito-frontal is ob- lique to this same strait, while the perpendicular and transverse diameters of the head are placed in apposition respectively with the two oblique dia- meters of the brim. This simple movement, then, of flexion, does what ? Why, as you have this instant seen, it so changes the relations of the head to the pelvis, that it not only removes the physical difficulties of which we have spoken, but, in lieu of these difficulties, it substitutes the greatest possible facility for the descent of the head, by placing the to the perineal strait unchanged, without occasioning any obstacle to its expulsion. I hold this statement to be, as a general rule, altogether an illusion; nor can the head, without the previous movement of flexion, pass into the pelvic cavity except when the head itself is unusually small, or the pelvis unusually capacious. * The head, it should be recollected, presents in such way that, instead of the vertex being, as it were, perfectly plumb, it is slightly turned or inflected laterally so that at the very beginning of labor, as soon as the head can be distinctly recog- nised, that portion of it with which the finger comes directly in contact (in the first vertex position) will be the right os parietale, and the sagittal suture will be detected occupying the oblique diameter, but slightly backward in the direction of the sacrum. It is, I believe, generally supposed that the credit of calling attention to this circumstance, is due to Naegele; but he was anticipated by that sound observer, Gardien, who distinctly says, " at the commencement of labor, one of the parietal bones usually presents." If the inclination of the axis of the superior strait be duly considered, it will be readily seen that the head, which is to acconr Fig. 24. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 47 smallest diameters of the latter in apposition with the largest at the superior strait. What a combination of wisdom and intelli- gence in this movement of flexion, and how emphatically does it demonstrate the ample provisions, when not interrupted, which nature is constantly making for the wants of the economy ! But you may be disposed to doubt that the head becomes flexed, or, at least, you may desire some demonstration of the fact. You have a right to assume nothing as granted which is susceptible of proof; if you pursue science by the assertion of this right, with an earnest demand for its fulfilment, the result cannot but be auspi- cious both for science and yourselves, for, under such circum- stances, the former will progress with a healthy growth, while you, instead of having your minds filled with rubbish, will have gathered substantial principles, which will guide you to truth. Now for the demonstration : if, at the commencement of labor, before the head has become flexed, you institute a vaginal exami- nation in the first position of the vertex, you will find the posterior fontanelle or occiput at the left acetabulum, and the anterior fon- tanelle or os frontis at the right sacro-iliac symphysis; the sagittal suture you will distinctly trace, coursing along the oblique diame- ter of the brim from left to right, looking a little toward the sacrum, because of the slight lateral inflection of the right os parietale, to which allusion has already been made.* This, there- fore, is the condition of things at this time ; the pains come on, the labor has fairly set in, and is progressing; after the lapse of a little time, a second examination is made, and what do you dis- cover ? The occiput or posterior fontanelle, instead of correspond- ing with the left acetabulum, lies diagonally in the pelvic excava- tion, while the sagittal suture is not in correspondence with the oblique diameter of the brim from left to right, but is placed obliquely from below upward. Admitting, gentlemen, what I have just stated to be true—and the lying-in room will abundantly corroborate it—what, allow me to ask, could have accomplished this change in the relations of the head and pelvis, except the movement of flexion ? The next inquiry is, how is this movement of flexion produced ? modate itself to the direction of this axis, should itself describe an oblique line, and present one of its sides, instead of being placed perpendicularly. " Dans le premier .moment du travail, e'est ordinairement un des parietaux qui se presente," etc.— TraiU a"Accouchemens, par M. Gardien, t. ii., p. 290. * The experience of the lying-in room will prove that the sagittal suture may be felt by the finger, but occasionally it will be impossible to detect either the anterior or posterior fontanelle; therefore, under these circumstances, although the general fact will be ascertained, viz. that the head occupies an oblique position, yet it can- not be known thus early, whether the occiput is at the left acetabulum or at the opposite point of the pelvis, because the fontanelles are alone the proofs of this latter fact. 4S THE PRINCIPLES AND PRACTICE OF OBSTKTKU'S. You will not have forgotten the two articulations of the fietal head; one for flexion and extension, the other for rotation; and you will recall to memory that the condyloid processes on either side of the foramen magnum o<>c>pitaIe are not at the centre of the base of the head, but are more posteriorly than anteriorly, thus necessarily giving the same posterior direction to the occipito- atloidien articulation, on which the movement of flexion and exten- sion depends. At the commencement of labor, the uterus, under the influence of its contractions, exerts a force, the object of which is to cause the expulsion of the child through the pelvis; the force is so displayed as to be parallel, or nearly so, to the axis of the superior strait, and, consequently, more or less parallel to the axis of the child's body, and that of the uterus itself. This force, you are to bear in mind, is concentrated upon the head of the Actus, and, for a time at least, is resisted by the neck of the womb, and, to a certain extent, by the brim of the pelvis. If, therefore, you will consider, for a moment, these circumstances, you will, I appre- hend, encounter no embarrassment in comprehending the influences which contribute to the movement of flexion. They are: 1. The contractions of the uterus; 2. The position of the occipito-atloidien articulation ; 3. The resistance of the os uteri and pelvic brim. Descent and Rotation.—You have now seen that the first movement which'the fcetal head undergoes is flexion, and you appreciate its causes and objects. As soon as the head becomes flexed, it occupies an oblique or diagonal position in the pelvic cavity (Fig. 24), and unless this be changed it will be physically im- possible for it to make its exit through the vulva, because of the dispro- portion between its clia- meters and those of the pelvis. Hence, the neces- sity for another move- ment, which is that of rotation, consisting of a demi-spiral turn, equal- Fig. 25. ling nearly the fourth of a circle, the immediate consequence of which is to change the position of the head, so that, instead of resting diagonally in the excavation, it is so rotated, that the occiput is brought to the symphysis pubis (Fig. 25), and THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 49 the face directed to the hollow of the sacrum. The object, there- fore, of this movement of rotation is' to overcome the physical difficulty of the head passing through the inferior strait, while con- tinuing diagonally, by placing it in the direct position, viz. with the occiput corresponding with the symphysis pubis, and the face with the concavity of the sacrum. You may, however, very pro- perly ask—how is this movement of rotation accomplished ? When describing the bones, your attention was particularly directed to the anterior and posterior inclined planes of the pelvis. After the movement of flexion has taken place, the head, urged by the impel- ling power—the contracting uterus—descends into the excavation, and, in its descent, the occiput is brought in contact with the inclined planes in front, while the forehead is in apposition with the posterior; the contact of the head with these planes results, under the continued impulsion of the uterus, in the rotary move- ment to which allusion has just been made. I think, therefore, it may be said, that the rotation of the head is due: 1. To the peculiar direction of the planes; 2. To the resistance offered by the walls of the excavation ; 3. To the con- tractions of the uterus. Some high authorities are disposed to doubt that the inclined planes exert any influence in causing the rotation of the head, and maintain that the latter does not undergo this change of position until it has reached the floor of the pelvis; they refer, therefore, the rotary movement, not in part to the peculiar direction of the planes, but to the resistance offered to the head by the perineum and adjacent structures, together with the contractions of the uterus. To this view, there is, according to my experience, an insuperable objection, and it is this—rotation, as a general rule, commences before the head reaches the inferior strait. The proof of this latter fact is within the reach of any practitioner at the bedside of his patient, provided he have experience and tact sufficient to recog- nise the evolutions of the fcetal head in its progress through the pelvic canal. Again : if we deny the action of the inclined planes, how is rotation to be explained in certain cases in which, from numerous antecedent deliveries, or other circumstances, such, for example, as previous laceration of the perineum, there is such an amount of relaxation in the parts, as to render any attempt at resist- ance utterly negative ? Extension.—When the head has been rotated, the relation of its diameters to those of the lower strait is as follows: the bi-parietal or transverse diameter of the head, measuring three inches and a half, corresponds with the transverse or bis-ischiatic of the strait, which is four inches ; while the occipito-frontal diameter of the head, four inches and a quarter, rests in the direct or cocci-pubic diameter of the strait, which, under ordinary circumstances, is four 4 50 THE PRINCIPLES AND PRACTICE OF OBSTKTUICS. Fig. 26. inches, but, at the time of labor, owing to the regression of the coccyx, increases from four and a half to five inches. It is not difficult to understand how the head is made to extend. From its peculiar position at the lower strait, after rotation is effected, the posterior surface of the child's neck is thrown closely against the sym- physis pubis, which be- comes a point of resist- X^^w^v^wT '^W&a ance, so that the force of uterine effort, which until this time had fallen on the occiput, is now con- centrated on the chin; the result of this change in the direction of the im- pelling power of the organ is necessarily to cause the chin gradually to leave the sternum (Fig. 26) until the movement of extension is completed. In confirmation of the fact that extension does really take place, watch carefully the first case of labor you may attend, with an occipito-anterior position of the vertex, and you will find the fol- lowing to be the progress of the head as it emerges from the vulva: You will first perceive the coronal suture, then the anterior portion of the os frontis, next the eyebrows, the eyes, the nose, the mouth, and finally the chin. Such is the order of the delivery of these various parts, which is demonstration itself that the order is due altogether to the movement of extension, which the head is gradu- ally undergoing, at this stage of the labor, during its passage into the world. Thus, the result of extension is to afford egress suc- cessively, through the antero-posterior or cocci-pubic diameter, to the perpendicular, occipito-frontal, and occipito-mental diameters of the head. It is at this period of the parturient effort that the perineum undergoes its maximum distension, so that the axis of the inferior strait is elongated forward and upward. The moment, however, the head has completely freed itself from the os externum, the anterior border of the perineum recedes, and comes directly in contact with the front of the child's neck. The immediate con- sequence of this recession of the perineum is to cause the head, which had previously been elevated toward the pubes, to fall by its own gravity downward toward the coccyx. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 51 External Rotation.—-The head is liberated—it has made its escape through the vulva, and now let us trace its further progress. When it first passes into the Avorld—in this left occipito-acetabular position—it is, as you have seen, so situated that the occiput is in correspondence with the symphysis pubis, while the face is down- ward regarding the coccyx. Almost immediately, however, after its escape, it undergoes another change of posi- tion, which results in placing the occiput to- ward the left groin (Fig. 27), and the face in the direction of the opposite ramus of the ischium. Until the publication of the paper of M. Gerdy, this fifth movement of the head was described as the movement of restitu- tion, and the following tvas the explanation given by Baudelocque, who, I think, was the first to direct attention to it—he supposed that when the head rotated in the pelvic cavity, it did so at the expense of the body of the child—in other words, the body did not participate in the movement; consequently, the head, for the time being, was twisted or in a state of torsion. The instant, however, it effected its egress, it righted itself by the institution of a parallelism between it and the body of the foetus, which resulted in giving to the head the identical position it had previously occupied at the superior strait before undergoing the movement of rotation. This, I repeat, was the generally received view until the appear- ance of M. Gerdy's paper. He has contested this explanation, and maintains that the rotary movement is not isolated—confined to the head—but participated in by the entire body of the foetus. I must confess that, although formerly believing the old opinion to be the correct one, yet close attention to the subject in the lying-in chamber has convinced me that M. Gerdy is right. As soon as the head has undergone rotation, the shoulders, instead of occupy- ing an oblique position, stretch across the pelvis transversely; this could not be so, if they did not rotate simultaneously with the head. Again: a very few seconds after this latter has found its way into the world, the shoulders become diagonal in the pelvis from right to left, and it is this diagonal position which accounts 52 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. for the change in the position of the head ; as the uterus contracts, the shoulders undergo another alteration of position, the right one being brought in apposition with the symphysis pubis, and the left with the hollow of the sacrum. This alteration in the direction of the shoulders necessarily imposes on the head another change in its position, so that now, in lieu of the occiput regarding the left groin, it looks directly toward the internal surface of the left thigh, and the face is turned toward the right thigh. You see, therefore, that the changes in the position of the head, after its escape from the vulva, are but the results of the changes in the position of the trunk and shoulders of the foetus ; while, on the contrary, the rotation of the head in the pelvic cavity is the cause of the rotation of the trunk and shoulders. Expulsion of the Shoulders and Body.—Having pursued the pas- sage of the foetus to this point, it will be proper to inquire in what way the shoulders and remaining portion of the child are expelled. When the shoulders have completely rotated, so that the right one is toward the pubes and the left toward the concavity of the sacrum, they continue to descend under the influence of uterine contraction ; usually, the one which is behind is disengaged first ;* sometimes, however, it will happen that the one in front is the first to be expelled, and again, I have known both to make a simul- taneous egress. Still, obedient to the efforts of the uterus, the remaining portion of the foetus makes its exit, and, as the body passes into the world, it is slightly curved upon itself, the concavity of the curve corresponding with the symphysis pubis, while the convexity regards the hollow of the sacrum. The reason of this is obvious; the pelvis being a crooked canal, the child, in its progress through it, must, of necessity, accommodate itself to its curves. Mechanism in the Second Vertex Position.—Right Occipito- acetabular.—In this position (Fig. 21), the occiput at the right acetabulum, and the os frontis at the opposite sacro-iliac symphysis, the mechanism is precisely the same as in the first position, with the single exception that if the rectum be distended with fjecal matter it may cause some little obstruction, during the rotary movement, to the os frontis, as it turns toward the concavity of the sacrum. In all other particulars the mechanism is identical for the movements of flexion, descent, rotation, and extension severally take place, and are accomplished in the same manner as in the first position. It may be well, however, to remind you that after external rotation is accomplished, the occiput, instead of turn- ing to the left, will, on the contrary, pass to the right. Mechanism in the Third Vertex Position.—Right Posterior * It may be remarked that this will depend much upon the state of the perineum • for, if it should have been lacerated in a previous labor, the anterior shoulder will be very apt to be expelled first. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 53 Occipito-iliac.—This position, you will recollect, according to Naegele, is the second in the order of frequency. The occiput is at the right sacro-iliac symphysis (Fig. 22), and the os frontis in appo- sition with the left acetabulum. This is the condition of things at the commencement of labor, and precisely the same phenomena occur in the progress of the delivery, as in the two preceding posi- tions. The peculiarity, however, of this right posterior occipito- iliac position is, that, during its passage through the pelvis, the occiput is rotated first from the right posterior to the right ante- rior section of the pelvic canal, and is ultimately brought, as in the two positions just described, in correspondence with the sym- physis pubis, while the forehead or face is directed to the hollow of the sacrum. The exceptions to this conversion of the occiput from the posterior to the anterior of the pelvis, are extremely rare—Naegele, as stated in the previous lecture, meeting with only seventeen instances, in twelve hundred and forty-four occipito- posterior positions, in which the conversion did not occur. Mechanism in the Fourth Vertex Position.—Left Posterior Occipito-iliac— (Fig. 23.) Here, again, the mechanism is the same, except that the occiput, under the influence of rotation, is brought first to the left anterior portion of the pelvis, and after- ward to the pubes. Deductions.—We have now completed the description of the mechanism by which the child, in the several positions of the vertex, is enabled, with safety to itself and parent, to pass into the world. But all that we have said on this important and interesting topic would be, comparatively at least, of little avail, if we were not to pursue the subject still more closely. I suppose it may be assumed, without much fear of error, that you now thoroughly' comprehend the different stages of the mechanism of labor; and you are, no doubt, prepared to exclaim with me, how wonderful is nature, how exquisite this mechanism ! The very exclamation, however, might possibly lead to wrong impressions ; for, if nature, it may be urged, be really so- full of wisdom, and so bountiful in her provisions, she requires no assistance from science, being thoroughly adequate to the efficient discharge of her duties. Here, then, is the point, and one, too, entitled to attentive con- sideration. Nature, it cannot be doubted, is, all things being equal, not only competent, but prompt in the accomplishment of her various offices ; but it will sometimes happen that she is con- travened in her arrangements by circumstances she cannot control, and, therefore, her relief must be found in the judicious interposi- tion of science. Allow me here incidentally to remark that, when you enter the lying-in chamber, your presence will involve one of two things; either you will be there as a silent spectator, an admiring witness, if you 54 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. choose, of the consummate skill displayed in the achievement of the parturient process, or it will devolve on you to give assistance, because of the intervention of some influence which has paralysed nature, and forces her to seek at your hands the needed succor. How, permit me to ask, can you render aid, with any well-founded hope of success, unless your minds be previously Imbued with the mechanism by which, when not interfered with, the delivery of the child is accomplished ? In one word, gentlemen, in aftbrding this assistance, you become nature's substitute ; but to be her substitute, in truth and in effect, you must have been her disciple, and learned, from her own teachings, the series of processes which, in the aggre- gate, make up what is known as the mechanism of labor. In this way only can you aid her, when subjected to influences which she herself cannot resist. In order that you may appreciate what I mean, and recognise the full force of the argument, permit me, by way of practical illustration, to imagine a case of labor under the following circum- stances. A lady is attacked with labor-pains at six o'clock in the morning; the medical attendant is sent for; he arrives, and, on examination, ascertains that the head presents in the first position of the vertex—the occiput at the left acetabulum, the os frontis at the right sacro-iliac symphysis ; there is no deformity of the pelvis, but the head may be a shade larger than normal. The pains con- tinue with marked regularity ; it is now six in the evening; twelve hours from the commencement of the labor ; but, notwithstanding the regularity and increasing character of the pains, there is no progress xohatever in the delivery ; the head is still at the superior strait, unchanged from its original position ; the mouth of the womb, responsive to the contractions of the organ, is well dilated, and the " bag of waters " ruptured ; the pains now become more vigorous, the scalp of the child's head is corrugated or furrowed, a demon- stration that it is exposed to pressure, which, if protracted, must necessarily prove serious; there is unusual heat in the vagina, and, in addition, the strength of the patient is giving way. The friends become alarmed ; the accoucheur is closely interrogated as to the cause of the difficulty; he assures them all is right, and offers words of encouragement to the patient, telling her that,, in a short time, she will be delivered. Time still rolls on ; it is now eleven o'clock; no progress what- ever ; seventeen hours since the commencement of labor; the lady is more exhausted, and the head of the child still the object of intense pressure—the pains recurring with increasing force. In this condition of things, the doctor is emphatically admonished, that something must be done; in his embarrassment, he says to the hus- band : Sir, there is an impaction of the head, and, in order to save the life of your wife, it is absolutely necessary for me to sacrifice THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 55 the child ! This language forms a striking contrast with his pre- vious assurances, and confidence in his judgment is so far shaken, that a consultation is demanded. Let us now suppose that, in this emergency, one of you should be selected as the consulting accoucheur ; you reach the house; learn the history of the case, and a vaginal examination enables you to detect, almost with the rapid- ity of thought, the entire cause of the delay. Nature has been vainly struggling to accomplish the movement of flexion / she has failed, and the consequence is that the head has been unable to descend into the pelvic cavity. After a brief consultation, you express your opinion, courteously but firmly, that there is no neces- sity for destroying the life of the child. The medical man in attendance differs with you; or probably will make a strong per- sonal appeal, that there should be no difference of opinion, on the ground that he has committed himself to the family, having stated, without qualification, that the only alternative was the sacrifice of the infant! It may, indeed, be that the instruments of death—the perforator and crotehet—are already on the table, awaiting only your sanction for their reckless employment. I need not say to you, gentlemen, that in circumstances like these, there is a paramount and sacred duty you owe the patient; all other considerations are of minor and insignificant import. There- fore, as there is but little time for argument, and death is at the very threshold, do all that you can as briefly as possible, to prove to your colleague that he is wrong; if he be a man of heart, he will readily concur in your suggestions; if without heart, and insensible to every influence, save his own selfish interest, the obli- gation devolves upon you to interpose, and protect from his mur- derous schemes both mother and child. Now, what is the sug- gestion you would make? Why, obviously, to aid nature in doing what she has failed in accomplishing; that is, to produce the move- ment of Jfencion. You may succeed, with a due degree of tact, in effecting this movement, as follows: gently grasp the head of the feet us, during the interval of pain, and with the greatest possible caution, bring the occiput downward; as this portion of the head descends, the chin will, of course, approach the sternum; this, in a word, is flexing the child's head. The whole difficulty of its descent from the superior strait is now removed, and if the pains continue active, the labor will probably soon be terminated. In what has this simple, but most important manipulation resulted ? Why, it has not only saved the child, and rescued the mother, but it has converted a house of gloom into one of joy; it has vindicated science, and made every member of that household your fast and abiding friend. Such, gentlemen, will be the precious results of true and available knowledge. Suppose, however, that after the movement of flexion has been accomplished, the strength 56 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of the mother is so much exhausted, through previous effort, as positively to indicate the necessity of immediate delivery. In such a contingency what are you to do? Before answering this ques- tion, allow me to ask what the precise position of the head is in the pelvic cavity after the movement of flexion has been accomplished? It rests, of course, diagonally ; then, if immediate delivery be necessary, the proper means of achieving it will be the application of the forceps ; but remember this essential fact, in the employment of the forceps, the head being in the diagonal position—after lock- ing the instrument, and before making any extractive force, the first thing to be done, is gently to turn the forceps from left to right, for the p>urpose of producing the movement of rotation* which will necessarily change the head from the diagonal to the direct position, by placing the occiput in apposition with the symphysis pubis, and the face in the concavity of the sacrum ; this being effected, you proceed to extract the head in the manner I shall point out, when discussing the subject of forceps delivery. • * Many a child has been sacrificed, and the mother cruelly lacerated, from the neglect of this fundamental principle in delivery by forceps. LECTURE V. Pelvic Deformities, how divided—Evils of Increased Capacity—Case in Illustration —Dangers of Increased Capacity during Pregnancy and Labor—Diminished Capacity — Dangers of—Varieties of Pelvic Deformities — Causes of—Rachitis, Mollifies Ossium—Distortion of Spinal Column does not necessarily cause Distor- tion of Pelvis. Obstructed Labor from Polypus—Removal of Polypus, and subse- quent Delivery of Child by Forceps—Pubic Arcade—Congenital Deformity of— Craniotomy—The Space through which a Living Child can pass—Experiments of the Author—Discrepancy of Opinion among Writers—The Space through which a Child may be extracted by Embryotomy. How to ascertain that Defor- mities exist—In the young Girl—In the married Woman. Measurements of the Pelvis—Baudelocque's Pelvimeter—How employed—Its reliabilities—Objections answered. The best Pelvimeter, the Finger of the well educated Accoucheur— The " Toucher"—How conducted. Genti.emex — I propose, in the present lecture, to direct your attention to the subject of Pelvic Deformities—a subject well worthy of your consideration, for the reason that these deformities not only exercise a very important influence on delivery, but oftentimes involve in serious peril the lives of both mother and child. A pelvis may be said to be deformed when its dimensions are either above or below the ordinary standard; hence these deformities are divided into two classes: 1st, Increased capacity; 2d, Diminished capacity. You might very naturally suppose that the larger the pelvis, the greater the facility for the transmission of the child, and, therefore, perhaps, be inclined to doubt the propriety of denominating a pelvis, with increased capacity, a deformity. It is, indeed, true that, so far as the mere passage of the child is con- sidered, the facility of transmission is usually enhanced in propor- tion to the increase in the size of the pelvis. But this facility, it must not be forgotten, is too often purchased at a heavy cost, entailing upon both parent and offspring the most dangerous results. I have described to you a normal or standard pelvis, and you now appreciate the provisions nature has made for the safe delivery of the child through it. Fortunate would it be if there were no departure from the natural dimensions of the foetus and pelvis, for then the paturient woman would be spared the anguish and danger incident to those disproportions, necessarily arising from an increase or diminution in size of one or the other. When a pelvis is deformed in consequence of an increased capacity, the female encounters other troubles than those con- 58 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. nected with parturition. For example, as the direct consequence of an augmented space, she would be very likely to suffer from malpositions of the uterus, such as prolapsion, anteversion, or retro-version, and the bladder itself might become displaced. Occasionally, you will be consulted by ladies who will tell you that they are much annoyed either by a frequent desire to pass water or to evacuate the bowels; as either of these conditions may be traceable to various causes, it is of no little consequence that, in yo-.ir investigation, you should arrive at a correct opinion, for the relief of the patient will necessarily depend upon the accuracy of the diagnosis. The following case is not without interest: In November, 1855, I was consulted by a married lady from the State of North Caro- lina, under the following circumstances: She was twenty-one years of age, and had been married two years; no children ; her first menstruation occurred just six months previous to her marriage; about two months before the appearance of the catamenia, she began to experience irritation about the bladder, giving rise to a frequent desire to micturate; and from that time until November, when I was consulted, this vesical irritation was more or less con- stant—being more annoying, however, a few days before her men- strual turns, and subsiding to a certain extent when these were over. This lady informed me that she had taken quantities of medicine, but without the slightest benefit. On an examination per vaginam, I ascertained the uterus to be in a state of prolapsion, but entirely free from disease of any kind ; and its inclination was slightly forward, pressing upon the neck of the bladder. There was now no difficulty in accounting for the frequent desire to pass water—it was owing, as you at once perceive, to the mechanical pressure of the uterus against the bladder. In the vaginal exami- nation, I soon discovered that the pelvis was unusually large, con- stituting a deformity with increased capacity. This, then, was an interesting example of prolapsion of the womb, not from any increase in the volume of the organ, or from relaxation of the vagina, or from the effects of concussion, but simply a case of pro- lapsion from an augmented capacity of the pelvis. What, under the circumstances, could be done to relieve this patient, or was she doomed to suffer without any hope of benefit ? All that I did was to introduce into the vagina a soft India-rubber ball, for the pur- pose of giving gentle support to the uterus, and thus relieve the bladder from pressure ; the result proved that nothing more was necessary.* Indeed, I do not know what else could have been * I am very partial to the India-rubber ball. It is soft and unirritating, and has usually given me great satisfaction. Before introducing it, it is pierced with a small hole to allow the air to escape; you then fold it lengthwise, lubricate it with oiL and carry it into the vagina, being careful that the orifice looks downward toward THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 59 done, as the support of the prolapsed uterus by a pessary was the only indication to be fulfilled. There are one or two points of more than ordinary interest about this case. In the first place, the lady did not menstruate until she was eighteen years and six months of age; and secondly, the first time she experienced irritation about the bladder was about two months before the appearance of the catameuia. The question now arises, why did she not for years previously suffer from the frequent desire to pass water ? This is readily explained : the uterus, before the establishment of the menstrual function, is, phy- siologically speaking, dead to the economy—it is not only without office, but is comparatively insignificant in size—and hence, from this latter circumstance, there was an immunity from the vesical irritation, whicli only commenced when the advent of the function was at hand, and consequently the tissues of the uterus in a state of development. Again, this pressure was always more severe a few days prior to the menses, and diminished comparatively after their completion. The uterus, at that time, was more or less loaded with blood; hence its increased volume, and, as a necessary result, its increased pressure against the neck of the bladder. During pregnancy, also, a deformed pelvis, from enlarged capacity, will involve more or less inconvenience from the various displace- ments to which the uterus is liable. One of the ordinary conse- quences of this species of deformity will be the descent of the fcetal head into the pelvic cavity during the latter weeks of gestation, bringing with it the inferior segment of the uterus, which can readily be detected by the finger. From this circumstance there will arise various morbid phenomena, such as unusual beaiing- down, constipation, troubles in micturition, either retention or a frequent desire to pass water, together with more or less distress in the thighs, the result of pressure on the pelvic nerves. But the greatest evils to be apprehended from an enlarged pelvis are more or less connected with the act of child-birth itself. For example, a too sudden expulsion of the foetus may result seriously in several particulars, viz. inertia of the uterus, with flooding, may occur; or, if the umbilical cord be naturally shorter than usual, or curtailed of its ordinary length by being encircled around the neck or other parts of the foetus, it may become ruptured in some portion of its extent, or torn from the umbilicus of the child, or from its attach- the outer opening of the canal; the ball immediately becomes filled with air, and forms an admirable support to the uterus. A string should be attached to it, so that the patient may withdraw it for the purpose of having it cleansed, which should be done at least once iu twenty-four hours. The patient should be tauglit to introduce it herself, whicli she can do without the least difficulty. Care mu.st always be taken that the ball is of a proper size, neither too small nor too large; in the former case, it will fall out of the vagina; in the latter, it will be apt to irritate. 60 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. ment to the placenta ; if neither of these accidents should ensue, the placenta itself may be suddenly detached from the uterus, or this latter organ become inverted, in consequence of the resistance of the afterbirth to the sudden traction of the cord. In addition, there may be the hazard of rupture of the neck of the organ, from its too rapid dilatation. The occurrence of one or other of these accidents would be followed by more or less peril. It is obvious, from what has just been said, that a patient with this class of pelvic deformity should, at the time of labor, be strictly confined to the bed, and on no account permitted to walk about the room, for the reason that the probability of any of these com- plications would be greatly enhanced during the act of progression. The patient should be instructed to make no effort during a pain; and the vigilance of the accoucheur will be needed, in order that early and efficient support be given to the perineum, to protect it against rupture from the sudden exit of the foetus. Whatever maybe either the inconveniences or evils to be appre- hended from a deformed pelvis with an increased capacity, they are immeasurably insignificant in contrast with those more formi- dable ones, necessarily connected with a pelvis, whose capacity is diminished. In this latter case oftentimes arise some of the most important questions connected with the practice of midwifery— questions in which the judgment of the accoucheur will be severely tested, and his feelings deeply touched. It is in instances like these in which you will be called upon to decide the issue of life or death—whether a child known to be alive in its mother's womb shall be sacrificed, or whether, with a view of equalizing the chances of survival between parent and offspring, the mother shall be subjected to an operation, which will necessarily involve her safety in the most alarming peril. These points, however, will be fully discussed under their appropriate head, when speaking of operative midwifery. I shall not, gentlemen—for I do not think it necessary—enter upon a minute description of the various pelvic deformities enume- rated by authors; I prefer to give you some general facts upon this subject, so that you may deduce from them practical lessons, which will serve you in the lying-in chamber. Your minds cannot be too well stored with facts, provided they are tangible, and made sub- servient to your requirements in the hour of danger. Theory and scholastic classifications may appear well enough in books ; but if these books be intended to aid the practitioner in the sick room, they would, in my opinion, have more effectually accomplished the object by elaborating what is really practical, and substituting for mere hypothesis and unprofitable lore, sound and truthful principles, which will not only abide the test of the bedside, but will consti- tute so many lights to guide the medical man, when surrounded by embarrassment, or lost for the time in obscurity. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 61 Varieties of Pelvic Deformity.—The pelvis may be diminished at the superior strait, at the inferior strait, or in the excavation. This diminution may exist simultaneously in these three portions of the pelvic canal, or only one portion be curtailed of its usual capacity ; while the other two will present their normal dimensions. For example, the two straits and excavation may be so diminished in size, as to render it physically impossible not only for a living child to pass, but impossible, also, for the child to be extracted in fragments, when subjected to the operation of embryotomy. Again, there may be no deformity at either of the straits, but the excava- tion abridged by the growth of an osseous or fleshy tumor; the excavation and upper strait may be normal, while there exists at the inferior strait a diminution, which will render it impossible for a living child to be extracted, or at least protract considerably the ordinary duration of labor. Now, the very converse of this will •sometimes occur—the superior strait may be so curtailed as to prolong the labor at its commencement, while the inferior presents its usual dimensions, and will afford ready exit to the child. Let us suppose that you are attending a case of parturition with the pelvis exhibiting this latter deformity. If you be not exceed- ingly careful, and do not ascertain the fact of the deformity at the very advent of labor, you may possibly give an opinion as to the termination of the delivery, which will be likely to result in pre- judice to your interest. You make an examination, and finding the head presenting naturally, and the uterus beginning to con- tract, in reply to the inquiry either of the patient or nurse, you say " All is right," and you entertain no doubt that the labor will progress most favorably. Twenty hours may be required for nature to cause the head to pass through the abridged upper strait; finally she succeeds, and the head begins to descend into the pelvic excavation. You are closely pressed by the friends for your opinion as to the probable duration of the labor; and it may hap- pen that you will assume as the basis of your calculation a very false principle—that is, you may argue in your own mind, if it needed twenty hours for the head to pass the superior strait, it will require at least the same time for it to escape through the inferior strait. This will prove false logic, and the result cannot but be injurious. The opinion, on the contrary, which would be given by the medical man, who had early discovered the deformity at the upper strait, would be more in unison with the result of the case. He is at once able to account for the delay in the labor at the com- mencement, and knowing that there was no narrowing of the pelvis at the inferior strait, he would most naturally and intelligently conclude that, save the occurrence of some unforeseen accident, the labor would be completed in comparatively a short period. The young practitioner cannot afford to prove a false prophet in the 62 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. lying-in room ; his opinions are weighed not unfrequently in a capricious balance, and there are few things which will tend to injure him more effectually than error in prognosis, whether as regards the termination of d'.sease or the duration of labor. ^Causes.— The causes of pelvic deformities are various ; when the capacity is increased, the deformity is almost uniformly congenital. This, however, is not always the case ; I now show you a pelvis (Fig. 28),which, although ori- ginally well-formed, ex- hibits both in its upper and lower straits, a re- markable increase of capacity. The defor- mity is the result of serious injury—the fe- male to whom it be- longed was crossing the street—she fell on her side, and the wheel of an omnibus passed over the lateral portion of the pelvis, causing a partial dislocation of the symphysis pubis, and also of the two sacro-iliac symphyses; these dislocations, as you perceive, have produced an extraordinary aug- mentation in the diameters of the pelvic straits. The causes, which usually are active in the production of defor- mity with diminished capacity, are principally as follows: 1. Rachi- tis, a disease of infancy, the pathology of which is a deficiency of earthy matter in the bones, thus depriving them of their ability to resist superincumbent and other pressure, and consequently resulting in more or less distortion of the pelvic canal; 2. MoUities ossium,* or, as it is termed by the Greeks, Malacosleon, which is also a softening of the bone; it is a disease incident to adult age, while rachitis originates in, and is peculiar to, infancy. Both of these pathological conditions usually exhibit their results first, in the spinal column, causing various distortions of the vertebras ;f and * Molliti-:* ossium rarely occurs in women who have not borne children; and there is an interesting circumstance of practical value connected with this fact—for example, a female may have brought forth several children without difficulty; but, in a future pregnancy, a deformity, the effect of moUities ossium, may occur, which will render embryotomy or the caesarean section necessary. It would seem, there- fore, that child-birth exercises more or less influence on this terrible malady, a lead- ing characteristic of which is a shortening of the stature of the individual, owing to the giving way of the spinal column. ■)■ It is important to recollect that distortion of the spinal column does not neccs- Barily involve a deformity of the pelvis. "Without a knowledge of this fact, the practitioner would sometimes be liable to error in forming his opinion as to the existence or non-existence of pelvic deformities. It has, I am aware, been asserted THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 63 you can readily understand why, in these affections, the superior strait of the pelvis should so frequently become the seat of defor- mity. The base of the sacrum receives the last lumbar vertebra, and, in this way, necessarily sustains the weight of the trunk; under these circumstances, when there is a softening of the bones, nothing would be more likely than a projection toward the symphysis pubis of the sacro-vertebral prominence, and necessarily an abridgment of the dimensions of the upper strait. In fact, either in Rachitis or MoUities ossium, as a general rule, the deformity of the pelvis will be in precise relation with the particular kind of pressure exercised on its different bones. If, for example, from disease or other circumstances, the individual keep her bed, and continue for a long time in a recumbent posture—if on her back, the deformity would be from before backward, because of the projection forward of the sacrum; if on her side, the deformity would be in the trans- verse diameter, because of the lateral pressure, thus causing more or less approximation of the sides of the canal. In addition to the causes already mentioned, there are others worthy of note, which will occasionally result in deformity of the pelvis—such as morbid growths, either osseous or sarcomatous, in the excavation,* fractures of the pelvic bones, ulceration of one or by some writers that there is a necessary and constant relation between distortion of the spine, and distortion of the pelvic canal. This, however, is not in accordance with facts. * Sometimes these morbid growths, such as polypoid and fibrous tumors, will curtail by their presence the dimensions of the pelvis, although there is actually no deformity in the bones of the pelvis itself—these growths being attached to the uterus, and sometimes, too, finding their seat in the vagina. Under these circum- stances, it becomes a very nice question, especially at the time of labor, to decide on the course to be pursued. The following case is in point: In September, 1853, I was requested to visit a patient twenty miles distant from the city, in consultation with Dr. James Ridley. She had been in labor with her first child thirteen hours before I saw her. Previous to, and during her preg- nancy, she had been subject to severe floodings; the patient was in an ancemic state, and evidently suffering from strong labor pains. My friend, the Doctor, stated to me that he had made several attempts to reach the mouth of the womb, but failed in consequence of a tumor in the vagina. During the throes of labor, the tumor was pressed toward the vulva, accompanied by considerable haemorrhage. "What was this tumor? At the Doctor's request, I made a vaginal examination, and, after some difficulty, succeeded in directing my index finger along the posterior wall of the vagina, as far as the os uteri; here, I very distinctly felt a stalk or pedicle attached to the posterior lip of the cervix. In bringing the finger toward the exter- nal orifice of the vulva, I could recognise a firm, uniform substance, increasing in volume as it extended toward the orifice; it was insensible on pressure. The exami- nation developed, therefore, some interesting facts—viz., that the tumor was pedun- culated, the pedicle being upward, and the base downward, together with insen- sibility on pressure; these are the very essentials of a polypus of the womb—and the other important feature of this character of growth wa3 present, viz. haemorrhage; and in addition, as I have already stated, the patient suffered from bleeding both before and during her pregnancy. Dr. Ridley concurred with me in opinion, as to 64 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. other of the acetabula, permitting the head of the os femoris to pass into the pelvic cavity ; syphilitic disease and mercurial cachexy will also, in some instances, contribute to a modification and defor- mity of the pelvis. It sometimes happens that a pelvis will present a general and corresponding diminution in all its dimensions, the result of origi- nal conformation; and, in such case, the woman will frequently exhibit no indication whatever of disease—but, on the contrary, in every particular she bears the evidences of excellent health. Here, then, is an example of primitive or original malformation— consisting simply in a uniform curtailment of the respective diame- ters of the pelvis, not traceable to any special cause—but which may give rise to very serious obstruction during the passage of the child. This species of deformity, however, is comparatively rare. The pubic arcade of the female pelvis will occasionally constitute the only deformity ; in such case, it bears a striking analogy to the arcade of the pelvis in the male—the rami of the ischium and pubes, on either side, instead of forming the usual angle, descend perpendicularly, thus curtailing the outlet in such way as to render it physically impossible that a living child can pass, and, therefore, calling for the operation of embryotomy or the caesarean section as the case may be. This species of deformity is, I think, extremely rare. On one occasion I met with it; in all other respects, the pelvis was well formed: Dr. Nugent, of Long Island, requested me, in May, 1851, to see a lady under the following circumstances; she was in labor with her first child; the pains had been regular and active, and everything progressed favorably until the head reached the the nature of the tumor, and the next important question was—what, under the circumstances, could be done? The labor pains were well marked and regular— the patient was weak from previous and present losses of blood—the tumor so nearly filled up the vagina, as to establish beyond peradventure the utter impossi- bility of delivery without its removal. Without hesitation, therefore, I proposed this as the only alternative—with the concurrence of my friend, and, at his request, I excised the tumor in the following manner: Directing my finger upward as a guide as far as the posterior lip of the os uteri to which the pedicle was attached, I then introduced flatwise along my finger a probe-pointed bistoury, with whicli I sepa- rated the pedicle from its attachment—the finger and instrument were then with- drawn, and the next point was to remove the polypus from the vagina. This was accomplished by means of hooks placed on either side of the tumor, which, after some considerable traction, was brought into the world. The polypus was quite firm, and weighed six ounces. The pains of labor increased with the extraction of tho polypus, and the patient, although much prostrated, bore her sufferings with remark- able heroism. It became, however, quite evident, after the lapse of six hours from the removal of the tumor, that the strength of the patient was fast giving way—the head had descended to the inferior strait, and the exhaustion of the lady becoming more and more marked, it was judged proper to have recourse to the forceps. At the request of Dr. Ridley, I applied the instrument, and extracted a fine living son. The mother and child are at this time both living, and in the enjoyment of good health. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 65 inferior strait; at this stage of the labor, although the pains were strongly expulsive, there had been no progress for a period of eight hours; the patient was becoming exhausted, and the head of the child encountered extreme pressure. It was under these circum- stances that I saw her; on an examination, I found the pubic arcade, in its widest portion, measurmg only two inches and an eighth. This contraction of the arcade at once accounted for the delay in the delivery, and there was no alternative but the operation of embryotomy. It was quite manifest that no force which the uterus could exercise would be adequate to accomplish the exit of the child through such a contraction; nor was there the remotest hope of consummating the delivery by means of the forceps.' In such a contingency, delay would have sacrificed the mother ; and much as I am opposed to this operation on general principles, yet, in the pre- sent instance, with the entire concurrence of Dr. Nugent, and at his request, having strong proof of the death of the child, I proceeded to remove it. The operation was accomplished without much delay, and the patient had quite an auspicious recovery. The deformity in this case was unquestionably congenital, constituting one of those anomalies in organization, which are occasionally met with, but which cannot be explained on any rational principle. It was evidently in no way connected Avith disease of the osseous structure. The health of the lady had always been excellent. Oblique Distortion of the Pelvis—oblique ovata.—Prof. Naegeld was the first to direct attention to a peculiar deformity of the pelvis, which he denominated pelvis oblique ovata (Fig. 29). His mono- graph on the subject has been translated into French by M. A. C. Danyau, and discloses a vast deal of research. Naegele collected thirty-se- ven examples of this species of distortion, only two of which were in the male sex. The deformity con- sists in an abridgment or flattening of one of the lateral portions of the pelvis; in the thirty-seven cases alluded to, the distortion was observed twenty- two times on the right, and fifteen times on the left side. On the affected side, there is complete anchylosis or fusion with the sacrum and innominatum; on post-mortem inspection, not the slightest trace 4 66 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of the synchondrose articulation can be discerned. The Professor supposes the fusion of the articulation to be congenital; others, among whom may be mentioned Dr. Rigby, attribute it to previous inflammation of the part. This deformity is of extreme danger at the time of labor, for, as far as the results have been obtained, Naegele says they have been fatal to both mother and child in every instance but one. What is the smallest space through which a living child may be extracted—and embryotomy practicable f—Let us now examine the most important question connected with the subject of pelvic deformities; for, after all, the great point for us as obstetricians is—what is the actual amount of curtailment, which will prevent the passage of the living foetus, and, therefore, call for an opera- tion which necessarily sacrifices the child, or places in imminent peril the safety of the mother? There is much discrepancy of opi nion among authors, as to the space required for the transmission of a living foetus; and the same discrepancy, too, exists as to the extent of contraction through which it is possible to extract a child, fragment by fragment, in the operation of embryotomy. It seems to me that these two questions are not matters of opinion— they are, on the contrary, questions of fact. Hypothesis here is of no possible avail, unless confirmed by positive and ample expe- riment. In order to settle the argument for myself, not by theory, but through actual demonstration, I caused, several years since, six wooden pelves to be constructed with the following dimensions —1st. The antero-posterior diameter of the superior strait measures three inches. 2d. The antero-posterior diameter measures two inches and three-quarters. 3d. The antero-posterior diameter measures two inches and one- eighth. 4th. The antero-posterior diameter measures two inches. 5th. The antero-posterior diameter measures one inch and three- quarters. 6th. The antero-posterior diameter measures one inch and a half. With the pelves Nos. 1 and 2, I have experimented with a view of ascertaining whether it was possible to extract a fcetal head, possessing the ordinary dimensions at full term, without subjecting it to such pressure and injury as necessarily to destroy life; and, after repeated and careful trials, I arrived at the conclusion that the smallest possible space, except in extremely rare instances through which a living foetus, at the end of gestation, can pass, is a diameter of three inches and an eighth antero-posteriorly__and even with such capacity, there will necessarily be much delay in the delivery, and, to a certain extent, more or less danger to the child. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 67 With the pelves Nos. 4, 5, and 6, I have repeatedly made the attempt, but unsuccessfully, to bring away the foetus piecemeal, and am satisfied that this cannot be accomplished—without the almost certain hazard to the mother of lacerations, which will more or less involve her life, or at least, entail upon her sufferings, to which death itself would oftentimes be preferable—with a contrac- tion in the antero-posterior diameter of less than two inches and an eighth. These results,* gentlemen, may strike you as singular, especially as they are at variance with the opinions of men of high authority, who have been regarded as almost oracular upon these important questions.f But I am quite sure that I am right. This subject will be again referred to, when speaking of the operations to be performed on the mother and child, in consequence of pelvic deformities. Measurement of the Pelvis.—You may be called upon to deter- mine the measurements of the pelvis under either of the following circumstances: 1. In a young girl, who may be suspected, by her mother, to have a deformity, which, in the event of marriage and pregnancy, might peril her life ; and, therefore, your opinion will be required to decide this important question. You at once perceive how sacred the responsibility of such a position, and what delicate issues will necessarily be involved in your judgment of the case. 2. A woman with a deformed pelvis may be in labor, and it will rest with you to determine what course is to be pursued—whether the deformity is such as to prevent the passage of a living child— whether the labor can be terminated by the forceps—or whether the alternatives of the caesarean section, embryotomy, or version, be indicated. These, gentlemen, are among the grave and trying points of our profession ; and their just solution requires sound judgment, ripe experience, and inflexible integrity. We will now suppose the case of the young girl. How are you to proceed in the examination to ascertain the condition of the pelvis ? Under these circumstances, an internal examination cannot be justified, nor is it at all necessary. You, therefore, conduct your investigation in the following man- * It may, perhaps, be urged that the deductions arrived at are not reliable, for the reason of the difference in the yielding of the natural and artificial pelvis; but with the full recognition of this difference, and a proper allowance for it, I have faith in the results. f Busch, of Berlin, says, for a living child to pass, the antero-posterior diameter must measure from two and a half to three inches; Scanzoni, two inches and three- quarters ; Burns, three and a quarter; and Dr. Joseph Clarke, three and a half inches. As regards the space through which it is possible to perform the operation of em- bryotomy, Burns says one and three quarters are required; Hamilton, one and a half inches; Osborn one and a quarter; Davis, one inch; Dr. Dewees would not advise the operation under two inches. 68 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ner:—In the first place, you will inform yourself of her early history—whether in infancy she was healthy; whether, during that or any subsequent period, there was any indication of rickets, scrofula, etc; examine into her present condition; is her appetite good—how is her digestion—is she strong and muscular—how is her sleep ? Has the catamenial function appeared—if so, is it regular ? Does she walk firmly, or is there evidence of lameness ? These questions, if properly answered, will aid you materially in arriving at a correct opinion. But, in addition, you can make an external examination of the pelvis as follows : It is better, I think, to have the girl in the standing position, with her back supported against the door or wall—then with your hand introduced, the chemise inter- vening between it and the pelvis, scrupulously avoiding all exposure of her person, you ascertain whether the symphysis pubis has its pro- per shape, whether too prominent or too flat; are the crests of the ilia natural, or do they approximate too closely ? How are the ante- rior-superior spinous processes—are they too nearly approximated, or do they maintain their natural position ? Then place your hand on the sacrum, and ascertain whether it is too projecting, or whether it recedes unnaturally. These are the special points to which your atten- Fio. so. tion is to be directed in this kind of exploration. You then have re- course to the pelvimeter, for the external measurement of the pelvis. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 69 Pelvimeter—how used.—The best instrument, and most reliable one for this purpose, is the pelvimeter "or callipers (Fig. 30) of Baudelocque. It consists of a scale and two extremities. In order to recognise the antero-posterior diameter of the superior strait, one extremity of the instrument is placed at the symphysis pubis, whilst the other is brought in contact with the superior spinous process of the sacrum. If the antero-posterior diameter be natural, the scale of the instrument should give you seven inches, and then you deduct two and a half inches for the thickness of the sacrum, and half an inch for the symphysis pubis, which will leave four inches, the measurement of the direct diameter at the superior strait. For the measurement of the oblique diameter, one ex- tremity of the instrument is placed upon the great trochanter, the other upon the opposite sacro-iliac symphysis—the scale should, in this case, yield nine inches; deduct two and three quarter inches for the thickness of the trochanter, neck, and head of the femur, and one and three quarters for the thickness of the sacro-iliac symphysis—this will make four and a half inches to be taken from nine inches, which will leave four and a half, the measurement of the oblique diameter at the upper strait. The pelvimeter of Baudelocque, I repeat, is an accurate and reliable instrument; but I can readily anticipate your objections to it. You will ask me, for example, how this external measurement will suffice to prove that there is no abridgment of the dimensions of the pelvis internally by the presence of tumors, or other forma- tions ? The question is a legitimate one, and I will endeavor to answer it. If there be a curtailment of the pelvic capacity in con- sequence of the presence of tumors, whether osseous, fibrous, or of any other character, these tumors would unquestionably give some indication of their presence by certain pathological phenomena, such as irritation, more or less, of the bladder or rectum, pain in the back, numbness of the lower extremities, a sensation of drag- ging, and pressure downward. Therefore, in the absence of these or other symptoms, I should be disposed to have faith in the develop- ments of the instrument. In order to become satisfied as to the configuration of the inferior strait, the pulp of the thumb is placed under the symphysis pubis, and the end of the index finger on the tip of the coccyx; Avith the thumb and finger thus separated, the space between them is measured by a scale, and the result will show whether the cocci-pubic diameter be normal or otherwise. In the same way, the measurement of the bis-ischiatic diameter can be ascertained, by placing the thumb on the tuberosity of one ischium and the index finger on the opposite tuberosity. ■ Internal Measurement.—Numerous contrivances have been sug- gested for the internal mensuration of the pelvis ; but, with all due respect for their inventors, I must, in candor, caution you against 70 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. their employment. They cannot be resorted to without subjecting the female to more or less pain ; and, moreover, they arc wanting in precision in their results. In the married woman, all instruments may be dispensed with, for here we can employ what I consider the very best pelvimeter, because it is the most searching in its explora- tions, and the most positive in its results—I mean the finger of the well educated accoucheur. This brings me to a i'ew general observations on the important subject of vaginal examination by the finger, or as it is termed by the French—the toucher. The patient should be placed either on her side or back—where there is no special objection, the back I think preferable—the accoucheur then places his thumb directly in the palm of his hand, and covers it closely with the middle, ring, and small fingers, so that the index finger may be free—this latter is the only one required for the vaginal examination; and the directions just given, if recollected, will frequently spare the practitioner much embarrassment, and his patient no little annoyance. I have known instances in which the vaginal examination has been attempted without regard to any rule or principle—the hand, with the fingers separated, carried toward the vagina, one finger, perhaps, finding its way into the meatus urinarius, another press- ing upon the clitoris, wdiile a third would probably be on the outer boundary, if, indeed, it did not penetrate the anus itself, consti- tuting in all truth a fun- damental operation, and causing the patient to re- buke, in severe language, the operator for his stupid- ity and ignorance! The index finger being lubri- cated with oil, or some mu- cilaginous material, is intro- duced gently into the va- gina, at first from before backward and then from below upward. A general sweep of the vagina is to be made during this exami- nation, to ascertain the con- dition of the excavation, whether its capacity is natu- ral or whether abridged by some foreign growth; the Fio. 81. radial border of the finger is then placed under the symphysis pubis, and the apex directed toward the promontory of THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 71 the sacrum (Fig. 31). With the index finger of the other hand, placed on the radial surface of the finger in the vagina just outside of the symphysis pubis, the finger is withdrawn from the vagina, and a scale applied for the purpose of measuring it; this will probably, in case of a natural conformation, give four and a half inches—but half an inch is to be deducted for the obliquity of the finger in its course from the symphysis pubis to the sacro-vertebral prominence, which would leave four inches the normal antero-posterior diameter at the superior strait. This mode of measurement has been objected to by certain writers on the ground, that, in some cases, the index finger could not reach the sacro-vertebral prominence. Well, it seems to me that, admitting the objection to be valid, it demonstrates the very thing we desire, viz. that there is no contraction in the antero-posterior or direct diameter. The measurements of the inferior strait are to be conducted as we have already de- scribed in the case of the young girl. Some authors, and Velpeau among others, recommend for the internal examination the introduction into the vagina simultaneously of the index and middle fingers, so that while the latter is extended toward the sacral prominence, the former may rest on the internal surface of the pubes. But I cannot see the necessity of this suggestion; while, on the contrary, there is, in my judgment, a positive objection to it—an increased irritation of the vagina. LECTURE VI. Organs of Generation—External Organs—The Mons Veneris, Labia Externa, Clitoris, Labia Interna, Yestibulum, Meatus Urinarius, and Urethra—Secretory Apparatus of the External Organs—Sebaceous and Muciparous Follicles—Vulvo-vaginal Gland—The Internal Organs—The Vagina, its Anterior and Posterior Relations. —The Urethro-vaginal, Vesico-vaginal, and Recto-vaginal Septa—Vesico-vaginal and Recto-vaginal Fistula?—How produced—Orifice and Superior Extremity of Vagina—The Hymen, its Absence no Test of Loss of Virginity—Its Presence no Evidence that Sexual Congress has not occurred—Retention of Menses mistaken for Pregnancy—Blood-vessels and Nerves of Vagina—Uterus, Uses and Situation of—How divided—The Structure of Uterus composite—External and Internal Coat—Intermediate Tissue is Muscular—Is the Uterus an Erectile Organ ?— Rouget's Researches—Blood-vessels, Nerves, and Lymphatics of Uterus—Recto- uterine Fossa, Importance of—Ligaments of Uterus—The Cervix, its Peculiarities before and after Puberty—Os Tinese, Cicatrices upon, not always reliable as evi- dences of Childbirth—The Fallopian Tubes—The Ovaries, the Essential Organa of Generation—Structure and Uses of the Ovaries. Gentlemen—The organs of generation in the female are usually divided by authors into external and internal, embracing, under the former head, those which are situated on the outside of the pelvis, while the latter are contained within the pelvic canal. This division is not strictly correct, for we shall see, as we proceed, that the organs external to the pelvis are not in reality those of generation; they are simply auxiliary to that act, and may, therefore, with much more propriety, be denominated the copulative organs. I need scarcely assure you that an accurate knowledge of these parts, both as regards their anatomical structure and relations together with the numerous pathological changes to which they are exposed, is absolutely essential to the obstetrician. Without this knowledge, you will, in the practice of midwifery, be constantly liable to error, nor can you hope to diagnose or successfully treat the varied and important maladies occurring in these organs. I ask your attention, therefore, especially to this subject, and shall endeavor to be as brief as is consistent with clearness in descrip- tion. External Organs.—They are as follows: 1. The mons veneris ■ 2. The labia externa ; 3. The clitoris ; 4. The labia interna; 5. The vestibulum; 6. The meatus urinarius and urethra. Most anato- mists comprehend these different parts under the name of vul/"e at which menstruation manifests itself for the first time is by no means uniform, and will be modified by various circumstances, such as climate, education, mode of life, temperament, constitution, and race. Climate.—The influence of climate on the early or late appear- ance of this function was, previously to the researches of Mr. * Genesis, chap. xxxi. 96 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Roberton,* supposed to be very decided; and the general opinion prevailed that girls, under the torrid zone, menstruated much ear- lier than those born in temperate, and higher latitudes. Mr. Roberton, however, has shown that the extreme difference in the time of the first menstruation in very hot and very cold climates is only three years ; thus, in Calcutta, the mean age is between 12 and 13, while in Labrador it is within a fraction of 16. In Jamaica, it is 14 ; at Bombay, 15. At Christiania and Copenhagen, according to Dr. Faye, it is between 16 and 17; in Paris, and London, between 14.50 and 15; and at Lyons, 13. It, therefore, will be seen that the influence of climate is much less than was formerly supposed. The annexed table, derived from Dubois and Pajeot,f exhibits some interesting data on this subject. It embraces observations made on six hundred women, in different climates, in reference to the period of the first menstruation : Warm Climate. Temperate Climate. Cold Climate. Southern Asia. France. Northern Russia Age. Number of Women Menstruating for the first time. 8 years......3......0......0 9 "......9......2......0 10 "......19......8......1 11 "......86......26......3 12 "......148......42......6 13 "......135......64......18 14 "......96......82......56 15 "......52......99......114 16 "......25......96......114 17 "......16......76......90 18 "...... 3......50......78 19 "......3......25......56 20 "......2......18......33 21 "......1......6......17 22 "...... 1......3......10 23 "......1......1......3 24 "......0......2......1 Thus it appears that the average age at which menstruation first appears in warm climates, is 12 years, 11 months, and 21 days; in temperate climates, 15 years, 3 months, and 17 days; in cold cli- mates, 16 years, 7 months, and 27 days. Education and Mode of Life.—Girls in the country, whose habits are more in accordance with the ordinances of nature men- struate later than those brought up in the city; and this difference is readily accounted for. The former are frugal in their habits retire early, and rise with the sun ; they are independent in feeling and in action ; their moral and physical education is usually calcu- » Essays and Notes on the Physiology and Diseases of "Women. London, 1841. f Traite complet de l'Art des Accouchemens par MM. Dubois et Pajeot, p. 325. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 97 lated to improve the mind, and fortify the body. They live in the open air, and are more or less constantly in exercise; in a word, their nervous system is strengthened, and they exhibit, not only in their personal appearance, but also in their very movements, the evidences of physical health ; they, indeed, are the living portraits of nature's own daughters. How different is it with those born and educated amid the tinsel and excitements of city life ! Look at our metropolis, New York, with its enterprise, its commercial prosperity, its immense wealth, its princely edifices, more like the palaces of the old world, than the unpretending structures of an infant but mighty Republic—look, I say, at all these things—the products of successful enterprise, and indomitable energy—and then turn to the pallid cheek and wasted features of those interesting creatures who are to do the honors, and constitute the gems, of these magnificent domicils. In this con- templation, the philanthropist will find cause enough for lamenta- tion ; he will see that city life, with its rounds of excitement, its prurient books, and no less prurient dance, has forced into prema- ture action the nervous system of the young girl, and thus entailed upon her the melancholy results of this contravention of the laws, which nature has declared essential to health. The life of the young girl, moved and swayed by the constant and exciting currents of city habits, is a life purely artificial; it is without substance, destructive alike to health and happiness, and too often without a redeeming feature to relieve the retrospect. You appreciate, there- fore, why it is that the catamenial function occurs earlier in girls surrounded by, and participating in, the follies and excitements of the metropolis ; these excitements tend directly to force into early development the nervous system, and under their prurient influence the sexual organs are stimulated to premature and sickly maturity; hence there is, oftentimes, a premature and sickly exhibition of the menstrual function.* Temperament, Constitution, and Race.—Temperament and con- stitution, under given circumstances, will exercise their agency in the early or late appearance of this function. Girls of a nervo- sanguineous temperament and robust constitution, will menstruate earlier, all things being equal, than those of an opposite condition of system. The influence also, of race is very remarkable, and appears to resist all the other circumstances known to modify the late or early development of the menses; for example, it has been * Briere de Boismont, in his full and excellent paper on menstruation, states that in Paris, among the daughters of the wealthy, the age of the first catamenia is thir- teen vears and eight months ; and, among the poor, fourteen years and ten months. It was observed in Vienna, by Dr. Szukiss, that in 665 women born in the city the mean age was fifteen years eight and a half months; while, in 1610 from the coun- trv, it was about sixteen years two and a half months. 7 98 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 6hown by Raciborski and others, that if a husband and wife, natives of New York for instance, should reside in the Ea^t Indies, and have children there, no matter how long the period of resi- dence, even if it extended to six or more generations, the daughters will continue to menstruate, not at the period usual for girls in the East, but in correspondence with the time at which this function usually occurs in the native homes of their parents ; and so, also, the reverse of this is equally true. Precocious and lardy Menstruation.—There are examples, recorded in the books, of menstruation occurring in young chil- dren ; but these, I think, should not be accepted without some qualification. One of the most remarkable cases I have read of, is related by Dr. D. Rowlett, of Kentucky ;* "■ Sally Deweese was born in Butler County, Kentucky, 7th of April, 1823 ; at twelve months of age she menstruated, and continued to do so regularly until 1833, when she became pregnant; on the 20th of April, ls:>4, she was delivered of a healthy female child, weighing seven and three fourth pounds." Other writers have also cited some extraordinary instances ; Briere de Boismont mentions two cases; in one, men- struation commenced at the third month, in the other at the third year. D'Outrepont records one at nine months; the infant had protuberant breasts, and menstruated every four weeks until her death, which occurred in the twelfth year of her age. Whatever credit may be placed on these and other recorded examples of menstruation in children, it is very evident that they should be regarded as extremely rare exceptions. Not so, however, with the cases of tardy menstruation ; I have known several examples of young women, in the enjoyment of good health, in whom the func- tion did not appear until the nineteenth, twentieth, and twenty- second year; there was one case of a female, who appeared at my clinic, and who, if her statements are to be relied upon—and after rigid scrutiny I could detect no motive for fraud—did not menstru- ate until she was thirty-three years of age ; she married at thirty- five, and was delivered of a healthy living child sixteen months from the day of her marriage. Causes of Menstruation.—In referring to the various and con- flicting opinions advanced by authors to explain the cause of the menstrual discharge, we cannot but be struck with two facts : 1. The manifest want of agreement; and 2. The absurdities to which mere hypothesis will oftentimes lead its supporters. Some ascribe the menstrual crisis to the influence of the moon ; others say that it is produced by general plethora of the system; while others, again, maintain that it is due altogether to local plethora; and so we might proceed to enumerate the different theories which * Transylvania Journal of Medicine for October. 1834. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 99 have been projected on this subject—but cui bono? Women menstruate not only at every phase of the moon, but they men- struate every hour and day in the year. What, then, becomes of this supposed lunar influence—a doctrine, I may mention, of very ancient date, and which has been warmly defended by some of the early fathers. Again: you will occasionally see females in infirm health, the very opposite of plethora, have their menstrual turns with more or less regularity; but why should this be so, if the menstrual function be owing to general vascular fulness of the system—a doctrine which, also, has had its eloquent advocates ? If this hypothesis of plethora be true, why could not menstruation be completely arrested by the abstraction of blood, upon the principle —causd sublatd tollitur effectus; but we know very well, from practical observation, that, in certain engorged conditions of the economy, loss of blood, either generally or locally, is sometimes the most prompt and efficient remedy to bring on the catamenial flow. A truce to theory, and let us come to facts. When a girl menstruates, it is because she has attained a point in her physical development, which enables her to perform this function. Function, in a physiological acceptation, is the specific act accomplished by, and peculiar to, a given organ. For example, the lungs decarbonize the blood; the liver secretes bile; the kid- neys urine ; the heart receives into its right cavities venous blood, and throws from its left cavities arterial blood. These, together with numerous others, are functions which, more or less, commence with the birth of the child, and which also are, more or less, directly connected with the maintenance of life. They, therefore, differ from the menstrual function in the broad fact that the latter does not manifest itself until some years after the birth of the being; and Avhile its periodical recurrence is material to the health, it is not, as I have before remarked, essential to the life of the individual. Now, it appears to me, that the true explanation of the cause of menstruation consists in the elucidation of the simple question, viz. Why is not the function of menstruation, like the functions of the lungs, heart, and kidneys, simultaneous with the birth of the child ? The solution of this interrogatory is, in my opinion, the only philosophical explanation of the cause of menstruation; and we proceed, therefore, in a very few words, to answer it. As soon as the child is born, and its existence becomes independent, the lungs commence their office of decarbonization, simply because the lungs are developed and prepared for this duty; the heart receives venous blood, and disposes of arterial blood, because the heart is developed and fitted for this office; the liver secretes bile, and the kidneys urine, for precisely the same reasons. But the difference with menstruation is this—it, like the other functions, is the off- spring, if I may so speak, of organic development; and the reason 100 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. that it is not coexistent with birth, and does not become established until a later period, is, that the organs, of which it is the specific function, have no physiological existence—that is, they lack physi- cal development, and, therefore, have not yet become participators in the acts of the system. These organs are the ovaries, the essen- tial and only organs of generation strictly so-called in the female. The development of the ovaries occurs at the period of puberty, and then it is that their physiological action commences. At this time, you will observe on the surface of these bodies, the Graaffian vesicle, containing the ovule, which, I have told you, escapes ordinarily with the menstrual blood. As these ovules on the surface become matured, the ovary itself forms the centre of a sanguineous afflux, a veritable congestion, in which the fallopian tubes and uterus participate; this congestion, as a general princi- ple, results in the escape of mucus and of blood, which pass from the uterus through the os tincae into the vagina, and thence exter- nally ; this is popularly denominated menstruation. I have just said that, as a general principle, the ripening of the ovules—ovula- tion—is accompanied by a muco-sanguineous discharge ; but you must bear in recollection that this muco-sanguineous discharge is not uniformly present; the want of this distinction has, I think, given rise to more or less embarrassment. Menstruation does not, be it remembered, essentially consist in the monthly evacuation, which usually occurs,* but in the cardinal physiological fact—that one or more ovules reach their maturity every month. With the appreciation, therefore, of this important truth, you can readily comprehend how, under certain circumstances, a female may become impregnated who, in the ordinary acceptation of the term, has never menstruated, examples of which we shall cite, when treating of gestation.f * It is undoubtedly true that, at each catamenial period, there is usually a san- guineous discharge from the vagina; but this discharge, so far from representing the essence of the menstrual function, is simply one of the ordinary links in the chain of phenomena which occur at this time. The periodical ovarian nisus is necessarily accompanied with more or less congestion of the uterine organs, and the passage of the blood into the world is nothing more than an effort of nature to relieve the vessels from their hyperaemic condition. If, however, as will sometimes occur this discharge of blood should not take place, numerous nervous disturbances may result from one of two causes—either from the sojourn in the general system of the noxious elements contained in the menstrual fluid, or from the irritation of the ovarian and uterine nerves in consequence of the continued engorged condition of the unre- lieved vessels. \ Dr. Szukiss, of Vienna, during a period of fourteen years, and in 8000 cases, met with fourteen instances of total absence of menstruation. In four of these in- stances, the women had borne several children; the other ten were barren • most of these, however, experienced, every three or four weeks, the ordinary symptoms or molimina menstruationis. In none was there any vicarious menstruation : but in two, imperfect development of the uterus was discovered. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 101 Le Cat has been the object of much ridicule for having origin- ated the theory that menstruation is the result of a voluptuous congestion of the uterine organs; but if, in his ignorance of what is now known in reference to ovulation, he could not more definitely explain his idea than by employing the term voluptuous, yet it is very evident that his mind was in the right direction on the subject. The ovular theory of menstruation, which has recently received much attention, and been the subject of special research, Avas well understood and described by a clever and logical writer as early as 1821—I mean Dr. John Power. Indeed, I think he is entitled to the credit of having accurately delineated the ovular phenomena. In order that you may appreciate the basis for this statement, I quote from him the following passage: "The generative powers of the human female are not limited to the production of a single ovum; on the contrary, a number may always be detected in the ovaria, under different states of progress. The loss or disappoint- ment of one matured ovum is followed by the maturation of another; this, in its turn, becomes disappointed, and thus an indefinite series is carried on throughout the period of generative capacity."* I do not wish to be understood that this interesting subject had not been alluded to by writers prior to the time of Dr. Power; but, in my judgment, to him is due the credit of having embodied in a clear digest what may, with some reason, be deno- minated the fragmentary notions advanced on the subject by his predecessors ; and I think, too, that he has, in a measure, antici- pated the investigations of those who have succeeded him in this field of inquiry. Periodicity of Menstruation.—But why should menstruation be periodical—that is, occur once in twenty-eight days, instead of being continuous and uninterrupted like most other functions of the system? Hallcr inculcated the doctrine that the true explana- tion of the periodicity of the catamenia was, that nature required twenty-eight days to repair the loss of blood sustained at each men- strual crisis, and that it was not until this lapse of time that the vessels again became filled so that they could pour out their contents. This great man, and accurate observer, however, was in error on this question. If you examine an ovary in its congested state, you will observe on its surface the matured ovules of which I have spoken, or at least the remains of the ruptured vesicles from which they have escaped ; examine the organ still more closely, and you will detect, imbedded in the subjacent tissue, other ovules, which are not matured, but which, as they approach the surface of the ovary, become so, precisely as did the first; so, in this way, there is at each monthly crisis a constant succession of ovules, one or * Essays on Female Economy. London, 1821. p. 25. l02 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. more of which either become fecundated by the seminal fluid of the male, or, in the absence of such influence, escape with the % catamenial fluid. This periodical maturation of the ovules con- tinues from the period of puberty until the final cessation of menstrual function. There is a singular coincidence as to the physiological condition of the ovary before the age of puberty, and at the time the woman ceases finally to menstruate. Previous to puberty, the ovaries, as we have already stated, are undeveloped, enjoy no action—in a word, they are inert; after the function has ceased, these same bodies fall into a state of atrophy, and are no longer engaged in ** the affairs of the economy. The similarity of condition in these organs, before and after the menstrual crisis, is explained in this way : menstruation is the evidence which nature affords that the female is susceptible of becoming impregnated, that she is in a state to carry out the cardinal office of her sex—the reproduction of her species. Menstruation, you have just been told, is but the result of the ripening of the ovules, which the female is required to furnish in order that she may perform her part in the great work of increase. The reason, therefore, that her ability to perform this latter duty is restricted to certain limits, is because it is only within ihese limits—from puberty to the final termination of the menstrual function —that the ovaries are capable of secreting ovules, which constitute the sijie qud non of procreation, so far as the female is concerned.* Source and Nature of the Menstrual Fluid.—There has been much controversy, and very discrepant opinions have been ad- vanced, regarding the source and mode of production of the menstrual fluid. It has been argued by many writers that the catamenia are simply an exudation ; others, on the contrary, say they are a secretion. It appears to me that the real cause of the contra- dictory opinions, entertained upon this subject, is traceable to the circumstance that the preliminary question—the one absolutely essential to the proper solution of the inquiry as to the true source of the menstrual discharge—has not been sufficiently considered. The question to which I allude is this: What is the menstrual fluid ? Is it really and truly blood, presenting all its elements and characteristics, or does it, in its constituents, disclose that it is not blood? Let us briefly examine this point. It has been very satis- factorily proved by Donne f and others, that the catamenial fluid * Several instances have been recorded in which, after the ablation of the ovaries, the menstrual function entirely ceased; but, perhaps, the most remarkable exam- ple is the case of the young woman mentioned by Pott. In this ease, both ovaries had been removed by the double operation. The catamenia, although previously regular, never re-appeared. \ Donne has subjected the menstrual fluid to a careful microscopic examination, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 103 in the uterus, and the catamenial fluid in the vagina, present a very important difference. In the uterus it is really blood, pos- sessing all its elements; in the vagina, on the contrary, it loses its fibrin, for the reason that this latter product is dissolved by the vaginal mucus, which contains more or less acetic acid. You see, therefore, that the menstrual fluid, as soon as it passes into the vagina, becomes deprived, through the destruction of its fibrin, of its power of coagulability. It will, however, occasionally happen, that large coagula do pass from the vagina, and this occurs in certain forms of profuse menstruation, in which the loss is so abundant in quantity, that there is not sufficient mucus to dissolve the fibrin. Therefore, if it be conceded that the catamenial fluid within the uterus contains red corpuscles—a necessary element of normal blood—it is very evident that it cannot pass from the vessels through endosmosis or percolation ; it can only escape through rupture of the engorged capillaries. Have you ever witnessed a case of profuse haemoptysis, or hajraatemesis ? If so, the inquiry may have suggested itself to you: Where, does this immense quantity of blood come from, or, more properly, how does it pass from the lungs and stomach? The mode in which the blood escapes, in these instances, either from the lungs or stomach, is precisely the same as in the case of the menstrual fluid. It is through rupture of the pulmonary and gastric capillary vessels. In answer, therefore, to the question, what are the source and mode of produc- tion of the menstrual fluid, it may be said that, at each catamenial crisis, the capillary vessels on the internal surface of the uterus and fallopian tubes become congested, and through their rupture afford escape to the fluid. The mucus, which is more or less commingled with the catamenial discharge, consists of an epithelial secretion from the mucous membrane of the organ. Duration and Quantity lost at each Menstrual Period.—The duration of each menstrual period is from three to eight days—and the quantity of fluid lost at each monthly turn will vary from one to eight ounces. It is well, however, to remember that both the duration and quantity lost will depend upon various individual circumstances, so that there is no fixed rule with regard to either of these points ; thus the extremes, which I have mentioned, may be normal, and in accordance with the general health. One female, for example, from some peculiar idiosyncrasy, will menstruate only for one or two days, and another for six or eight; one will lose from four to six ounces, another only one or two ounces. The im- and presents the following as its constituents: 1st. Ordinary blood globules, with their special characteristics, in large quantity. 2nd. Mucous globules. 3rd. Epi- dermic or epithelial scales detached from the mucous membrane of the uterus and vagina. 104 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. portant fact, which you are to bear in recollection, is this: that the time and quantity of the menstrual discharge are always to be considered as natural, and in harmony with the demands of the economy, unless constitutional disturbances shoidd follow; these latter are the only evidences that the interposition of the practi- tioner is necessary. Is Menstruation Peculiar to Woman ?—The doctrine has gene- rally been maintained that menstruation is peculiar to the human female. If, by this, it be intended to convey the idea that the function, as it exhibits itself in woman, with all its phenomena, its duration, etc., is exclusively recognized in her, then I can see no objection to the doctrine, if, perhaps, we except the monkey tribe, for it is founded upon undeniable evidence.* If, on the contrary, it be argued that, during the period of heat, which is nothing less than a periodical aptitude for procreation, certain of the lower mammalia do not have any sanguineous discharge, no matter how slight or for how short a time, then I object to the doctrine, for it is adverse to the evidence furnished us by accurate observation. Examine, for example, the slut at the time she is about to take the dog (her period of heat), and you will find not only congestion of the parts, but also a slight sanguineous show; and during this sea- son of heat the same phenomenon is observed, so characteristic of the menstrual function in women, viz. the spontaneous maturation and escape of ovules, f Are there Poisonous Elements in the Menstrual Fluid?—Al- though, as we have stated, the menstrual fluid, while within the uterus, is essentially blood, yet there still exist differences of opinion regarding the other properties of this discharge. The ancients entertained peculiar views on this subject. It was sup- posed by some that it contained such concentrated poison, that its very exhalations would turn the purest milk sour, and throw a blight over the freshest and loveliest flowers of the garden. In- deed, I am not so confident that Pliny, and many of the writers among the Arabians, did not at least approach the truth when they * It has long been known that monkeys are subject to a periodical sanguineous discharge; and some interesting details have recently been presented by M. Neubcrt, of Stuttgart. He has had in his possession, since 1830, forty monkeys, in which he closely observed the phenomena connected with this discharge. Menstruation was regular every four weeks, as in women, and continued three or four days; this cir- cumstance was noticed in several different species. During tlie months of July and August, however, the flow was absent. The discharge occurred whether the females lived apart, or with the males; and it ceased after fecundation. As an exception, the monkeys of Australia menstruate only twice a year, and take the males only at these periods [Moniteur des Hopitaux.] \ Some interesting details will be found on the subject of menstruation in animals in a paper by Breschet, entitled, Recherches sur la gestation des quadrumanes. [Memoires de TAcademie des Sciences, t. 19.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 105 advanced the opinion that the catamenial discharge incorporated certain noxious elements. These writers, it must be conceded, were fanciful, and some of their illustrations supremely ridiculous; but laying these exuberances aside, I believe there is much truth in the aggregate of opinion they entertained on this subject. Most modern authors, however, are disposed to smile with something less than contempt at what they are pleased to term the " crude notions" of the early fathers respecting the properties of the men- strual blood. The smile might be pardoned, if those who indulge in it had given us something positive and well-defined touching this question, so interesting both in its physiological and pathological relations. I have myself no experiments to offer with the view of demon- strating that the menstrual blood positively contains noxious materials, but I argue the affirmative of this question from the pathological states which are observed to follow certain abnormal conditions of the catamenial function. For instance, in one hundred unmarried women, who may labor under suppression of the menses from the operation of any of the influences known to produce this result, such as cold, mental emotion, etc., it will be discovered that, in at least ninety-five, the suppression will be followed by more or less disturbance of the nervous system. In some, it is true, the symptoms will be slight and evanescent, but in others thev will assume a more marked character, sometimes even producing mania, coma, epilepsy, catalepsy, or chorea. May not these phenomena be due to a species of toxaemia, or blood-poisoning, traceable to the poison of the menstrual blood upon the nervous centres ? * This opinion seems to be confirmed by the important fact that the nervous disturbances cease with the return of the function. I have enjoyed full opportunities for observing the effects on the economy of the various forms of menstrual aberration; and I have also not failed to notice an extremely interesting and significant circumstance —a circumstance which certainly tends to corroborate the hypothesis that the derangements of the nervous system, under unnatural suppression of the menses, are owing to a species of blood-poisoning. The circumstance to which I allude is this: when the catamenial discharge, suddenly or otherwise, becomes abnor- mally arrested, the urinary secretion is usually diminished in pro- portion to the intensity of the nervous symptoms ; and what is still more significant is, that the nervous perturbation will yield in proportion to the effects of diuretic and sudorific remedies. There i * These nervous derangements may also be explained by the congested state of the spinal cord, as is shown in cases of paraplegia. A very decided proof that the menstrual blood contains more or less noxious elements is demonstrated by the cir- cumstance, that oftentimes gonorrhoea will be produced in the male if intercourse be had during the catamenial flow. This latter fact is beyond a peradventure. 106 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. is no.error as to the fact—its truth is readily susceptible of demon- stration. * Critical Period.—The period at which the menstrual function finally ceases in the female may be said to vary between tho ages of forty and fifty years; although it will bo found that some cease to menstruate before the age of forty, while others will exceed the period of fifty years. I think we are warranted in saving that, as a general rule, the earlier the menstrual function commences, the earlier it becomes suspended, and vice versa. The time of final cessation has been termed, very properly, I think, the critical era of female life, for the reason that certain morbid affections are apt to develop themselves at this period. You can readily understand, for example, that various diseases of the uterus may, through the monthly disgorgement effected by menstruation, be held measurably in check, although there should be a strong predisposition to their development; but when the important climacteric arrives, and there is no longer this periodical unloading of the vessels, the elements of trouble collect, and become embodied in one or other of the affections, more or less formidable, to which the organ is liable. Again : diseases of the mamma? are apt to exhibit themselves at this period, having up to this time been controlled by the derivative influence of the catamenial discharge. If to these facts we add the various local congestions—sometimes of the brain, sometimes of the lungs, liver, etc., and comprehend, also, in this enumeration of mor- bid phenomena, the various nervous perturbations, which occur at the period of final cessation, it cannot but be admitted that it is justly entitled to be denominated critical. There is one topic to which I cannot too emphatically direct your attention, and whicli has a very important bearing in a practi- cal point of view. It is extremely common for women, as the period of final cessation approaches, to be troubled with metror- rhagia; and hence it will be your duty, in such cases, to distinguish between this sanguineous discharge—which is oftentimes nothing more than one of the ordinary results of the struggle in which nature is engaged to terminate the menstrual crisis—and the dis- charge which is sometimes the prelude of carcinomatous disease of * In this connexion I may remind you of the interesting fact recorded by Andral and Gavarret in their researches on pulmonary respiration ; they have shown that, in the male, from the period of puberty to the age of thirty years, the consumption of carbon increases; while in the female, from the first menstruation and during the entire child-bearing period, the amount of carbon consumed is always the same. It would, therefore, appear that this difference in the destruction of carbon, in the two sexes, is due to the function of menstruation, which, in this respect, at least, may be regarded as an excretion liberating the system from a noxious element. If, there- fore, the function be preternaturally arrested, according to this view the economy becomes oppressed by a superabundance of carbon, and hence an infinity of patho- logical phenomena may ensue. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 107 the neck of the uterus. We are, if I remember correctly, ind^frted to Louis and Valleix for this latter essential fact. Therefore, in all cases in which, at the turn of life, metrorrhagia may occur, I would advise you to institute a vaginal examination for the purpose of ascertaining whether or not it is connected with organic disease. Should the female escape the dangers incident to this period of existence, she will, as a general rule, pass on, with the en» lyment of health, to a ripe old age. The spring-time of life is over, and she now lapses into the cold shades of winter. One of her great offices has been completed ; she has fulfilled her destiny in the birth and tender care of her children, and she now lives still to guide them by her counsels, and rejoice in their position as useful members of society. Such, then, are the three great eras of woman's exist- ence, each marked by its own striking peculiarities, and each, too, surrounded by more or less peril—the eras to which I allude are those of puberty, child-bearing, and the final cessation of the men- strual function. Aptitude for Impregnation.—There is, in the human female, as in the various species of animal creation, a period in which the aptitude to become impregnated, is much greater than at others; and it will be well for you to recollect the fact, for it may occasion- ally enable you, by judicious advice, to consummate the happiness of the married by blessing them with offspring, after years of patient but unrequited effort on their part. You know that, at the men- strual crisis, there is on the surface of the ovary a matured ovule; this, as I have told you, either becomes deciduous matter, and passes away with the menstrual blood, or, if it should have life imparted to it by the seminal fluid of the male, it lives, becomes developed, and constitutes the future being. Indeed, the ovule, at this special period of its maturity, is not unlike the luscious peach, as it hangs in full ripeness and flavor from the parent tree—if there be no hand to pluck it in its tempting richness, it falls to the ground and decays. Woman, then, is most apt to become fecundated at this particular time, when the ovule, in all its development, lies on the surface of the ovary ; therefore, the simple suggestion, on your part, to the husband to have intercourse Avith his wife just before the catamenial crisis, will very likely result in impregnation. I am quite confident that I can refer to more than one instance in which I have suc- ceeded, in this way, in adding to the happiness of parties, who for years had been honestly but vainly toiling for the accomplishment of their hopes. It is a matter of historical record, that Henry II. of Erance, after protracted disappointment, and almost desperate under baffled hope, consulted the celebrated Eernel as to the modus in quo of impregnating his Queen, Catharine de' Medici; the king was advised to cohabit with her royal highness only at the menstrual 108 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. evolution; this counsel was scrupulously observed, and the result was the birth of an heir to the crown. In India, young girls are made to marry immediately on their first menstruation, for the reason, that the doctrine is maintained there that, at each catamenial crisis, there is an ovule ready for impregnation, and if it be not fecundated, it becomes destroyed, and, therefore, it is held that the party is guilty of child murder.* It appears that this has been the law for a very long period in India, and, as it is evidently based, in a measure, on the ovular theory of menstruation, it is quite manifest that this theory is not altogether of recent origin. You perceive, gentlemen, that, in discussing the general subject of menstruation, I have said nothing of the numerous pathological conditions to which the function is exposed; these I have treated of fully in my work on the Diseases of Women and Children. * " It was upon an ancient theory respecting generation, very much resembling our own, that early marriages seem to have been instituted in India. It was said, that if an unmarried girl has the menstrual secretion in her father's house, he incurs a guilt equal to the destruction of the foetus; that is, according to the doctrine of Pythagoras, and the theory of the ovarists, all the material of the new ovum, and the ovum itself, is formed by the female: menstruation was, therefore, the loss of the ovum, or loss of the foetus." [Dr. "Webb, Prof, of Military Surgery, in the College of Medicine, Calcutta.] LECTURE VIII. Reproduction—Its Importance and Necessity—Early Opinions concerning—Meaning of the term Fecundation; in what it consists—Reproduction the Joint Act of both Sexes—The Female furnishes the " Germ-cell"—The Ovisac or Graaffian Vesicle— Membrana Granulosa—Discus Proligerus—Zona Pellucida—Germinal Vesicle— Germinal Spot—Modifications in the Ovisac previous to its Rupture—Corpus Luteum—" Coagulum" does not contribute to its Formation—Corpus Luteum not a Permanent Structure—True and False Corpora Lutea—Former connected with Pregnancy, Latter with Menstruation—Characteristics of each—True Corpus Luteum an Evidence of Gestation, but not of Childbirth—Can two " Germ-cells'' be contained in one Ovisac?—The Male Vivifies the " Germ-cell"—Spermatozoon, the True Fertilizing Element—What are the Spermatozoa ?—Contact between " Sperm- cell" and "Germ-cell" necessary for Fecundation—How accomplished—Opinions concerning—Aura Seminalis—Electrical and Magnetic Influence—Doctrine of the Animalculists—Chemical Hypothesis—Mr. Newport's Experiments on the Frog— Deductions—Where does this Contact take Place ?—Experiments of Bischoff and Valentin—Theory of Pouchet—Movements of Spermatozoa—Deductions from Analogy—Experiments of Nuck and Haighton—Fimbriated Extremity of Fallo" pian Tubes—Peculiarities of. Gentlemen—The subject next in order for our consideration is one which cannot fail to interest you, for it involves the important question—the origin and reproduction of the human species. To treat, therefore, of our own individual origin, and the mode by which the human family is propagated, is, it cannot be denied, to discuss a topic at once full of interest, and not altogether free from mystery. It would be somewhat out of place in lectures intended, as far as I can make them so, to be essentially practical, to speak of generation except so far as it relates to the production and develop- ment of the human fcetus. It may, however, be observed, that organized beings can be perpetuated only through reproduction. Let the earth be covered, the waters filled, and the universal globe crowded with living beings, and yet how soon would life become extinct, and the world a blank, were it not for the constant genera- tion of new beings to take the place of those who have run their race, and yielded to the inexorable demands of time. Look at the bills of mortality; see what myriads of the human family are swept from earth every year by disease, and the natural decay of the system—and the same argument applies to all animated creation— and then tell me whether this prodigious waste does not require a corresponding supply. It is with all living things, as it is with the 110 THE PRINCIPLES AND PRACTICE OV OBSTETRICS. existence of governments and nations; both arc to be perpetuated through the law of succession. Were it not for this great fact, how rapid and final would be the victory of death ! The subject of reproduction has occupied the attention of man from the very earliest periods of his history; and you will find that, in the remotest times of our science, hypothesis followed hypothesis in the earnest attempt to elucidate this profound and vexed problem. If we are sometimes amused at the novel and singular views advanced by the early fathers in their explanation of this funda- mental vital act, it must be remembered that their theories and reasoning were the theories and reasoning of those, who had nothing to guide them but their own observation; they were lost, as it were, in the darkness of the night; they were without the torch- lights, which the progress of science has furnished to the men of modern times, through the developments of physiology, pathology, and chemistry. While, therefore, I honor the philosophers of the" present and proximate ages, for their rich contributions of science, and bid them God-speed in their profound researches, yet I cannot but look back upon the early apostles of our profession with feel- ings of filial reverence. As pioneers, they have accomplished much ; as accurate observers, they have given us many substantial principles. Reproduction—Meaning of the Term.—Reproduction, in its strict physiological meaning, implies the development of a being, >so that it may be capable of an external or independent existence ; • hence, it consists of a series of processes, which, when completed, constitute the entire reproductive act. The first of these processes, in the human species, is the contact of the two sexes, knoAvn as copulation. The second process is fecundation, which consists in the exercise of a vitalizing influence, through the male, on the germ furnished by the female. This act of vitalization, or impart- ing life, gives rise to another process, conception. In strict physio- logical truth, it may be said the male fecundates, and the female conceives. Then follows gestation, during which the embryo grows and becomes developed; and when its development has been sufficiently accomplished, labor occurs, the object of which is to expel it from the uterus. As soon as this is effected, the entire relations of the new being are changed. It breathes, and, therefore, has a circulation of its own. It is no longer dependent upon its parent for the elaboration of its blood; its lungs, which, before birth, were without function, commence at once their round of duty; the first gasp of the infant may be considered its declaration of independence. Its organic existence is now called into action; it receives food, which, through the operation of its digestion, is converted into chyle; this latter passes through the thoracic duct into the venous THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Ill system, whence, by the ascending and descending vense cavae, it is conveyed to the right cavities of the heart, and thence to the lungs, where, through the elaborative action of these organs, it becomes decarbonized, or, if you choose, arterialized; it then is taken to the left cavities, and distributed, through the ramifications of the aorta, to all portions of the system, imparting nutrition and development to every tissue. It is a physiological truth, that reproduction is the joint act of the two sexes, and it now remains for me to show you what science has disclosed as to the respective parts assumed, in this wonderful scheme, by the male and female. It would not be profitable to array before you the numerous and conflicting theories, which have been maintained with more or less zeal on this subject; I prefer rather to present to you what I believe, at the present day, to be the accepted and recognised facts touching this interesting topic. The Germ-cell.—The female, in the act of reproduction, furnishes the ovule, or " germ-cell," which, as you have already been informed, is a product of the ovary. This ovule has no inherent power of development beyond its mere growth as an ovule ; and, as I have remarked to you, after it has reached its maturity, if it be not vitalized by the male, it perishes and passes off with the menstrual blood. The human ovum, like that in all vertebrated animals, is contained within a sac, which, externally, is in apposition with the substance or stroma of the ovary ; this sac, through courtesy to its discoverer is known, in mammals, as the Graaffian vesicle or ovisac. Its internal surface is supplied with a number of nucleated epithe- . lial cells, constituting the membrana granulosa; these cells likewise furnish a disk-like covering to the ovum—the discAs pro- ligerous. The Graaffian vesicle contains a quantity of fluid, and, in its centre, is observed the ovule. This latter, in the human subject, is extremely small, measuring not more than T^th of an inch in diameter, and sometimes much less; it has an external membrane, which, from its transparent character, is called the zona pellucida, inclosing the yolk or vitellus, the object of which is to furnish nourishment to the germ during the earlier stages of its develop- ment. In the centre of the vitellus is the germinal vesicle, which is regarded as the essential portion of the ovum; the nucleus of the germinal vesicle is denominated the germinal spot. Although the ovum is at first in the centre of the Graaffian vesicle, yet, in proportion as the contents of the vesicle approach maturity, the tendency of the ovum is to move toward the circumference of the ovisac, so that, just prior to its extrusion, it is quite near the surface of the ovary; the advance of the ovum toward the outer portion of the ovary is one of the ordinary processes preparatory to its fecundation, and is supposed by Valentin to be due to the fact that, as the ovule progresses in development, there is effused in the 112 THE PRINCIPLES AND PRACTICE OF OBSTETK1CS. lower portion of the ovisac a fluid, which presses the discus proligerus before it against the opposite wall. The Graaffian vesicle or ovisac, is said to be composed of two envelopes or layers, and it is proper that you should have a clear appreciation of its structure. In reality, the ovisac presents but a single vascular tunic formed of laminous cells, and of those so- called cells of the ovisac, irregular and grainy. This tunic is covered by a nucleated epithelium, and is immediately surrounded by the stroma of the ovary. You have been told that the ovule, when it has attained its maturity, escapes through rupture of the ovisac. But, previous to this rupture, it is interesting to note the changes which occur in the ovisac itself; for example, there is a general increase in its vascularity and an appearance of fatty cells, with an increased development of those of the ovisac, exhibiting a yellowish color, intended for the production of the corpus luteum, which is regarded by some physiologists as a mere hypertrophy of the membrana granulosa, or internal coat of the ovisac. When the ovum escapes from the ovisac, the internal surface of the latter pre- sents at first a sort of irregular cavity, from the fact that its epithelial lining is thrown into folds or wrinkles, the direct result of the contraction of the ovisac; this cavity, however, soon begins to lessen in consequence, in the first place, of the increased develop- ment of the granular cells; and, secondly, from the contraction of the ovisac itself. Ultimately, the cavity is almost entirely obli- terated, and is represented by what has been described as the stellate cicatrix. When the rupture of the ovisac is accomplished, there is an effusion of blood in the remaining cavity, forming, of course, a coagulum; this sometimes becomes deprived of its color- ing matter, and is absorbed, assuming the attributes of a fibrinous clot; at other times, the fibrine is absorbed at once, the red cor- puscles become grainy, and disappear slowly; the clot maintaining its reddish color which is due to the hematoidine. Tlie Corpus Luteum of Pregnancy and of Menstruation.—The corpus luteum was at one time supposed, when recognised on the ovary, to be a positive indication of previous gestation, and the number of these bodies represented the precise number of children borne by the parent. This opinion, however, recent researches have shown to be fallacious. In the first place, the error was no doubt, in part, owing to the circumstance that the corpus luteum was regarded as a permanent structure; and, secondly, that its color was looked upon as its exclusive characteristic. It has been very satis- factorily demonstrated that neither of these assumptions is correct, for small yellow spots may exist on the ovary independently of im- pregnation ; while the corpus luteum itself, which is the direct result of gestation, disappears after a certain period, and, therefore, is not permanent. You must also bear in mind, that whenever there is a THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 113 rupture of the Graaffian vesicle, no matter from what cause, there will necessarily be, as the product of that rupture, a corpus luteum. You have been reminded that, as a general rule, there is an escape of the ovule at each menstrual crisis; hence, there are two classes of corpora lutea, one the result of menstruation, the other of impregnation ; and, therefore, the division of these bodies into false and true—the former representing the corpus luteum of menstrua- tion, the latter that of gestation. This is an important distinction for the reason that, in more than one instance, the previous exist- ence of pregnancy has been attempted to be proved by the recogni- tion, in a post-mortem examination, of these bodies on the ovary, their mere presence constituting the only basis for such an opinion. It must, therefore, be manifest, how essential it is to have a just idea of the characteristics of the true corpus luteum, and understand in what way it is to be distinguished from the one which is simply the offspring of menstruation. I need not tell you that upon this—as on many other questions of science—there is a difference of sentiment among writers, but I believe there is a sufficient concurrence, as to the general points of distinction, to afford reliable data for opinion.* Prof. J. C. Dalton, in an elaborate paper, gives the following summary as the result of his investigations on this subject: " The corpus luteum of pregnancy arrives more slowly at its maximum development, and afterward remains for a long time as a noticeable tumor, instead of undergoing rapid atrophy. It retains a globular or only slightly flattened form, and gives to the touch a sense of resistance and solidity. It has a more advanced organization than the other kind, and its con- voluted wall is much thicker. Its color is not of so decided a yel- low, but of a more dusky hue, and if the period of pregnancy is at all advanced, it is not found, like the other, in company with unruptured vesicles in active process of development."! It is now, I believe, generally conceded that the corpus luteum, unconnected with pregnancy, and simply the product of menstrua- * After a careful review of the subject, the following conclusions have been deduced as being most likely to enable the observer to arrive at a just opinion: " 1. A corpus luteum, in its earliest stage (that is, a large vesicle filled with coagu- lated blood, having a ruptured orifice, and a thin layer of yellow matter in its walls), affords no proof of impregnation having taken place; 2. From the presence of a cor- pus luteum, the opening of which is closed, and the cavity reduced or obliterated, only a stellate cicatrix remaining, also no conclusion as to pregnancy having existed, or fecundation having occurred, can be drawn, if the corpus luteum be of small size, not containing as much yellow substance as would form a mass the size of a small pea; 3. A similar corpus luteum, of larger size than a common pea, would be strong presumptive evidence, not only of impregnation having taken place, but of pregnancy having existed during several weeks at least; and the evidence would approximate more and more to complete proof, in proportion as the size of the corpus luteum was greater." [Baly's Supplement to Muller's Physiology, page 57.] \ Transactions of the American Med. Association for 1851. s Ill THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tion, is seldom of greater volume than a small pea, while, usually, it is even less than this; from six to eight weeks it undergoes such rapid and positive diminution as to represent only a very small point on the surface of the ovary ; hence this latter will ordinarily exhibit false corpora lutea, in greater or less number, in women who have their menstrual periods with regularity. The corpus luteum of pregnancy is characterized by great vascu- larity, and this, no doubt, is explained by the fact that, at the time of fecundation, the uterine organs become the centre of an extra- ordinary afflux of blood, far greater than during an ordinary men- strual crisis. The size, too, of this corpus luteum is worthy of atten- tion, as constituting a broad distinction between it and the one which is merely the result of menstruation. As a general rule, it will occupy from one-fourth to one-half the surface of the ovary, depending upon the particular period of gestation at which it may be inspected. It is usually larger during the earlier months, say till the third to the fourth; its volume, however, will vary, occa- sionally, even at given periods of gestation, in different individuals. As the completion of pregnancy approaches, the corpus luteum begins to decline in size, and undergoes a very marked alteration—its vascularity rapidly diminishes, and its color becomes much lighter ; after parturition, whether at the full term, or as the consequence of premature action of the uterus, this body begins to fall into a state of atrophy, and so completely loses its characteristics as to render its recognition next to impossible. It is admitted that two or three months after delivery it completely disappears from the ovary ; and it is now well agreed that a corpus luteum of a previous conception (provided the gestation arrive at the full term) is never found to coexist with that of a subsequent fecundation. After the disappearance of the corpus luteum, its original site is usually noted by a small cicatrix, or line; and it is important to recollect that these cicatrices, like the corpora lutea themselves, are not perma- nent, but become, in the progress of time, more or less effaced. An exceedingly interesting question now arises in reference to the presence of the true corpus luteum on the ovary, and it is Avell worthy of a moment's thought. Is this corpus luteum always an evidence of previous childbirth, oris it only an evidence of previous impregnation ? That it is not an invariable proof that the female has borne a child, is demonstrated by the fact that there are well- authenticated instances in which the corpus luteum of gestation has been recognised without previous parturition ; but, on a critical investigation, it has been shown, in all these instances, that abortion had occurred; so that the existence of the corpus luteum, although not an evidence of childbirth, must be regarded as a proof that fecundation had taken place. A multitude of influences may ope- rate to destroy the germ, after it has been fecundated, and cause it THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 115 to undergo such marked degeneration as to prevent its recognition. Therefore, it may be, in such instances, that the presence of the corpus luteum will afford the only evidence of the conception. Again: Is it possible for a woman to bring forth twins, and have only one corpus luteum ? The reply to this question is, that there are recorded examples of two ovules being contained in one ovisac, and, consequently, in such case, there would be but one corpus luteum.* It is quite remarkable that those clever observers, Todd and Bowman, in their late work on physiological anatomy, should hold the following language, which is certainly in direct conflict with well-observed facts: " In cases of twins, two corpora lutea are always present."! As regards the existence of the true corpus luteum, and what it proves, it may, I think, be safely affirmed that the researches of modern science have demonstrated the truth of the aphorism long since put forth by that accurate observer, Haller —" Nullus unquam conceptus est absque corpore luteo." The Sperm-cell.—While, as it has been stated, it is the office of the female to provide the ovule, it is the province of the male to impart to it life, so that it may attain, through successive develop- ment, its foetal maturity. But what is this vitalizing element ? The testes are, to the male, what the ovaries are to the female. They are glands which constitute the essential organs of generation— they secrete, after the period of puberty, a seminal fluid which, according to the experiments of Prevost and Dumas, consists of elements obtained from three sources: 1. The fluid which comes • directly from the testicles; 2. The fluid which is secreted by the prostate gland; and, 3. That which is derived from the vesiculse seminales. The two latter elements are, as it were, but mere vehi- cles for the seminal fluid of the testicles. This latter contains sper- matozoa, which constitute the real fecundating element; they are small filamentous bodies, which enjoy the power of spontaneous motion, and hence they are regarded by some clever writers as veritable animalcula. It seems, however, to be shown that they are not animalcula, but partake of the character of the reproductive portions of plants, which also possess a spontaneous movement as soon as they have been thrown from the parent mass; and it is like- wise conceded that the ciliated epithelia of mucous membrane will continue for some time in movement after their separation from the body. Among those who maintain that the spermatozoa partake of the character of animalcula may be mentioned Monro, Haller, Spallanzani, Valentin, Pouchet, and others; while Coste, Charles Robin, and other observers believe the contrary. In man there are developed within the tubuli of the testicles * An interesting example of this kind is cited by Dr. Montgomery, in the second edition of his work, p. 375. f Page 851. 116 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. what are known as the spermatic cells, within each of which is a vesicle of evolution,* as it has been termed, and in each vesicle there is a spermatozoon. It is quite obvious that the sper- matozoon, the duty of which is so important, cannot boast of much magnitude—in the human being it consists of a small, oval- shaped body, measuring, in length, from ^th to ?^oth of a nne 5 its tail, terminating in a very delicate point, is from Jjjth to TVth 0I> a line. Its power of movement, it appears, is chiefly through the undulations of the tail. M. Godardf has recently discovered in man a new species of spermatozoon, with a very small head, and the tail is endowed with much more rapid and durable movements than the tail of the common and well-known spermatozoon. The essential fact to be recollected is, that the spermatozoon represents the true fertilizing element, and possesses the exclusive power of imparting life to the ovule of the female. It has been shown by Donne that the spermatozoa are deprived of all power of motion under peculiar conditions of the vaginal and uterine secretions—for instance, when there is a morbid acidity of the vaginal mucus, or an excessive alkaline secretion from the uterus. This inability to move is, of course, tantamount to the destruction of the fecundating attribute now so generally ceded to the spermatozoon. Therefore, the practical fact is to be deduced that these morbid secretions of the uterus and vagina may sometimes, through their influence on the spermatozoa, be the cause of sterility. Wagner has not found spermatozoa in the mule ; and it is well known that most hybrids do not produce offspring. Indeed, it was formerly supposed that all hybrids failed in the fecundating power. It has very lately been shown, however, that there are some exceptions to this rule.J Theories of Fecundation.—It is curious to note the various and discordant theories, which have been advanced from time to time in explanation of the true modus in quo of fecundation. For example, it was once imagined that there passed from the seminal fluid of the male a vapor—an aura seminalis—and that it was through the agency of this latter that life was imparted to the ovule ; and, again, it was maintained that the fluid, after being deposited in the vagina, was absorbed, and reached the ovule through the circulation. Electrical and magnetic influences have also been invoked to demonstrate the profound problem of vivifica- tion. The animalculists, too, contended that each drop of the male sperm contained myriads of living germs already formed, and that, during coition, they are thrown into the uterus, and all of * While in man there is but one vesicle of evolution in each spermatic cell, in animals there are several. f Etudes sur la Monorchidie, etc. 1857. pp. 73, 74. % Memoire sur l'Hybridite en general, etc. By Paul Broca. Journal de la Physiologie de l'Homme et des Animaux. p. 433. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 117 them, with the exception of one, die; the one which is fortunate enough to escape destruction passes through the fallopian tubes to the ovary, and penetrates a small vesicle which has been prepared for its reception—it then is brought back through the tube to the uterus, where it remains until its full development has been com- pleted. This doctrine of the animalculists is indeed fearful for the con- templation of the philanthropist—it implies a slaughter of human beings unexampled in the pages of history. There is nothing in the carnage of the battle-fields of ancient or modern warfare, which can approach this melancholy sacrifice of human life. With this hypothesis, the reproduction of one's species is no trifling matter—conscience, in my opinion, must become veritably seared before engaging in any such enterprise ! On the supposition that the spermatic fluid, like the blood, is chemically so constituted that constant motion is absolutely neces- sary for the maintenance of its fecundating properties, Valentin, Bischoff, and others, have advanced the hypothesis that the only object of the spermatozoa is, through their active movements, to preserve the chemical composition of the fecundating liquor. Carpenter, and other physiologists, are of opinion that Mr. New- port's* recent observations render it very probable that the contact between the ovule and spermatozoon causes the latter to undergo solution ; and that the essential act of fecundation consists in the passing of the product of this solution into the interior of the ovule, thus blending, as in plants, the contents of the " sperm-cell" with those of the "germ-cell." Indeed, it seems now conceded by the very best observers, that it is not simply contact between the "germ-cell" and "sperm-cell," but that actual penetration takes place at the time of fecundation. Among others, in confirmation of this view, I may cite the names of Martin Barry, Mensner, Kohen, and even Bischoff, who for a long time had doubted the fact—all these have absolutely seen the spermatozoa penetrating the ovum. Seat of Contact between the Germ and Sperm Cells.—In what particular portion of the uterine organs does this contact between the "sperm-cell" and "germ-cell" take place ? Is it in the uterus, fallopian tube, or ovary ? There has existed, and there still con- tinues to exist, much difference of opinion upon this subject. The early fathers maintained that the uterus itself was the seat of this * In his experiments testing the mode of impregnation in the frog, Mr. Newport has shown that the spermatozoa become imbedded in the gelatinous envelope of the ovule in a few seconds after contact has been accomplished; thence they penetrate the vitelline membrane, and pass to the interior of the ovule. These experiments of Mr. Newport have been fully confirmed by Bischoff—[Philos. Transac. 1853 pp. 226, 281.J 118 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. contact—and, no matter how discrepant their theories regarding other points touching the question of reproduction, yet there appears to have been a very general assent to the tact that the uterus constituted the special seat in which vivification was accom- plished. At the present day, however, some of the cleverest physiologists believe that the "germ-cell" is vivified by the " sperm- cell" very generally in the ovary ; and this opinion, it seems to me, is founded upon acceptable, if not irresistible, evidence. Bischoff, Coste, Wagner, Barry, Valentin, and others, have positively recog- nised spermatozoa on the ovary of animals killed soon after copula- tion. The following passage from Bischoff is to the point: " I had frequently observed spermatozoa in motion in the vagina, womb, and fallopian tubes of bitches ; but, on the 22d of June, 1858, it was my good luck 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, p.m., and again on the following afternoon at two o'clock; at the expiration of half an hour, that is, twenty hours after the first copulation, I killed her, and found several living spermatozoa, endowed with very active motion, not only in the vagina, uterus, and tubes, but even amid the fringes of the latter, in the peritoneal pouch which surrounds the ovary, and on the surface of the ovary itself." Valentin speaks as follows: " On opening the body of a female mammal, one or more days after it has received the male, semen may be found, not only in the body and horns of the uterus, but also in the oviducts, and on the sur- face of the ovary." Here, then, we have more than mere hypothesis ; we have posi- tive affirmation ; and this same character of testimony could be much increased by other observers, but I do not deem it necessary to make further quotations. If, together with the essential fact that living spermatozoa have been seen, soon after copulation, on the surface of the ovary, it be recollected that the existence of ovarian and ventral pregnancy has*been satisfactorily demonstrated, it does appear to me that it follows, almost as a necessary consequence, that the seat of contact between the two germs is in the ovary. Nature rarely runs vagrant; while she is abundant in her pro- visions for the wants of the system, yet she always exercises a wholesome jurisdiction ; superfluity is not one of her faults ; on the contrary, in all her operations she is characterized by a prudent and conservative economy. Why, then, should living spermatozoa be found on the ovary, soon after coition, if it be not in accordance with nature's design ? Will it be said that this is a mere coinci- dence, an exception to the general rule, as Pouchet has endeavored to show ? This latter writer, I think, has signally failed in his theory upon the subject. He advances as an argument why the ovary cannot be the point of contact between the germs, that the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 119 peristaltic movement of the fallopian tube is from within outward, and that, on this account, it cannot convey the semen of the male from the womb to the ovary. It does not appear to me that there is much force in this reasoning, so far as the question at issue is concerned, for, admitting the truth of the direction of the peri- staltic movement of the tube, it does not, in my judgment, in any way invalidate the opinion that the fertilizing element of the semen reaches the ovary, and there vivifies the "germ-cell." You have been told that the spermatozoa enjoy a power of movement, and it is now ascertained that their progress is equal to one inch in thirteen minutes. I believe, therefore, that they find their way to the ovary m virtue of their own movement; as soon as they are thrown from the male into the vagina they commence their journey. The experiments of Nuck and Haighton are quite conclusive as to the ovary being the seat of contact between the germs. You will remember that, in placing a ligature, soon after copulation, around the fallopian tube, and some time afterward killing the animal, Nuck found that fecundation had occurred, and that the development of the ovum was going on in the ovarian extremity of the tube. Haighton, on tying the tube in rabbits, ascertained that fecundation did not take place on that side in which the ligature had been applied. Indeed, the most recent observers seem generally to agree that the ovary is the place of meeting of the two germs. Montgomery says, "After the best consideration I could give to it, it is the conclusion arrived at in my mind." In connexion with this point, it maybe stated that Coste has recently started a new theory in explanation of why the ovary must neces- sarily be the place of union between the sperm and germ cells. He says, the ovule, as soon as it passes from the Graaffian vesicle, undergoes alterations, which render it totally unfit for fecundation. In conclusion, I think it may be affirmed, without denying the occasional meeting of the germs in the uterus and fallopian tubes, that the union is most generally accomplished in the ovary. How does the Fecundated Ovule find Admission into the Fallo- pian Tube?—This question has generated numerous hypotheses; but none of them are without objection. It has. generally been supposed that the fimbriated extremity of the tube is made to grasp the surface of the ovary, through the contraction of its muscular fibres; it is very evident, however, as Rouget has remarked, that it is the action of the longitudinal fibres only which could in any way affect the position of the free extremity of the tube ; but the immediate result of the contraction of these fibres would be a diminution in the length of the tube; consequently, instead of approximating its extremity to the ovary, the necessary tendency would be to place it more remote from that body. He, 120 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. therefore, repudiates this explanation, and refers tlie contact of the fimbriated extremity of the tube with the ovary, at the time of ovulation, to the combined contraction of what he terms the ovarian-tubal muscular fasciculi. It is a veritable spasmodic con- traction of this«nuscular apparatus, which consummates the contact. But the question arises as to the special influence, which origi- nates this muscular contraction, or, in other words, what is it that throws these fibres into action ? When the Graaffian vesicle has attained its development, and is matured, the distension of the muscular fibres proper to the stroma of the ovary begets a reflex movement, which is immediately transmitted to the tubo-ovarian muscular system. This latter contracts, and this "brings the extremity of the tube in close contact with the ovary. The ovule is detached, and then conveyed through the vermicular movement of the tube itself to the uterus, where it remains sufficiently deve- loped to prepare it for an independent or external existence. Precisely the same thing takes place in menstruation ; so that whether the ovule be fecundated or not, it drops, as it were, from the ovary, and is received into the tube to be conveyed in the latter case to the uterus, and pass off as a deciduous body with the catamenial discharge. The approximation of the tube to the ovary, at the menstrual period, is explained upon the same principle as when fecundation occurs.* I have now, gentlemen, given you, very briefly, what may, I think, be considered the accepted facts of science touching this interesting question of reproduction in the human species. In the discussion of the subject, I might have entered into many import- ant details, elucidating propagation in the vegetable and animal kingdoms; but, as I have already remarked, such details would not be in keeping with the practical tendency of these lectures. * In certain cases of local peritonitis, it will sometimes happen that, as the result of the inflammation, there will be an adhesion of the fimbriated extremity of the tube so remote from the ovary as to prevent contact at the time of ovulation. This, of course, would result in sterility, or in extra-uterine fcetation. LECTURE IX. Pregnancy; Definition and Divisions of—Is Pregnancy a Pathological Condition?— The Uterus and Annexaj before and after Fecundation—Two Orders of Pheno- mena following Impregnation; Physiological and Mechanical—How the Uterus Enlarges—Microscope and its Proofs—Development of the Muscular Tissue of the Uterus; how accomplished—Solid Bulk of Uterus at Full Term—Meckel's Esti- mate—Increase of Blood-vessels, Lymphatics, Nerves, and other Tissues of Uterus — \ausea- and Vomiting; how produced—Influence of Nausea and Vomiting on Healthy Gestation ; the Explanation of this Influence—Blood—how Modified by Pregnancy—Is Plethora characteristic of Gestation ?—Cause of this Hypothesis— Treatment of Acute Diseases in Pregnane)'—Aphorism of Hippocrates on this Question—Increase of Fibrin in Inflammation—Deductions—" Buffy Coat" not always the Product of Inflammatory Action—" Buffy Coat" in Chlorosis, Preg- nancy, etc.—Kiestine; what its Presence indicates—Blot's Experiments—Sugar in the Urine of the Puerperal Woman—Deductions—How are we to know that Pregnancy exists? Importance of the Question; its Medico-legal bearings; Illus- tration —The Proof of Pregnancy altogether a Question of Evidence; how this Evidence should be examined. Gexixemen—We shall speak to-day of the important subject of pregnancy; in all its bearings it is full of interest, and whether in its normal, pathological, or legal relations, claims the profound thought of the practitioner. Pregnancy may be defined to be that condition of the female, which exists from the moment of fecunda- tion until the exit of the child from the maternal organs. It is divided into true, false, uterine, extra-uterine, and interstitial. In true pregnancy, there is really a foetus; in false, the enlargement is dependent upon something other than a foetus ; when the product of conception is situated within the uterus, the gestation is called uterine ; when, on the contrary, the foetus is lodged externally to this organ, it is known as extra-uterine, of wdiich there are three vari- eties, viz. abdominal, fallopian or tubal, and ovarian. In the first of these varieties, the embryo, under a rule of exception, does not reach the uterus, and becomes developed in some portion of the abdominal cavity; in the second, in the fallopian tube; and in the third, it receives its growth in the ovary. We shall hereafter have occasion to describe more particularly each of these varieties. There is another form of gestation in which, strictly speaking, the foetus is developed neither within nor without the uterine cavity ; and you may well ask—How is this ? It is called inter- stitial pregnancy, for the reason that the foetus does not rest under 122 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. either the peritoneal or mucous coverings of the uterus, but is found amid the meshes of muscular fibres of the organ, and hence the propriety of its name—interstitial. There have been many attempted explanations of the manner in which the fecundatoo ovum finds its way into this intermediate structure, but none of them are satisfactory, for they do not seem to be founded on cor- rect data.* The cardinal fact, however, that interstitial pregnancy does sometimes exist, cannot be denied, for it has been recog- nised by several trustworthy observers. In addition to the varieties already enumerated, pregnancy is divided into simple, compound, and complicated. In the first, there is but one foetus ; in the second, there are two or more; while iu the third variety, besides a foetus, the gestation may be complicated with an abnormal growth, such as a polypus, fibrous tumor, or ovarian enlargement. Pregnancy not a Pathological Condition.—There has been a difference of opinion as to the true nature of pregnancy, so far as the general laws of the economy are concerned ; and conflicting views have been advanced as to whether it is or is not a patholo- gical condition. There can be no doubt that the general system, as the direct consequence of impregnation, undergoes numerous modifications ; and it is entitled to consideration whether, as a general rule, these modifications should be regarded as evidences of morbid action, or whether, on the contrary, they should not be accepted as testimony that nature is engaged in the attainment of an object, which she cannot accomplish except through the opera- tion of certain changes, which, although not morbid, will neces- sarily encroach more or less on that integrity of function, or, if you prefer it, equilibrium of forces, which, in the unimpregnated female, is looked upon as the standard of health. It does seem to me that this question has been somewhat misapprehended by certain writers, and they have mistaken natural processes for pathological phenomena; they have regarded the workings of nature, under peculiar circumstances, as the manifestations of morbid influence; and hence, in their judgment, the important and interesting period of gestation is a period of diseased action. Even without invok- ing the aids of science, common sense, it seems to me, runs directly counter to such an hypothesis. The destiny of woman would, indeed, be one of bitter anguish, if, in addition to her other sorrows, it were decreed that, while engaged in the great act of the reproduction of her species, she * One author, Breschet, says, that if any obstacle should oppose the ovum in its entrance into the uterus, it might glide into some one of the venous sinuses, which, he maintains, are found to open at the origin of the fallopian tubes. The existence of these sinuses has never been demonstrated, and it is now admitted that this eminent anatomist was in error. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 123 should necessarily be subject to the inconveniences and perils of disease. So far, then, from regarding gestation as a pathological state, we maintain that, as a general principle, it is entitled to be denominated a period of increased health. I am speaking now of the general rule, and not of the exceptions, to which we shall here- after have occasion to direct your attention. Indeed, some of the very best observers have declared—and the fact is well established by statistical data—that the probability of prolonged life is increased as soon as pregnancy occurs. Let us now take the con- verse of this proposition, and you will see, in its results, an addi- tional proof that gestation is not in truth a diseased condition; look, for example, at those females who, either from choice or necessity, lead a life of celibacy, and see how much greater is the record of their mortality. Marriage* and pregnancy, therefore— however true religion and an earnest love for God may fill the cloister by devoted and self-sacrificing ladies—should be regarded as among the covenants of nature, and the demonstration is found in the fact of the better health and greater longevity of-those who keep these covenants inviolate. Pregnancy, although not a condition of disease, is one of excite- ment, in which the entire economy more or less participates ; and to show you how emphatically and promptly the system responds * It is worthy of remark that marriage is conducive to health and longevity, with certain qualifications. Some interesting facts have recently been presented by Dr. William Farr upon this subject, based upon statistics derived from the population of France; these statistics receive additional importance from the circumstance that tho returns extend over the whole of France, and include all grades of its population- According to the census of 1851, with a view of showing the influence of the conju- gal relation, the population is divided into three classes: 1. The married: 6,986,223 husbands; 6,948,823 wives = 13,935,046 married persons. 2. The celibates, or those who have never married: bachelors, 4,014,105; spin- sters, 4,449.941 = 8,464,049. 3. The widowed: widowers, 835,509; widows, 1,687,583 = 2,523,092 It appears that, in France, marriage is legal for males at 18, for females at 15; and it is shown that the mortality among the married women under 20 years was double that among the unmarried; while the mortality among the married men at this youthful age was greatly in excess of that of the unmarried. The rate of deaths in the married women was 14.0 in 1000, and among the maidens it was only 8.0# In the married men it was 29.0 in 1000; in the unmarried 7.0. These facts carry with them their own comment, and should serve to admonish parents against the early marriage of their children, before the physical system is sufficiently developed to sustain the requirements of that state. From the ages of 25 to 30, the mortality of the unmarried is slightly in excess, being 9.2 to 9.0. From 30 to 40 the deaths among the wives were 9.1, and among spinsters, 10.3. After 40 years of age, the rate of mortality is still more in favor of the married in women, being, from 40 to 50, 10.0, while in the unmarried it is 13.8. From 50 to 60, married, 16.3; unmarried, 23.5 ; and above 60, married, 35.4 ; unmarried, 49.8. It would seem, therefore, that, all things being equal, matrimony tends to the pro- motion of health and longevity. 12-1 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. to the changes induced by impregnation, it may be mentioned that oftentimes, with the quickness of thought, constitutional sympa- thies, more or less marked, supervene on the act of fecundation; it is only necessary to understand why this is so, in order that you may appreciate, and, at the same time, see in these sympathies an evidence, not of a pathological state, but an evidence that a new link has been added to the chain of phenomena which nature recognises as rightly belonging to her. It is interesting to note the considerate kindness with which the pregnant female was treated in ancient times. Indeed, she became the object of special attention and regard. Among the Jews she was, during the period of her gestation, permitted to partake of whatever meats she desired, no matter how strongly prohibited by the Mosaic commandments at any other time. It was a recognised custom, too, among the Athenians, to absolve from punishment the murderer, whose hands were yet wet with the blood of his victim, if he sought shelter in the house of a woman carrying her child. Changes in the Uterus during Pregnancy.—The uterus and its annexae in the unimpregnated female are, except at the menstrual periods, in a state of quietude, and have but little participation in the affairs of the economy. But as soon as fecundation has been consummated, and even before the vivified ovule reaches the womb, this organ is summoned upon active and continued duty, involving changes in its local condition, which immediately awaken constitu- tional excitement, and lead directly to increased vital action.* The uterus now becomes a new centre; from a comparatively inert, passive organ it is suddenly converted into one of the highest grade of activity—new duties now devolve upon it—it is no longer in a state of rest—it is converted into a domicile for the accommo- dation of the embryo ; but as this latter requires for its develop- ment something more than a place of temporary sojourn, and as, like all living beings, it can only grow by being nourished, there is an afflux of fluids directed toward the uterus, freighted with ele- ments necessary for the nourishment of the germ. These duties and changes incident to the organ, necessarily impart to it increased structure and volume; and in proportion as these changes take place, two orders of phenomena ensue—1. Physiological; 2. Mecha- nical. The former class appertains to the transmission of influences to the various portions of the economy through the ganglionic system of nerves ; the latter has special reference to the pressure and consequent disturbance exercised by the developing uterus on * Harvey has compared the sudden change occurring in the uterus from impreg- nation to the lip of a child stung by a bee, " nempe ut puerorum labia (dum favos depeculantur, ut mella liguriant) apum, spiculis icta, tument, inflammantur orisque, hiatum aretant." [Harv. Exercitatio 68, p. 4:ss.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 125 the adjacent organs. We shall, when speaking of the symptoms of pregnancy, call attention in detail to these phenomena, and endeavor to give to each one of them its true value. Development of Impregnated Uterus—Mucous Membrane.—The microscope has revealed some very interesting facts regarding thp. manner in which the uterus commences to increase in volume, as a consequence of impregnation. For example, the first change in the structural arrangement of the gravid organ is recognised on its internal or mucous membrane ; as early as the second week, it becomes notably thickened in its texture, and assumes a much more lax character ; its color is quite red, the result of increase in the contents of the blood-vessels, and folds or plicae are now per- ceptible, so that it can be distinctly separated from the muscular coat of the organ. All these changes become much more apparent as the period of pregnancy advances, and the result is that the mucous membrane (except that portion lining the cervix) lapses into an hypertrophied condition, and constitutes the decidua vera, to which Ave shall more particularly allude when treating of the envelopes of the foetus. Peritoneal or Serous Membrane.—It is only necessary to recollect the distribution of the peritoneal covering on the anterior and posterior surfaces of the uterus, together with its firm attachment to portions of these surfaces,* to appreciate the necessity for an increase in its elements so that it may, without undergoing lace- ration, continue the same relations with the gravid uterus, which are shown to exist between it and the unimpregnated organ. It was formerly supposed that the broad ligaments—simply dupli- cations of the peritoneum—were arranged in folds which, under the influence of gestation, expanded, and thus enabled the peritoneal membrane to keep pace, without involving its integrity, with the developing uterus. There is no truth in this hypothesis, and it is now admitted that the peritoneum, in common with the other tissues, really receives, as one of the results of pregnancy, an increase of elements, or, in other words, exhibits an hypertrophied condition. Muscular Structure.—The muscular tissue of the uterus also undergoes important modifications, which result in a general increase in the volume of the organ. It is a well-established fact that this muscular tissue becomes developed in two ways: 1. By an increase in the pre-existing elements; and 2. By a new formation of them. For the first five or six months of gestation there are generated new fibres, and those which previously existed assume an extraordinary growth, their length presenting an addition of from seven to eleven times, and their width from two to five. The connecting tissue, which unites the muscular fibres, also pre- * See Lecture 6th. 126 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sents an increase, so that at the end of pregnancy, distinct fibres can be recognised.* Such is the gradual development of the uterus from the time of fecundation until the completion of the period of utero-gestation, that its solid bulk has been estimated by Meckel to be, at the end of the ninth month, twenty-four times greater than in the unimpregnated organ. This excess of development is principally due to the enhanced growth of the muscular tissue, and, as obstetricians, it is interesting for you to know that, until the sixth month of pregnancy, the -walls of the uterus undergo a successive thickening, while the cavity also becomes increased; but, after this period, the walls diminish in thickness, and the area of the uterine cavity, in order to accommodate the foetus, is still much augmented. The serous or peritoneal covering, as has just been remarked, also becomes thickened; and there is, in fact, an increase in all the tissues of the organ; the blood-vessels and lym- phatics become larger and more distended, and the nerves, whether partly from the production of new nerve-fibres or not, are enhanced in length and width by the growth of their pre-existing elements. Such, very briefly related, are some of the structural modifica- tions produced in the uterus as the result of pregnancy; and you cannot fail to perceive that all these changes are intended for the accomplishment of two objects, viz. in the first place, for the accommodation of the growing embryo, thus affording it a place of temporary sojourn ; and secondly, for the provision of the elements necessary to its nourishment. There has been much discrepancy of opinion as to the special arrangement or distribution of the muscular tissue of the gravid uterus. Madame Boivin, who gave much attention to the subject, and whose fine delineations of this structure have commended themselves to the highest consideration, recognises in the impreg- nated womb three orders of fibres : 1. On the external surface of the organ, there are planes of fibres, which proceed from the median line obliquely downward and outward, toward the inferior third of the uterus, passing in the direction of the round ligaments, of which they constitute a large portion; some of these fibres pass also to the fallopian tubes and ovaries; 2. On the internal surface, there are observed circular fibres, and their central point is the in- ternal orifice of the tubes; 3. Between the two planes of fibres just described, there is a third layer, which is regarded as inextricable. On the other hand, Deville has quite recently endeavored to show that Madame Boivin was in error in her description. There are according to this observer, two orders of muscular fibre on the exter- nal surface of the organ—one transverse, the other longitudinal. The former are derived from the round ligament, fallopian tube, KdUiker"8 Microscopical Anatomy, p. 650. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 127 and ovary, and also from the wing of the corresponding round liga- ment. Near the median line, these transverse fibres are inter- sected perpendicularly by a longitudinal band, describing curves more or less marked. This longitudinal band originates, in front, near the union of the body with the neck of the uterus, and passes from below upward to the fundus, and again proceeds from above downward on the posterior surface, terminating a little below the junction of the neck and body of the organ. There is, he remarks, a positive line of continuity between the transverse and longitudinal fasciculi. The former, as soon as they approach the median line, become curved, some downward and others upward, so as to become longitudinal, and in this way do actually constitute the median longitudinal fasciculus. This is observed on both the anterior and posterior surfaces of the organ. On the internal surface, there is the same general description of the muscular fibres as on the external surface. In Figures 37 and 38, taken from Cazeaux, who acknowledged his indebtedness for them to the courtesy of M. Deville, the arrangement of the mus. cular structure, as described by this anatomist, is graphically exhibited. Constitutional Sympathies.—The changes in the local condition of the uterus are promptly followed by more or less constitutional excitement. One of the very first organs in which this excited action is manifested is the stomach, as is shown by the nausea and vomiting, which, in many instances, so quickly, and, in the great majority of cases, so generally, supervene upon pregnancy. There is very little doubt, I imagine, now entertained as to the manner in which the nausea and vomiting are produced. The uterus, you have seen, becomes, as soon as fecundation is accomplished, a new and active centre. Extraordinary changes of structure ensue; all this necessarily induces more or less irritation from the uterus to 128 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the stomach through a reflex action of the spinal cord; this irri- tation is transmitted to the stomach, and, as a consequence, nausea and vomiting are developed. Now, I can readily understand that you may, at first sight, imagine this to be an argument against the assumption that pregnancy cannot be properly considered a patho- logical or diseased condition. But such an inference has no just basis, for I hold that the nausea and vomiting of pregnancy, under ordinary circumstances, instead of being regarded as pathological, are, in truth, physiological phenomena; and it is, in my judgment, precisely for the want of* such distinctions that the error has obtained regarding the true condition of the female, while in gestation. I do not think there is any fact, as a general fact, better esta- blished than that pregnant females, who escape nausea and vomit- ing during gestation, are exceedingly apt to miscarry. If this really be so—and your future observation will, I am quite sure, abundantly corroborate the statement—there must be some im- portant connexion between this gastric irritability and a normal pregnancy—a connexion which holds the relation of cause and effect. What are the facts? As soon as impregnation takes place the uterus becomes suddenly congested, and this tendency of the blood toward the organ continues in unbroken currents until the completion of gestation.. Without some derivative influence, in the earlier periods of pregnancy, to hold in salutary check this determination of blood toward the uterus, its nervous structure would become so overwhelmed and irritated that premature action of the organ, and expulsion of its contents, would be the con- sequence. In order, however, to guard against such contingencies, nature has found it necessary, in the plan of her operations, to institute two phenomena—nausea and vomiting—the direct result of which is, for the time, to produce relaxation of the general mus- cular tissue, and increased activity of that essential emunctory— the perspiratory surface. I need not explain to you how relaxation of the muscular system, and increased perspiration, necessarily tend to antagonize local congestions. This law, so well established, constitutes the funda- mental basis for the therapeutic treatment of inflammatory affec- tions. Why are you told in aggravated attacks of inflammation of any of the vital organs—in pneumonia, for example—to bleed to syncope? Is it not because of the absolute necessity, in order that life may not be sacrificed, that an immediate and powerful impression be made on the system—and what so potent in its influence to break up the local congestion as the two immediate results of syncope—relaxation and free perspiration?* There is * I am so well satisfied of the importance, so far as a healthy gestation is con- cerned, of the two phenomena—nausea and vomiting—and so truly do I regard them as necessary links in the chain of processes instituted by nature for the sue- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 129 another argument, I think, to show how necessary this gastric disturbance is to the completion of pregnancy, and it is this—as a general principle, it subsides about the middle period of gestation, the uterus, by this time, having become accustomed to its new condition, and, therefore, from this cause at least, in no danger of premature action. Changes in the Blood.—But, gentlemen, let us look at another modification resulting from pregnancy, and see how far, as many writers claim for it, it is entitled to the denomination—pathological —I allude to the change which the blood undergoes during gesta- tion. Through the researches of that clever observer, Andral, subsequently confirmed by the observations of Becquerel and Rodicr, the important fact has been established, that, for the first five months of gestation, the absolute quantity of fibrin in the blood is diminished, and that the red corpuscles are also less in quantity. The amount of fibrin, they allege, after this period, is subject to variation; but it ordinarily becomes increased between the sixth and seventh, and eighth and ninth months. It must be remembered that this condition of the blood is not a mere coin- cidence ascertained to exist in one, two, or three given cases of pregnancy; but the value of the circumstance consists in the broad cessful accomplishment of the work of reproduction, that, when these phenomena are absent, I invariably have recourse to minute doses of ipecacuanha for the pur- pose of inducing an irritable condition of the stomach. In more than one instance, I have succeeded in this way, in carrying ladies to their full term, who had previ- ously miscarried—and in whom, on inquiry, there could be detected no cause £>r the miscarriage, except that they had experienced neither nausea nor vomiting. In illustration, the following case, among several others, is not without interest: In November, 1851, I was consulted by a lady from the State of Georgia, who imagined she was laboring under some disease of the uterus, which, as she supposed, had prevented her from bearing a living child, having miscarried twice successively at the third month of her gestation. After a very careful examination, I could detect no disease of the uterus, nor could I ascertain, on inquiry, that any of the ordinary special causes had operated in the production of the miscarriages. On questioning her particularly as to the state of her health while pregnant, she laughingly observed: "Why, sir, my health was, in both instances, most remarkable; my appetite was surprisingly good, and I did not know what it was to have a moment's sick stomach." Judging that this was a case of miscarriage from the absence of the usual symptoms—nausea and vomiting—I so expressed myself to the lady, and enjoined upon her, as soon as she again discovered herself to be pregnant, to commence with from a fourth to half a grain of ipecacuanha once, twice, or thrice a day, as circumstances might indicate, for the purpose of producing nausea, thus simulating, as nearly as possible, the course pursued by nature, when not contra- vened by influences which she cannot control. This treatment to be continued until about the fourth month of pregnancy, at which time, sometimes earlier, some- times later, the nausea and vomiting, usually attendant upon gestation, as a general rule, cease. My patient returned home, and, in twelve months afterward, I received a letter from her physician, Dr. Raymond, in which he remarked: " Your remedy has been attended by the happiest result. Two weeks since I delivered Mrs. H. of a fine son." 9 130 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ground that this is the general characteristic of the blood during gestation; henec, a pregnant woman may be said to be chloro- aiuemic, simulating, somewhat, the condition of chlorosis, between the pathology of which and the blood of pregnancy there is a striking analogy. This seems, indeed, to come in direct conflict with the very general opinion that pregnancy is usually accompanied by a state of plethora; and hence, under this latter impression, the too common practice is, for any supposed fulness in the head, or pain in the chest or abdomen, the free abstraction of blood by the lancet. This is not only, in ray judgment, empirical, but it is oftentimes very pernicious practice. To the abstract practitioner, pain in the head, etc., may indicate plethora, and, consequently, the wisdom of blood-letting. Not so, however, with the well-educated physi- cian, who rejects the testimony of mere symptoms as utterly worthless, unless accompanied by a knowledge of the causes to which they are due. Who, for example, does not know that one of the prominent accompaniments of an anaemic or bloodless con- dition of the system is intense cephalalgia, with intolerance of light —and are not these, also, the two prominent and distressing symp- toms of that most fearful disease, phrenitis, or inflammation of the brain ? Then, gentlemen, in the name of truth, what is the value of symptoms, unless elucidated by their antecedents? In the two examples which I have just cited, you see precisely the same character of symptoms, but due to precisely opposite causes. In thje one, tonic and stimulant treatment is indicated—while, in the other, the only hope of rescue is in the prompt and uncomprising use of the lancet, and other depletory measures. The opinion that pregnancy is accompanied by a plethoric con- dition of system is by no means of recent origin—and it seems to have sprung from the belief generally entertained that, as during gestation there is usually a suppression of the catamenia, the very accumulation of this fluid in the system of the gravid female must necessarily induce a state of plethora. This, however, is false reasoning; for the quantity of blood thus retained can, by no mode of calculation, compensate for the amount provided by the mother for the foetus and its annexse, during their intra-uterine develop- ment. So generally did the idea of plethora and pregnancy pervade the teachings of many of the early schoolmen, thatk Avas one of their injunctions to bleed the pregnant female at least three times while carrying her child; indeed, the observance of this maxim was regarded as essential to the safety of both mother and offspring. Unfortunately, the error has reached our own times, and as a mere matter of tradition, has a strong popular support. When engaged in practice you will appreciate the necessity of firmly resisting this delusion, which may almost be considered a popular superstition. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 131 Allow me here to remark that, as a general principle, if the preg- nant female observe strictly the ordinances which nature has incul- cated for her guidance ; if, for example, she take her regular exer- cise in the open air, avoid, as far as may be, all causes of mental or physical excitement, employ herself in the ordinary duties of her household, partake of nutritious and digestible food, repudiate luxurious habits, the exciting accompaniments of the dance, late hours, late suppers, etc.; if, I say, she will steadfastly adhere to these common-sense rules, the reward she will receive at the hands of nature will be, general good health during her gestation, and an auspicious delivery, resulting in what will most gladden and amply repay her for her discretion—the birth of a healthy child, which is to constitute both the idol of her heart, and the study of her life. But if, in lieu of these observances, the pregnant woman pursue a life of luxury, " eat, drink, and become merry," neglect to take he> daily exercise, and prefer her lounge—then the case is entirely reversed; she becomes plethoric, and, if not relieved by the employment of the lancet,* and other appropriate remedies, she oftentimes dies, having blotted herself from life by her own folly! You see, therefore, that pregnancy per se is not, in reality, a condition of plethora, but becomes so through the vio- lation of the laws prescribed by nature; and this is equally true with regard to the general health of the female during her gravid state. It must, however, be borne in mind that gestation exercises no talismanic influence, nor can it constitute itself an iEgis by which to guard the female against the invasion of diseases incident to human nature. For example, a pregnant woman may be attacked with pneumonia, pleurisy, or other of the formidable phlegmasia?; in one word, she is liable to any of the numerous catalogue of human maladies; and this brings me, for a moment, to the consi- deration of the treatment of these affections, when occurring in a state of gestation. Hippocrates propounded the maxim that " an acute disease of any kind, seizing a woman with child, generally proves mortal"—mulierem utero gerentem morte quodam acuto Uthali.\ Van Swieten, the illustrious commentator of the no less illustrious Boerhaave, in speaking of this aphorism of Hippocrates, concludes that this unfavorable prognosis of an acute disease in pregnancy was necessarily deduced from what he held touching the abstraction of blood in gestation—" a woman with child, from open- ing a vein is apt to miscarry "—mulier utero gerens vend sectd abortet. It is very evident that neither of these maxims of the * It is very probable that the plethora, in these cases, is due simply to an increase in the amount of water in the blood; but, still, with this assumption, the advantage of the lancet, as a means of temporary relief, cannot be questioned. \ Aphor. 3 torn., ix., v. 213. 132 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. father of medicine receives confirmation at the bedside, where, after all, their true value is to be tested. In the first place, in certain conditions of plethora, brought on in the manner already indicated, accompanied by a bearing-down sen- sation, febrile excitement, and a bounding pulse, the abstraction of blood from the arm will oftentimes act like magic, imparting to the disturbed system quiet and calmness, such as the lulling of the tem- pest, and the falling of the waves produce on the bosom of the ocean. Ao-ain: my own experience teaches me that acute diseases, if promptly treated, are as amenable to remedies as under any other circumstances; and, furthermore, their therapeutic management should be characterized by the same degree of activity as if pregnancy did not exist. Diseases of a high inflammatory grade are, I am quite confident, frequently fatal in the pregnant female for the reason that the practitioner is timid, his indecision growing out of fear that positive depletion may destroy the child. It seems to me that this is a very false philanthropy; nor has it anything in science either to sustain or justify it. For instance, in a severe inflammation, the mother will perish without prompt and efficient depletion ; and, should she die, what becomes of the child she carries in her womb—especially if it should not have attained a uterine development which will enable it to enjoy an independent existence, in which event, it is true, there is a remote possibility of saving it by a post-mortem Caesarean section ? But, gentlemen, will the active depletion, material to rescue the patient in cases of serious acute disease, necessarily compromise the safety of the child, by depriving it of the nourishment essential to its development ? This is an exceedingly interesting and important question, and one concerning which there is a diversity of opinion. It appears to me, however, that it is one of those points not to be determined by the forum, nor by the disputations of the contro- versialist—it is simply a question of facts. The facts which, to my mind, are conclusive on this subject, and which every observant accoucheur with a moderate field of practice will, from his own personal experience, be enabled fully to confirm, are as follows : 1. Pregnant women, affected with exhausting diseases, and in the last stage of phthisis pulmonalis, are oftentimes delivered of apparently healthy and well-developed children ; 2. In cases of excessive nau- sea and vomiting—continuing nearly the entire period of gestation —thus preventing the female from taking her ordinary nourish- ment, the child exhibits no evidence of impaired nutrition; 3. When pregnant women are over-fed, it often occurs, especially if they increase much in adipose tissue, that they bring forth diminished children, instituting a striking contrast between their condition and the corpulence of the parent; 4. After convalescence from diseases which have needed prompt and bold depletion, during gestation THE PKINCIPLES AND PRACTICE OF OBSTETRICS. 133 the child exhibits no want of growth or development, but, on the contrary, usually bears the evidences of having been adequately nouiished; 5. The attempts made, in cases of pelvic and other deformities of the maternal organs, to cause a diminished growth of the foetus by restricting the diet of the mother have completely failed.* There is an interesting circumstance connected with the chloro- anaemic condition of the gravid female, to which it is not unimport- ant for the moment to allude. Andralf has demonstrated that, in all cases of acute inflammation, there is invariably an increase in the quantity of fibrin; and, furthermore, that this increase is always proportionate to the intensity of the phlegmasia. In order that a clear understanding may be had of this practical point, and proper deductions made in other than inflammatory types of the system, the following table is presented as disclosing the ordinary variations in the quantity of the chief constituents of the blood in a state of health: Fibrin, . . . from 2 to 3£ parts per 1000. Red corpuscles, " 110 " 152 " " " Solids of Serum, " 72 " 88 "' " " Water, ... " 760 " 815 " " " According to Andral, the increase in the quantity of fibrin is so unequivocal a sign of inflammatory action, that if more than 5 parts of fibrin in 1000 be detected in the progress of any disease, it may positively be affirmed that some local inflammation exists.J It is also shown that, under the influence of inflammation, the maximum increase of fibrin is 13.3, the minimum 5, while the ave- rage is 7; and the important fact is proved that, in acute rheuma- tism and pneumonia, the greatest increase is recognised. Some practitioners are in the habit—and unfortunately the doctrine per- vades too many of the books now in your hands—of judging of the necessity of further depletion simply by the peculiar appearance of the blood after it is abstracted from the system—known as the " buffy coat." It would be a sad tale if the countless dead could * A prominent writer, M. Depaul, suggested in the Union Medicale, 12th of Janu- ary, 1850, the practice of repeated bleediugs, together with restricted diet, during the latter half of pregnancy, with the view of arresting the full development of the foetus. This suggestion, as is evident, was founded upon inaccurate data, and con- sequently proved valueless, so far as concerned the object for which it was intended. f See his admirable Essai d'Hrematologie Pathologique. J; What a precious disclosure for the truly observant physician! How often does it liappen that, with all the vigilance whicli can be brought to bear, and all the soundness of human judgment, he is baffled in his diagnosis—especially in what may be termed masked inflammatory action—whether the symptoms are really due to inflammation, or whether the disturbance may not be one of the ever-varying grades of neuralgic pain. In such case, the abstraction of a small quantity of blood ; will at once develop the mystery by ascertaining the relative proportion of its fibrin. Such, indeed, are the rich fruits growing out of scientific inquiry. 134 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. return to earth, and tell how this error has led to their premature destruction ! The " buffy coat," while it is indicative, under certain circumstances, of inflammation, is also one of the characteristics of anamia; and it now seems to be the accepted doctrine that its presence, under any circumstances, is due to one of two conditions: either a positive increase of the fibrin in the blood, in which case the amount of corpuscles may undergo no change ; or there is merely a relative increase, in which there is a loss or diminution of the cor- puscles. This, you will perceive, is a very important distinction; for it is in the latter instance, especially, in which the "buffy coat'' will display itself, not because of the inflammation, but simply because ofa disproportion between the fibrin and corpuscles. Now, such disproportion is found to exist in pregnancy, in chlorosis, etc., and, as a consequence, both of these conditions of system are cha- racterized by the "buffy coat."* You see, therefore, gentlemen, how necessary it is, in the practice of our profession, to take an enlarged view of science—to collect, as it were, all the facts, and not be. content with an isolated or frag- mentary consideration of a principle; rigid and searching analysis, and legitimate deductions from well-established premises, are the elements which our science greatly needs, and they are the elements, too, which will consecrate her discoveries as so many truths, and give them value and efficiency when applied to the amelioration of human suffering, or to the arrest of disease. How often, in the clinic, have I had occasion to call your attention to the subject of chlorosis, and, in connexion with its pathology and management, to remind you that one of the characteristics of this affection, which is essentially a disease of debility, is the "buffy coat." You have been told of the fatal error of depletion in chlorosis—and yet this error is constantly committed by those who believe that the " buffy coat" is always the index of inflammatory action. It may surprise you—but still the fact is susceptible of demonstration —that even at this day, amid the rich accessions which research and progress are daily contributing to our professional domain, and amid the lights which science is constantly shedding upon those who worship at her shrine, the general belief, so far as practice is concerned, is that whenever the "buffy coat" is recognised, it is an urgent indication for the necessity of further depletion ! * The fibrin increases during pregnancy; its general average quantity in this con- dition is 3.40, but during the last two months it is 4.08. The blood of the pregnant woman also undergoes a change in the proportions of its albumen, water, and iron. The average quantity of albumen contained in blood is 70.5; M. Regnauld has shown that the average of this element during gestation is 67.17. In the first seven months it is 08.84; in the two last, 66.42. The increase in the water of the blood is also shown by the same observer. Theaverage quantity of water is 791.1 ; while during pregnancy it is 817. Becquerel and Rodier have demonstrated that there is a slight diminution in the quantity of iron. [Dubois and Pajeot, op. cit.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 135 Modifications in the Urinary Secretion.—That the urine of the pregnant female undergoes certain changes, is by no means a dis- covery of our own times. The fact is alluded to in the writings of Hippocrates and other of the early fathers.* Within the last twenty or thirty years, special attention has been directed to an element in the urine—kiestein ; this name was, I believe, given to it by Nauche, who, together with numerous others, including our own countryman, Dr. Elisha Kane,f has made some interesting contribu- tions on the subject. Kiestein consists of a whitish pellicle; and, when completely formed, its appearance has been compared to the scum of fat, which is observed on the surface of cold broth. Dr. Kane, in eighty-five cases of pregnancy, recognised a well-defined pellicle in sixty-eight; in eleven the pellicle was but partially formed, while in six it was absent. The pellicle will sometimes be detected thirty- six hours after the excretion of the urine, and again not until the eighth day. Kiestein has been observed as early as the fifteenth day after fecundation, and frequently at the second month. From the third to the sixth month, it exhibits its most marked charac- teristics ; from the seventh month, it gradually diminishes. Why should this element, kiestein, be found in the urine of the pregnant and parturient female ? It is absurd to suppose that it is there as a mere coincidence ; and we, therefore, are justified in ask- ing some explanation of its presence. Is the kiestein in the urine anything less than a demonstration, that nature is engaged in the elaboration of food necessary for the infant as soon as it is born— and is the passage of this substance from the system, through the kidneys, any less of a demonstration than its accumulation in the blood would be productive of injurious consequences ? Both of these circumstances seem to receive confirmation from the import. ant fact, that, when the child takes the breast, and the secretion and excretion of milk through the mammary organs are in full operation, there is no longer any kiestein to be detected in the urine ; in addi- tion, among the constituents of kiestein is casein, which, you should remember, is an important element in human milk.J Again : recently Blot has announced to the French Academy of Medicine the interesting fact that sugar exists normally in the urine of all parturient women, of all nursing women, and likewise in the urine of a certain number of pregnant women.§ Here, then, are two ele- * In 1560, Savonarola spoke very particularly of the modifications of the urinary secretion consequent on gestation, and his description of these changes would seem to indicate that the substance known as kiestein had actually been recognised by him, although not under that name. [Practica Canonica de febribus, pulsibus, urinis. er sc, as to the existence or non-existence of gestation ; and I may observe, while you remember the general rule, that pregnancy is followed by suppression of the menses, you are also to bear in mind the nume- rous exceptions. 2. Nausea and Vomiting, icith Drpra>'c.d Appetite.—I have already remarked to you that women, when they become pregnant, are usually affected with sick stomach, and you have also been informed of the importance of this gastric irritability to a healthy gestation. It is an interesting fact that, in some females, nausea manifests itself almost simultaneously with the act of fecundation. I have known ladies who, from this very circumstance, would positively affirm that they were pregnant, and the result proved that they were right.* The nausea and vomiting of gestation are peculiar, and differ from idiopathic or primary vomiting in the important fact that, in the latter, there is an indication of more or less primary disease of the stomach; while, in the former, there is no such indication, nor ** are there any symptoms of general ill-health ; as soon as the con- tents of the stomach have been ejected, the female is, for the time being, quite comfortable. Ordinarily, the nausea and vomitino- of pregnancy cease about the period of quickening, and frequently earlier. Sometimes, however, they will recur during the last two * There are some curious cases reported in support of this opinion. " I was engaged to attend a lady in her fourth labor, which she told me she expected would take place on the 12th of November, early in the morning of which day I was sent for, and she gave birth to a daughter; she told me that she had always reckoned nine months from the first feeling of nausea, and had never been mistaken." [Montgomery, p. 90.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 147 or three months of gestation, and this seems to be dependent upon mechanical causes. The uterus in its ascent at this period induces more or less irritation of the stomach through the pressure exer- cised upon it, and hence vomiting, under these circumstances, will be more likely to take place immediately after a meal, in conse- quence of the greater distension of the organ. I say that the irri- tability of the stomach in the latter periods of pregnancy is chiefly mechanical; it is well to distinguish it from the nausea and vomit- ing of the earlier months, which I hold to be altogether physio- logical, and which has been explained, in the preceding lecture, to be due to a reflex action of the spinal cord from the uterus to the stomach.* It must, however, be borne in mind, that mere functional or organic disease of the uterus will oftentimes be followed by this irritability of stomach ; it is, indeed, a very common result of sup- pression of the courses from any of the causes, with which preg- nancy itself has nothing whatever to do. I am not a little surprised that so accomplished an obstetrician,! and so valued an authority as Paul Dubois, should say, that vomit- ing is not necessarily associated with gestation. Indeed, I regard this symptom as among the most constant accompaniments of preg- nancy, and its relation to this state, as a general rule,'is based on sound physiology. 3. Depraved Appetite.—A frequent consequence of impregna- tion is a depraved appetite—a longing for unnatural food-^so that some of your patients will consume, with infinite gusto, chalk, slate- pencils, and other kindred dainties. Some become passionately fond of fruits; I knew a case in which the lady exhibited such a passion for oranges, that the quantity she consumed is altogether incredible. On the authority of Tulpius,"'; salt fish will sometimes present irresistible charms. I attach more than ordinary importance, as a sign of pregnancy, to this depraved appetite, and am disposed to regard it, under certain conditions, as quite a significant circumstance. For example, if a married woman, whose general health has been uniformly good, should suddenly exhibit this morbid taste, I should be much inclined to look upon it, all things being equal, as a strong presumptive evidence of impregnation. If you ask me to explain why, my answer is, I cannot, except as a matter of observation. But there * It was the opinion of Haller that the vomiting in gestation is occasioned by a putrid element in the seminal fluid of the male, which, becoming mingled with the blood, constitutes a sort of poisonous miasm; this may be classed among the fanciful notions not unfrequently met with in the writers of the past. \ Traite Complet de l'Art des Accouchemens, p. 503. \ " I once saw a woman who, being with child, was so exceedingly fond of salted herrings, that before delivery she had eaten fourteen hundred, and this without any offence to her stomach, or prejudice to her health." [Art, Obstetric-compend., p. 68.] 148 THE PRINCIPLES AND PRACTICE OF OHSTETRICS. are many things, which I firmly believe, and yet cannot compre- hend, except on the principle of faith. Man's belief would be sadly curtailed if he rejected everything for which he could not give a satisfactory explanation. You believe in God, and yet who apiong you can comprehend his infinite existence ? You believe in eternity, and where is the human intellect adequate to the compre- hension of the vast theme ? Salivation.—In connexion with this depraved taste, it may be mentioned that some women, during their pregnancy, will exhibit full ptvalismor salivation, and secrete enormous quantities of saliva. But the ptyalism of pregnancy differs from that of mercury in the fact that there is no mercurial foetor, no soreness or sponginess of the gums, the irritation being confined to the salivary glands them- selves ; and here allow me to remark, by way of episode, that these distinctions should not be lost sight of, for it may, peradventurc, happen, that your reputation may be more or less involved in the recollection of them. Let us suppose a case in illustration : Mrs. A. consults one of you during her pregnancy; her bowels are torpid, or, for some other reason, you judge it necessary to order an aperi- ent medicine. Soon after this she becomes salivated. You are at once charged with having administered mercury; you are severely censured, and, in all probability, your exeat will be very unceremo- niously furnished you, not with a God-speed invocation, but with all imaginable prejudice against you and your skill as a physician. To a young man just commencing professional life, and without reputation to sustain him, such a contingency would prove a severe trial, unless he could promptly and satisfactorily show that the salivation complained of was one of the occasional phenomena of pregnancy; and his justification would be fully established by the diagnostic evidences of this latter form of ptyalism, to which we have already alluded. The question of salivation during pregnancy, in a physiological sense, is interesting, for there can be no doubt of the sympathy existing between the sexual organs, both in the male and female, and the salivary glands. In parotitis, or mumps, in which the parotid gland becomes the seat of inflammation, it is quite usual, after a few days, for the testes in the male, and the mammae in the female, to become enlarged and painful; as soon as this enlargement takes place, the tumefaction of the parotid disappears. Instances, also, will sometimes occur of malignant disease, developing itself in the submaxillary and parotid glands of women at the period of the final cessation of the menses. 4. Changes in the Breasts—The Secret ion of Milk—Tlie Are- ola.—The general rule is that, soon after impregnation has taken place, the breasts become the centre of an afflux of fluids, and con- sequently enlarge; the enlargement is accompanied by more or less Fifth month SrS* AREOLA OF THE RRKAS' Sixth month THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 149 of a pricking or stinging sensation; they are much firmer to the touch, and enjoy a greater degree of mobility. This greater firm- ness and mobility are not usually observed in the mammae, when their increase of size is merely dependent upon the accumulation of fatty material. The nipple, in consequence of the tumefaction, is more prominent, and oftentimes painful. The veins, coursing along the breasts, become distended, and can be distinctly traced by the naked eye. The particular period after pregnancy at which these changes occur is variable; sometimes they begin to develop themselves in two or three weeks, sometimes not until the lapse of two or three months, and, in women of delicate constitution, there will oftentimes be little or no change in the size of the mam- mae until the latter months of gestation. Indeed, I have seen cases in which, even after delivery, there could be detected not the slightest physical alteration, and generally, in such instances, the secretion of milk does not commence for several days after the birth of the child, and occasionally, there is not a drop secreted at any period after delivery, thus depriving the mother, whose heart is in the right place, of that most natural and sacred duty—the nursing her infant. The mammae are really annexse of the generative organs in the female, and, according to the general law, have an important office imposed upon them—the elaboration of food adapted to the wants of the new-born child. Charles Robin has pointed out an extremely interesting fact in reference to the true physiological relations of the mammae to the uterus during the progress of pregnancy. He has shown that there is a correspondence in the development of the tissues of the uterus, and the glandular culs-de-sac of the mammary organs. These glandular culs-de-sac, in a state of partial atrophy when gestation does not exist, become cognisable, and are lined with their epithelium at the time the fibre-cells of the uterus undergo an increase in volume. There are numerous causes, other than pregnancy, capable of giving rise to an increase of volume in the breasts. It is quite common for women to suffer more or less from tension of the mam- ma} at the time of the menstrual turns. In fact, this fulness of the breasts is sometimes the very indication by which the female becomes aware of the approach of her catamenial period. Again : nothing is more common than enlargement of the breasts following sup- pression of the courses—the same thing occurs, also, in various diseases of the uterus—more especially in cases in which there may be morbid growths, such as polypus, submucous fibrous tumors, hydatids, or other morbid developments. Milk in the Breasts. -The presence of milk in the breasts is regarded by many as a very important evidence of gestation; but while it is one of the usual accompaniments of pregnancy, it must 150 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. not be forgotten that the secretion of milk may take place in vari- ous conditions of the system in which impregnation has not occur- red. The very mammary sympathies to which we have just alluded, including the secretion of milk, so far from being necessarily due to pregnancy, are, in fact, oftentimes the results of ovarian excite- ment,* no matter from what cause. Hence, milk will sometimes be secreted in disease of the ovary, and in the various menstrual aber- rations. It is a well-established fact, that milk has been recognised in the breasts of young virgins, and also of males. An interesting case is mentioned of a faithful young woman who, in order to quiet the infant of her mistress, was in the habit of applying it to her breast, the consequence of which was a free secretion of milk. Perhaps one of the most extraordinary examples of this kind on record—and whicli is regarded as perfectly authentic—is that of a little girl, in France, eight years of age, deaf and dumb, who, by the repeated application to her breast of a young infant which her mother was suckling, had sufficient milk to nourish the child for a month, during which time the mother was unable to nurse it on account of sore nipples. This little girl was exhibited to the Royal Academy of Surgery on the 16th of October, 1783, and had such a quantity of milk that, by simply pressing the breasts, she caused it to flow out in the presence of the Academy; on the same day, she did the same thing at the house of Baudelocque, before a large class of pupils.f The fact may surprise you, but it is well known that virgins, old women, and even men, are often employed as wet- nurses in the Cape de Verde Islands. In the lower animals, milk will occasionally be found in the teats as the mere result of sexual excitement—in some instances, in which coition has taken place without fecundation, and in others, in which the female has become excited without intercourse with the male.J * On the 11th of May, 1857, Mrs II. came to the clinic for professional advice under the following circumstances: She had been married twenty-three years; was forty-two years of age, and her only child was nineteen years old. With the excep- tion of the period of pregnancy and lactation, her courses had always been regular, until about six months before she applied for advice; but she had within these six months become much alarmed from the occasional swelling of one of her breasts ■ and, on inquiry, it was ascertained that at the time the courses should have appeared, the tumefaction of the breast invariably occurred, and subsided as soon as the cata- niciiial flow took place. There was not the slightest indication of tumor or other disease of the mamma; it was simply an example of what, perhaps, might be pro- perly termed mammary metastasis. The patient was directed to have four leeches applied to each groin a few days before the usual time for the return of the menses, with a view of relieving the ovarian irritation. This simple suggestion had the effeot of restoring the function, entirely removing the engorgement of tlie mamma. I have seen several cases of hypertrophy of the breasts following amenorrhcea, and the hypertrophy has always yielded on the restoration of the menstrual function. f Baudelocque, L'Art des Accouchemens, torn, i., p. 188, in 8vo. Paris, 1815. X Harvey, in speaking of bitches which did not conceive after coition, and which, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 151 The Areola.—The next change in the breasts to which I shall allude, as indicative of pregnancy, is the condition of the areola— that peculiar circle which immediately surrounds the nipple. In the virgin, in a normal state, this circle is characterized by a beau- tiful hue, not unlike the tint of the budding rose. But I have seen it, even in the virgin, under certain conditions of morbid action, change this tint for a discoloration more or less marked ; it is essen- tial that you should understand the error, which seems to have been perpetuated by many clever writers respecting the color of the areola. According to them, the color is the principal or character- istic attribute. This, however, is not so, and the sooner the error be corrected and heeded, the better it will be for just opinions. Remember, gentlemen, I am now alluding to what maybe denomi- nated the true areola, by which I mean the areola which, when recognised, is, in my opinion, a very solid evidence that gestation exists. There is no doubt that, under ordinary circumstances, when pregnancy occurs, there is a discoloration of the areola; but as there are other conditions of the system in which this change of color takes place, it is quite evident that there must be some characteris- tics more reliable in order that a correct diagnosis may be arrived at; in other words, if the areola be worth anything as a test of pregnancy, it must have some marked and peculiar developments dependent exclusively upon gestation ; and this is a question which we shall examine presently. Females who are subject to hysteria and the various menstrual aberrations, will occasionally have dis- coloration of the areola; and I have observed it as by no means an unusual accompaniment of dysmenorrhoea dependent upon chronic inflammation of the ovaries.* It is worthy of remark that the deposit of coloring matter, both in pregnancy and in undue irritation of the sexual organs, has been observed in other portions of the system than in the areola of the nipple. For example, Blumenbach cites the case of a female peasant, whose abdomen became entirely black during each successive preg- nancy ; and a very remarkable instance is mentioned by Camper of a woman who, at the commencement of her gestation, began to turn brown, and before its completion, became perfectly black; the discoloration, however, gradually disappeared after the birth at the time corresponding with the completion of their gestation, if they had been fecundated, appeared to be in great distress, says: "Some of them have milk in their teats, and are obnoxious to the distempers incident to those which have already pupped." * Besides the change in the color, sometimes observed in dysmenorrhoea and other menstrual aberrations, there are occasionally certain developments characteris- tic of the areola of pregnancy, such as slight turgescence of the integument, and elevation of the follicles—but these developments are transitory, and disappear as soon as the menstrual excitement ceases. 152 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of her child. These and other instances, seem to prove, to a greater or less extent, a very marked relation between this deposit of black pigment, and excitement of the sexual organs. Again: it is not unusual to observe, around the umbilicus of the pregnant woman, a dark areolar surface; and also a dark, sometimes brown, line extending from the pubes to the umbilicus. The areola has been studied with great attention by Dr. Mont- gomery,* of Dublin, and his description of its true characteristics, so far as being the result of pregnancy, is so faithful to nature, that I shall recall to you briefly what he says on the subject. " I cannot," he observes, " say positively Avhat may be the very earli- est period at which the changes may be observed, but I have recognised them at the end of the second month, at which time the alteration in color is by no means the most obvious circum- stance ; but the puffy turgescence (though as yet slight) not alone of the nipple, but of the whole of the surrounding disc, and the development of the little glandular follicles, with the developed state of the mammary veins, are the objects to which we should principally direct our attention; the color, at this period being, in general, little more than a deeper shade of rose, or flesh color, slightly tinged occasionally with a yellowish or light brownish hue. During the progress of the next two or three months, the changes in the areola are in general perfected, or nearly so, and then it presents the following characters: a circle around the nipple whose color varies in intensity, according to the particular complexion of the individual, being usually much darker in persons with black hair, dark eyes, and sallow skin, than in those of fair hair, light- colored eyes, and delicate complexion. The area of this circle varies, in diameter, from an inch to an inch and a half, and in- creases in most persons as pregnancy advances, as does also the depth of color. "In the centre of the colored circle, the nipple partakes of the altered color of the part, is turgid and prominent, its apex being more or less covered with little branny scales, produced by the drying of a sero-lactescent fluid which oozes from the part; the surface of the areola, especially that portion of it more immedi- ately around the base of the nipple, is rendered unequal by the glandular follicles, which, varying in number from twelve to twenty, project from the sixteenth to the eighth of an inch ; and, lastly, the integument covering the part appears a little raised ; emphysematous, turgescent, softer, and more moist than that which surrounds it; while on both, there are, at this period, especially in women of dark hair and eyes, numerous round spots, or small mottled patches of a whitish color, scattered over the outer part * Signs and Symptoms of Pregnancy. 2d Edition, p. 97. Seventh month AREOLA OF THF. BRLAST Eighth month THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 153 of the areola, and for about an inch or more all round, presenting an appearance as if the color had been discharged by a showrer of drops falling on the part. Dubois, referring to this appearance, applies to it the designation of secondary areola. This appearance is not recognised earlier than the fifth month, but toward the end of pregnancy is very remarkable, and constitutes a strikingly dis- tinctive character, exclusively resulting from pregnancy / the breasts themselves are, at the same time, generally full and firm ; and venous trunks of considerable size are seen ramifying over their surface, sending branches toward the disc of the areola; together with these vessels, the breasts not unfrequently exhibit, about the fifth and sixth months, and afterward, a number of shining, whitish, almost silvery lines like cracks; these being most perceptible in women who, having had before conception very little mammary development, exhibit a rapid and marked enlarge- ment on becoming pregnant. When once formed, these lines con- tinue permanent, and, therefore, will not serve as diagnostic marks of a subsequent pregnancy, and sometimes they do not form at all."* Such are the essential characters generally belonging to, or con- nected with, the true areola, the result of pregnancy ; and I quite agree in opinion with Dr. Montgomery that when these peculiar features are recognised in the areola, they should be regarded as positive proof of pregnancy, no other condition being capable of producing them. The true areola, I repeat, in my judgment, and this opinion is founded on extended observation, is not recognised except as a consequence of gestation. The remarkable case which came under the observation of Hunter, it may be well to mention as an instance of his faith in this sign. It was chiefly on the presence of the areola that he founded his opinion of the existence of pregnancy in a young woman, who had been examined after death by his pupils, and in whom there was an intact hymen; and, therefore, the appearance of virginity. In laying open the uterus, it was found that Hunter was right. Let us for a moment look at the per contra of this question. Can pregnancy exist without the development of the true areola? In my opinion it can, and upon the principle of an exception to a very general rule.f I have already remarked to you that some * See Plates 1, 2, 3, 4, 5, transcribed from Dr. Montgomery's work, and which are most graphic delineations of the areola in the different stages of pregnancy. \ In December, 1856, I received a letter from Dr. H. P. Ferguson, of Western Virginia, who kindly sent me a patient, for advice, who had been under his profes- sional care for some months. The lady was twenty-seven years of age, had been married eight years, but had never borne any children, nor had she ever been preg- nant. Her general health had always been good, and her menstrual turns regular, 154 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. women will pass through their gestation without the slightest enlargement of their breasts ; and you will occasionally meet with cases in which the changes in the areola do not commence their development until the latter months of gestation. It must also be recollected that nursing women, who have recently miscarried, may present the peculiar attributes of the areola; so that it may de- volve on you to show, not only that the true areola is absolutely the product of pregnancy, but that the pregnancy of which it is the product, still exists.* Probable Evidences: Changes in the Uterus and Abdomen.—You have already been told that, when fecundation takes place, immediate and remarkable until the June previous to my seeing her. From that time until December, when she first consulted me, her courses had been suppressed ; she had most of tho ordi- nary symptoms of pregnancy, except that there was not the slightest change in the breasts, nor any approach to the formation of the areola. This lady had been much annoyed by nausea and vomiting for four months after the menses became sup- pressed, and her appetite had been remarkably depraved; her abdomen was en- larged corresponding with a six months gestation—and yet the breasts, which had always been small, exhibited not the slightest change in development. The patient observed to me, in reply to my inquiry, that she had not felt any movement in her abdomen; and, although she was most anxious to be a mother, she said she was quite confident she was not pregnant. Dr Ferguson, in his letter, remarks, "Were it not that the breasts remain unchanged, I should say that Mrs. L. is undoubtedly in gestation; have you ever seen a case of pregnancy unaccompanied by the slightest mammary development?" As this lady was most anxious to have her true situation ascertained, and as she had been rendered very unhappy by the apprehension that her enlarged size was occasioned by the presence of a tumor, which would destroy her life, I proceeded to a very thorough investigation of her case. On a vaginal examination, I soon discovered that the abdominal enlarge- ment was caused by the enlargement of the uterus; applying one hand to the abdomen, with a view of gently grasping the uterus, and the index finger of the other hand placed on the posterior portion of the cervix uteri, with an alternate movement of ascent and descent made with the hands thus applied, I very distinctly felt the passive motion of the foetus, known by the French as the ballolenient, and sometimes described by the English under the term repercussion, to which I shall have occasion hereafter more particularly to allude, when speaking of the vaginal explorations in reference to the diagnosis of pregnancy. So certain and unequivo- cal do I regard the ballotement as proof of gestation, that I at once, without the least qualification, assured the lady she was pregnant. This opinion seemed to give her great pleasure; and she very quietly, but pointedly, asked me, " Whether I would stake my reputation on the opinion I had given." I immediately replied that I was quite content to abide by the revelations of the future, and that she would discover the future would fully indorse my opinion. She left New York January 3d for her home in Virginia, bearing with her a letter to Dr. Ferguson, in which I expressed my positive conviction of her pregnancy; all doubt in her mind was dissipated by the birth of a daughter on the 27th of the following March. * It will be observed that I have classed the areola among the presumptive evi- dences of gestation, for the reason that I did not desire to separate it from the consideration of the mammary sympathies. At tlie same time, I regard the true areola as among the most positive signs of pregnancy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 155 changes begin to exhibit themselves in the uterus; these modifica- tions we now propose to examine, in order that they may receive their true value as evidences of gestation. It is only necessary to remember the important duties which the uterus is called upon to discharge in the brief period of nine months—the accommodation and nutrition of the growing embryo—to appreciate the urgent necessity there is for marked and rapid alteration both in its structure and functions. Almost simultaneously with the act of fecundation, and even before the product reaches the uterus, this organ becomes the centre, so to speak, of an extraordinary fluxion. This concentration of fluids results necessarily in increase of vo- lume, because of the increase of tissues. Descent of the Gravid Uterus during the First Two Months.— Contrary to what might, at first view, be imagined, the tendency of the uterus for the first two months after impregnation is, not to ascend into the abdomen, but to descend into the pelvic cavity; and there are certain phenomena, during the earlier periods of pregnancy, consequent upon this depressed condition of the gravid organ, which it is important to remember : 1. As the direct result of the descent of the uterus, there will be more or less frequent desire on the part of the female to pass water, because of the pressure of the organ on the neck of the bladder ;* sometimes, also, there will be a species of tenesmus, more particularly if the pressure of the uterus, instead of falling on the neck of the bladder, should, as sometimes will be the case, be directed against the rectum. 2. It is only necessary for you to refer to what was said, when describing the relations of the pelvic viscera to each other, to understand why an alteration in the position of the uterus must necessarily affect, more or less, the position of the bladder ; so that, as the uterus descends into the pelvis, so measurably must the bladder; the effect of this change of position in the latter oro-an, will be pain at the umbilicus, and a cup-like appearance of the cavity. Sir Charles Clarke claims to have been the first to direct attention to this pain at the umbilicus as a result of procidentia vesica1, and explains the connexion between cause and effect on very rational grounds. The superior ligament of the bladder, formed by the remains of the two umbilical arteries, extends from the fundus of the organ to the umbilicus ; the bladder being prolapsed, the ligament is put upon the stretch, and hence the pain and increased cup-like fossa.f * This desire for frequent micturition is not exclusively the result of a mechanical cause; it is in oart due to reflex influence. f I am disposed to attach more than ordinary importance to the pain and increased excavation of the umbilicus as early indications of pregnancy, especially if there have previously been no displacement of the uterus or bladder from other 156 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Together with these peculiarities, which usually accompany early pregnancy, there is a condition of the abdomen at this period well worthy of attention. One would very naturally suppose that, as soon as the impregnated uterus began to increase in bulk, there would necessarily be a corresponding development and promi- nence of the abdomen. But this is not so ; for the first two months after fecundation, the abdomen, so far from becoming prominent, actually recedes, and presents in the hypogastric region the aspect of flatness. This fact had been well observed by the early writers, and hence the ancient aphorism ventre plat, enfant il y a—a flat belly denotes pregnancy. On the contrary, about the third montl there is oftentimes quite a prominence of the hypogastric region, which, in a short time, becomes measurably lessened, and hence, a woman who is really pregnant may suppose that she is not so, for the reason that at the fourth month she will frequently be smaller than at the third. It is important that you should comprehend the cause of this difference. At the third month, just as the gravid uterus begins to leave the pelvic excavation, it is not at all unusual for the small intestines, which rest, as it were, upon the fundus of the organ, to become more or less distended with flatus, and it is owing to this circumstance that the greater volume of the abdomen is due ; as, however, the period of the fourth month approaches, this distended condition of the intestines disappears. What is it that produces the flatulent state of the bowels at the third month ? May it not be due, in the first place, to the irritation experienced by the gan- glionic nerves of the uterus, and thus transmitted to the chylopoie- tic viscera; and, secondly, to a reflex influence occasioned by the physical changes going on in the uterus itself? I am inclined to think that this is the explanation ; but you may urge the objection, if these causes should occasion the collection of flatus at the third month, why should they not also, d fortiori, occasion it during the entire period of the subsequent pregnancy ? I answer that it is probably because the digestive mechanism becomes in a short time accustomed to these combined influences, and ceases as a conse- quence to suffer any derangement. Be the explanation satisfactory or otherwise, the fact is worthy of recollection. Positions of the Gravid Uterus.—Let us now recall to memory the various positions of the impregnated uterus from the earliest moment of conception until the completion of the full period of gestation. These gradual changes of position it is absolutely necessary for you accurately to comprehend, for they have a very important bearing, not only on the question of whether pregnancy causes; for it must be recollected that, in p.-olapsion of either of these viscera, altogether unconnected with gestation, the umbilicus will usually undergo the same changes as in pregnancy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 157 exists, but also as to the particular period of the gestation itself. For the first three months, the impregnated organ is confined within the limits of the pelvic excavation ; this is the general rule but there are occasionally exceptions to it. The uterus, while lodged in the pelvic cavity, continues to grow and increase in size, and has a tendency to incline toward the hollow of the sacrum, which will consequently cause the cervix to diverge slightly for- ward from the centre of the excavation; and at the same time, because of the ordinary position of the rectum to the left, the fun- Natnral state. Third month of gestation. dus and body of the organ are pushed to the right, which will necessarily induce a deviation of the cervix slightly toward the left of the pelvic excavation. Thus, you perceive, gentlemen, that, for the first three months after impregnation, for the reasons just stated, the direction of the neck of the uterus presents three pecu- liarities, viz. downward, forward, and slightly to the left. I have repeatedly remarked, especially in a first pregnancy, that the patient would complain, in the earlier periods of gestation, of a sense of numbness and darting pains in the lower extremities'; and you see how easy it is to account for these phenomena—the sacral plexus of nerves, situated in the cavity of the sacrum, becomes, from the pressure of the uterus, more or less irritated, and this irri- tation is immediately transmitted to the great ischiatic and its tri- - butaries, and hence the feeling of numbness and pain. At the third month (Fig. 40), in consequence of its progressive 75 158 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. development, the fundus of the uterus emerges from the pelvis, and is recognised above the superior strait, imparting to the touch the sensation of a round resisting tumor, occupying the lower and cen- tral portion of the hypogastric region. It will, however, require some tact and nicety of manipulation to detect the organ at this early period through the abdominal walls, especially in a primipara, and in women with much adipose or fatty matter. As soon as the gravid womb has left the pelvic cavity, and fairly entered the abdo- men, the direction which it then pursues is altogether changed; it now follows a line parallel, or nearly so, to the axis of the superior strait; consequently, its course is upward and forward ; and this alteration in its direction necessarily produces a change in the nosi- tion of its cervix, which becomes slightly elevated, and instead of inclining forward, looks backward, and frequently a little to the left. You perceive that, as the uterus pursues the axis of the supe- rior strait, it receives a point of support from the abdominal walls, the direct consequence of which is, that the pressure exercised pos- teriorly by the gravid organ on the aorta, ascending vena cava, ureters, and upper portion of the rectum, is much diminished. Right Lateral Obliquity.—It is an interesting fact to note that, in the great majority of* cases, the gravid uterus, after leaving the pelvis, becomes slightly oblique to the right in its long axis, consti- tuting what is known as the right lateral obliquity ; and various theories have been suggested to account for the circumstance. Some, with Lev ret, have imagined that it was due to the insertion of the placenta on the right lateral half of the fundus uteri; but in order to make this explanation satisfactory, proof is required that, in all cases of this species of obliquity, the placenta is actually in adhesion at this particular point of the organ ; this proof cannot be furnished, for it is directly adverse to facts, and, therefore, the the- ory is without a basis. Madame Boivin thinks that the obliquity is owing to the shortness, greater muscularity, and strength of the round ligament on the right side. I have, myself, never been able to detect any difference in the length or structure of the two round ligaments, although I have had an opportunity of examining a large number in autopsies. Again : it has been attempted to show that the more frequent use of the right arm, and the greater dis- position to recline on the right side, give rise to this obliquity of the organ. But this is not sustained by facts. Without alludinc further to the various opinions of writers, alloAV me to observe that, although, perhaps, difficult satisfactorily to explain, yet the fact itself is interesting and important to be remembered. At the fourth month, the fundus of the organ is midway between the symphysis pubis and umbilicus. At the fifth, it is on a level with the umbilicus; at this time the cervix is still higher in the pelvis, and inclined more backward. It THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 159 is not unusual for the pregnant female to complain at the fifth or sixth month of pain in the right side; this is often occasioned by pressure of the ascending uterus against the liver. I have gene- rally been enabled to palliate the pain with an occasional mercurial pill, followed by a saline draught. It will usually, however, be more or less annoying until the birth of the child. At the sixth month (Fig. 41), the fundus is two fingers' breadth Fig. 41. Fig. 42. Sixth month of gestation. Ninth month of gestation. above the umbilicus; and, at this period, the latter becomes partly inverted with a partial disappearance of its cup-like fossa, and forms a slight prominence. This peculiar appearance of the umbilicus is worthy of recollection ; it has, under ordinary circumstances, some value as a sign of pregnancy, although I have seen it as the mere result of abdominal tumors and advanced ascites. At the seventh month, the fundus has reached midway between the umbilicus and the curve of the stomach ; at this time the umbi- lical fossa has completely disappeared, and the umbilicus itself, in consequence of its inversion, forms a marked projection. The cer- vix is still more elevated and inclined posteriorly. At the eighth month, the fundus of the organ is-high up in the epigastric region. There is now great prominence of the abdomen, with more or less oppression in breathing, in consequence of the pressure of the ascending uterus against the diaphragm; and it is not unusual for the woman to be troubled more or less with a cough 160 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and palpitation of the heart. It is just as well for you to remem- ber in this connexion, that the cough is unaccompanied with fever or an excited pulse; it is not the cough of inflammatory action. It, like the palpitation, is simply the result of the mechanical irrita- tion experienced by the lungs and heart, in consequence of the greater elevation of the diaphragm, thus curtailing the usual capa- city of the chest. I speak of this in order that you may not, through erroneous diagnosis, subject your patient, for this cough and palpitation, which will yield as soon as the pressure is removed from the diaphragm, to the absurdity of antiphlogistic treatment.* Toward the close of the ninth month (Fig. 42), the uterus descends into the pelvic excavation, and, as a consequence, there will be more or less vesical irritation, and sometimes a feeling of tenesmus occasioned, in the former instance, by the pressure of the organ against the neck of the bladder, and, in the latter, against the rectum. But this descent of the uterus, at the close of the ninth month, is followed by a circumstance which should not be for- gotten ; I mean a diminished prominence of the abdomen, which will sometimes give rise to the apprehension, on the part of the female, that something is wrong; that she is not pregnant, or that her foetus is dead. Again: In consequence of the settling down of the gravid womb, the pressure is removed from the diaphragm, and, hence, the respiration is freer, the cough disappears, and the patient experiences a buoyancy of spirits, forming a striking con- trast with the oppression of the previous few weeks; this she can- not account for, but which you, knowing the cause of the change, can readily appreciate. Why does the impregnated uterus descend toward the end of the ninth month ? May it not be that, at this period, the organ increases in its transverse diameter, and, at the same time, diminishes in length ? But, gentlemen, if you ask me whether the descent of the organ at this period be necessary, whether there be any special benefit derived, I ask you, in return, to reflect, for a moment, on the important work in which nature is so soon to become engaged, viz. the expulsion of the foetus from the maternal organs. The object, therefore, of this change in the uterus, is directly connected with the birth of the child ; it is, as it were, one of the arrange- ments preliminary and essential to the important act of labor. These various changes in the position of the uterus, to which we * Although it is true that these derangements in the respiratory organs, at the latter period of gestation, are usually traceable to the ascent of the diaphragm; yet it must be recollected that these phenomena will sometimes develop themselves at a less advanced period of pregnancy, and here the dyspnoea, cough, etc., may be due to a nervous, or a congested condition of the lung (possibly to oedema of the organ) i the therapeutic indication will depend upon the special cause; for example, if it be traced to nervousness, hyoscyamus, thirty or forty drops of the tincture; or if to congestion, the judicious intervention of the. lancet. iM.ATK !\ I .4' # ••c AREOLA OF* THE BREAST Ninth month THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 161 have thus briefly alluded, are liable to certain modifications. For example, in a multipara—a female who has borne several children —the uterus in its ascent usually does not reach as high up in the abdomen in the latter periods of pregnancy as in a primipara ; and, at the same time, the abdomen is much more protuberant. These two circumstances arise from the fact, that previous pregnancies having so distended and relaxed the abdominal walls, the gravid womb, encountering but little resistance as it passes upward, has a strong tendency to fall forward, constituting a species of ante- version of the organ; whereas, in the primipara, its direction is more in accordance with the axis of the superior strait of the pelvis. In a first pregnancy, the parietes of the abdomen undergo extraordinary distension, and consequently become thin; occa- sionally, there is a separation of the two recti muscles; and you will remember an interesting case, in the clinic, of a female, who, having been confined with twins, was afterwards much annoyed by the protrusion of the intestines through the space left by the separation of these muscles.* Change in the Direction of the Urethra.—When the gravid uterus leaves the pelvic cavity, and during its progress in the abdomen, very important changes are effected in the position of the bladder and urethra; the ascent of the uterus necessarily occasions the ascent of the bladder, which, of course, draws up the urethra in such a way that, instead of occupying an oblique position, as it does under ordinary circumstances, it becomes more and more vertical, so that, in the latter periods of gestation, it will be found almost parallel with the internal surface of the symphysis —a most important fact to be recollected in connexion with the introduction of the catheter, ignorance of which will oftentimes lead to results mortifying to the practitioner, and disastrous to the patient. The superior portion of the urethra will sometimes be so greatly pressed upon by the gravid uterus, that its lower extremity, in consequence of the impeded circulation, will become very much engorged, thus giving rise to an enlargement, which, if not under- stood, might result in erroneous conclusions. This condition of the excretory duct is not unusual, particularly in first pregnancies, and arises simply from mechanical obstruction in the blood-vessels. It is of no special import, except that without this explanation you might possibly, in making a vaginal examination, misapprehend the nature of the enlargement, and suppose it to be a foreign growth. Oedema of Loicer Extremities.—The oedema of the lower ex- tremities, as an ordinary accompaniment of gestation, amounting sometimes to a fully developed anasarca, is also explained in the * See Diseases of "Women and Children, p. 211. 11 162 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. same way; that is, obstruction, from pressure of the impregnated womb, in the venous circulation,* thus preventing the free passage of blood from the lower extremities to the ascending cava, and thence to the right cavities of the heart. In the same manner, also, do you account in part for the appearance of hemorrhoidal tumors, so common in pregnancy; I say in part, for they are like- wise due to the constipation, which is the usual accompaniment of this condition; the constipation very frequently arising from the pressure of the uterus against the upper portion of the rectum. You have seen in the clinic several examples of enlargement of the veins in the vagina, traceable to the presence of various kinds of abdominal tumors; and you have been told that these venous en- gorgements are simply the result of obstructed circulation. In pregnancy, also, you will occasionally meet with the* same phe- nomena; and I have known, under these circumstances, thrombus of the vulva, to produce fearful hemorrhage. In the latter con- tingency, the great remedy is well directed pressure by means of pieces of sponge.f * There are other causes than obstruction in the venous circulation, which may occasionally produce oedema, or dropsy of the cellular tissue, during pregnancy; for example, organic disease of the heart, the existence of albuminuria, anaemia, etc. f For an interesting case of thrombus of the vagina, together with its treatment, ■ee Diseases of Women and Children, p. 463. LECTURE XI. Evidences of Pregnancy continued—The Effect of Fecundation on Development of Uterus—Order of Development—Fundus enlarges first three Mouths—Body from third to sixth Month—Wisdom of this Arrangement—Shape of Impregnated Uterus—Modifications of Cervix in Pregnancy—Error of certain Authors— Uterine and Vaginal Extremities of Cervix—Cervical Canal—Relaxation of Tissues of Cervix—Cervix does not Lengthen—Error of Madame Boivin—Promi- nence of Os Tincae—Softening and Moisture—Mucous Follicles—Development of —Increased Mucous Secretion not a Pathological State—Uses of this Secretion— Cervix begins to shorten at its Uterine, and not at the Vaginal Extremity— Proof—Opinions of Stoltz and Cazeaux—Placenta Prsevia and Shortening of Cer- vix—Modifications of Cervix in Primipara and Multipara—Increased Development of Uterine Appendages in Pregnancy—How does the Cavity of the Uterus enlarge?—Ancient Theory—Increased Nutrition the true Cause—Thickness of Uterine Walls; Opinions respecting—Os Uteri at Time of Labor—Discoloration of Vagina as a sign of Pregnancy—Is this Discoloration peculiar to Pregnancy? Gkntlkmen—From the instant of fecundation until the accom- plishment of the full term of utero-gestation, the womb is con- stantly undergoing the process of development; this increase of tissue and capacity is in accordance with the growth of the embryo. In one word, the exclusive and only object of these changes is to provide accommodation and sustenance to the growing germ. But the development of the gravid organ is not without order; in the arrangement, which nature has instituted for the successive in- crease in the volume and structure of the uterus, the obstetrician will find much of interest. The increase in the size of the organ, although successive, is not uniform ; as an evidence of this fact, the growth of the uterus for the first three months is principally through the development of its fundus; the body of the organ undergoes striking changes from the third to the sixth month ; while it is not until the three last months of gestation that the cervix or neck contributes its share to the general accommodation of the embryo. You cannot, gentlemen, fail to perceive the wisdom of this order in the successive developments of the impregnated uterus; it is essentially conservative, and for the protection of both mother and child. Suppose, for illustration, the order were reversed ; and, instead of the fundus, the cervix should be the first to undergo the physical changes necessary for the requirements of the growing foetus. Do you not perceive, at once, the inevitable results of such 16-1 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. an arrangement—premature delivery, and the consequent destruc- tion of the germ ? But nature, in this, as in all her other opera- tions, is constantly disclosing to her disciples motive for every act she performs. For the first six months of gestation, in consequence of the increased volume of the uterus being caused chiefly by the enlargement of the fundus and body only, the organ presents a peculiar shape which has not been inaptly compared to that of a gourd or bottle; after this period, as the cervix begins to shorten, the form of the uterus becomes more ovoid. Changes in the Cervix.—You will find, in reading the various works on midwifery, that most writers have alluded to the modifi- cations of the neck of the uterus during pregnancy ; but there is more or less discrepancy of opinion as to two important circum- stances connected with these modifications: 1. The degree of value to be attached to them so far as being guides in the diagnosis of the particular period of gestation ; 2. The manner in which the cervix commences and continues to shorten. I propose briefly to examine these questions, and to give to each of them, as far as I may be able to do so, its true bedside importance; for, after all, gentlemen, these questions, so practical in their bearing, must be decided by the revelations of the clinical room. In order that you may have a comprehensive and accurate idea of the phases through which the cervix of the uterus passes during the entire period of pregnancy, I shall divide it into three portions: 1. The lower or vaginal extremity ; 2. The upper or uterine extremity; 3. Its canal, being bounded respectively by these two extremities. Your attention has already been drawn to the important fact that fecundation constitutes the uterus an active centre; this very centralization of forces, if I may so define it, toward the organ, imparts to its physical condition a very rapid and remarkable change, and the most palpable appreciation of the nature and ex- tent of this change will be had by comparing the impregnated organ of a primipara with the uterus of the matured but virgin female. In the latter, the organ presents a dense, resisting, and, to all external appearances, homogeneous structure, it being impossi- ble to discern distinctly with the naked eye any of the elements forming the components of the different tissues. Indeed, it may be said with all truth, that so far as its physical nature is concerned, the characteristic of the virgin womb is compactness ; while, with equal propriety, it may be affirmed, that the characteristic of the impregnated organ is softening or looseness of structure, which is the direct result of the fluxion, of which it becomes so active a centre ; so that, in the earlier periods of gestation, the increase in the volume of the uterus is to be attributed, not only to new formations, but to the relaxing and spreading out, through tho agency of increased circulation, of its pre-existing elements. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 165 For the first six months of utero-gestation, the modifications in the cervix are more or less confined to a softening, and consequent increase in volume of its two extremities and canal; and it is not until the beginning of the seventh month that there is any percep- tible shortening of the cervical portion of the organ, as we shall presently endeavor more particularly to show. Madame Boivin, a woman of extraordinary cleverness, and whose field for practical observation was vast, put forth the idea that, at the second month of pregnancy, the cervix uteri is so much increased in length that it measures two inches ; this opinion has been more or less adopted by her successors, more, I imagine, from the weight of her autho- rity, than from any conviction founded on actual investigation, that the opinion is correct. I must confess I am somewhat surprised that Madame Boivin should have promulgated such a statement— accurate as she generally is in her deductions—for, as far as I have been enabled to test the point, from no limited observation, it is not in accordance with facts. Can it possibly be that this distin- guished woman may, for the moment, have forgotten that the tendency of the impregnated uterus is, for the first two months, to descend into the pelvic excavation, and thus have confounded this descent of the organ with the supposed elongation of its cervix ? Or is it that she may have mistaken a congenital elongation for what she imagined to be a lengthening, the consequence of early gestation?* Be it as it may, I am quite certain that the cervix does not increase in length during any period of pregnancy.f One of the very first changes observed by the vigilant accoucheur, as connected with the general softening of its structure, will be a slight tumefaction of the anterior and posterior lips of the os tincae, and at the same time the orifice begins to lose its transverse"shape, and becomes more circular; this latter condition is in part owing to the increase in volume of the two lips, and also to the circum- stance that the anterior lip now becomes more protuberant, so that the two lips are equal in size and prominence. But there is another circumstance connected with the condition of the os tincae at this period of gestation, which becomes more marked as pregnancy advances; as far as I know, it has not been mentioned in connexion with the modifications of the cervix at the commencement of gestation. I allude to a peculiar moisture of the two lips, which, according to my experience, is a cotistant accom- * The neck of the uterus will sometimes exhibit an elongation from simple hyper- trophy of the part, giving rise to prolapsus, etc. M. Huguier has recently written an exceedingly interesting memoir on this subject, entitled, " Allongements Hyper- trophiques du col de l'Uterus." [Memoires de TAcademie Imperiale de Medecine, vol. xxiii. p. 279.] f Dr. Matthews Duncan is also of opinion that there is rather an elongation of the cervix in the early period of utero-gestation. [Edinburgh Med. Jour., March, 1859.] 166 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. paniment of pregnancy. The moisture is occasioned by the pour- ing out of mucus, which is nothing more than the necessary result of an increase in the size of the mucous follicles, which you are aware are found, in more or less abundance, on the internal surface of the cervix. You are not to mistake this secretion of mucus for a morbid or pathological state of the parts—it is in every way a natural and healthy function, and, during the entire progress of gestation, is intended to subserve a most important purpose. Let us examine this point for a moment. After the full development of the foetus has been accomplished, and it is sufficiently matured in its physical organization to enable it to live independently of its parent, a new train of phenomena is instituted, the object of which is to secure its safe expulsion from the maternal system. Now, in this expulsion, the sexual organs must of necessity be subjected to extraordinary distension, and the os uteri become amply dilated; the walls of the vagina are called upon to contribute largely, and so are the labia. Xature, with consummate forethought, and a provident arrangement worthy of our profound admiration, has taken good care to prepare these organs for the great work of dis- tension. The mucous follicles, so abundant in the cervix uteri and vagina, are the instruments which she brings to her aid. As pregnancy advances, these follicles become more and more developed, and in proportion to their development will be the secretion of mucus. This very mucus serves to moisten and relax the parts, and thus prepares them for the excessive distension to which they are soon to be subjected. In the latter months of gestation, the mucus is apt to become so abundant as to cause the female to imagine that she has that vague and unmeaning disease the "whites."* She sends for her medical man, and begs him to give her something to arrest this discharge. If the practitioner be guided by the declarations of his patient—if he should have no mind of his own—or if, in a word, he should not at once perceive that this mucous secretion, in lieu of constituting a pathological condition, is simply one of the wise provisions intended for the successful accomplishment of cer- tain ends, he would most likely prescribe some astringent injection, the tendency of which would be to arrest the discharge, and thus come in direct conflict with the purposes of nature. So you see, gentlemen, how essential it is to distinguish between healthy and morbid phenomena.! Shortening of the Cervix.—At the same time that these changes are going on in the two lips, there is a progressive increase in the * See Diseases of Women and Children, " Leucorrhcea," p. 408. ■j- While observing the caution suggested, yet it is proper also to recollect that the pregnant woman may, under certain circumstances, be affected with a morbid die- charge from the vagina, which will need attention. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 167 volume of the cervical canal, the tissues of which not only become softer, but there is also an augmented capacity in the canal itself. I cannot but think that authors have labored under a remarkable error in stating the mode and degrees of shortening, which the neck of the uterus undergoes during the various periods of preg- nancy. It is maintained by many that, at the fifth month, it loses one-third of its length, at the sixth, one-half, two-thirds at the seventh, three-fourths at the eighth, with an entire obliteration at the end of the ninth month. I believe this error is partly traceable to the circumstance that sufficient importance has not been attached to the fact that the cervix, as one of the immediate results of ges- tation, becomes increased in volume, and this increase of volume is mistaken oftentimes for a diminution of its length. As far as I have been enabled to arrive at a just conclusion upon the subject—and no little attention has been given to the investiga- tion—I do not think there is any actual loss in the length of the cervix until near the end of the sixth month, and this brings us to the consideration of the manner in which the shortening is accom- plished. You have already been informed that the order of deve- lopment of the gravid uterus is first an enlargement of the fundus, then of the body, and lastly of the cervix ; and it is not until toward the termination of the sixth month that the cervix begins to contri- bute its share to the general capacity of the uterus. At this time, the uterine portion of the neck commences to widen, from which there are two direct results : 1. A shortening of its long axis; 2. An increase in the uterine cavity. This expansion of the uterine extremity of the cervix now pro- ceeds with more or less uniformity, producing consequently a gra- dual shortening of the cervix, and at the same time a gradual increase in the capacity of the uterus, so that, at the end of the ninth month, the cervix has so completely surrendered its length, that it presents simply a ring, which is known in obstetric language as its obliteration. If you examine a female in the fifth month of her gestation, on introducing your index finger into the vagina— in the manner we shall hereafter point out—and passing it along the outer surface of the cervix uteri, you will very readily ascer- tain that its length is unchanged ; make this same examination at the seventh month, and, when your finger reaches the uterine por- tion of the neck, you will at once recognise a remarkable alteration in the condition of things, viz. that this portion of the organ is more expanded, giving an increase to its various diameters, and then it is that you will also appreciate the important circum- stance that the cervix commences to diminish in length, this dimi- nution, remember, beginning above, and not below—or, to be more explicit at the uterine, and not at the vaginal extremity of the part. 163 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. I am thus emphatic upon this point for the reason that a high authority in midwifery, the learned Stoltz, of Strasburg, main- tains that the cervical portion of the uterus begins to lose its length from below upward, and positively asserts that the uterine extremity undergoes no change until the latter part of the ninth month. This opinion of the distinguished professor is also par- ticipated in by Cazeaux, who, as a writer and observer, occu- pies deservedly a high position.* I cannot account for the opi- nion of these distinguished writers. I am confident it is founded in error, and is altogether adverse to bedside experience. If I did not feel the strongest conviction—a conviction amply con- firmed by repeated investigation—that I am right in regard to this question, it would be with no little hesitation that I should thus unequivocally, but yet most respectfully, doubt an opinion emanating from such valued authority. There is, in my judgment, a very essential practical fact con- nected with the manner of the shortening of the cervix ; and it is strange that attention has not been more specially called to it, for it embodies a lesson of great value to the accoucheur, while it is of the deepest interest to the patient. It is as fol- lows : In the course of your practice you will occasionally be consulted by pregnant women in consequence of more or less dis- charge of blood from the vagina ; this necessarily will produce much disquietude in the mind of the patient, and the loss of blood may result from the various causes capable of promoting a miscarriage; such, for example, as blows, falls, or fright. But the cause of the discharge of blood to which I allude, in connexion with the shortening of the cervical portion of the ute- rus, is of a very different kind, and traceable to a peculiar cir- cumstance. In placenta praevia, the placenta being attached over the mouth of the womb, either centre for centre, or in a por- tion only of its circumference, one of the most likely things to occur during the seventh, eighth, and ninth months of gesta- tion will be flooding to a greater or less extent—and why ? Do you not see the almost necessary connexion between hemorrhage at these terms of pregnancy and placenta praevia ? What are the facts ? The after-birth is attached, through vascular and other connexions, to the internal surface of the upper or ute- rine portion of the cervix; you have just seen that, at the end of the sixth mouth, this portion of the cervix begins to widen, for the purpose of giving increased size to the uterine cavity; now this very expansion will be at the expense of some of the vascular connexions, to which we have just alluded, and hence the flooding. If, therefore, gentlemen, a patient without any assign- * Traite Theorique et Pratique de l'Art des Accouchemens. Par P. Cazeaux. Cinquieme Edition, p. 97. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 169 able cause on her part, should, in the latter months of pregnancy, be attacked with a discharge of blood from the vagina, you may legitimately infer that it is because of the implantation of the after- birth over the os uteri. In such an event, the most judicious treat- ment will be called for; in a future part of the course, when dis- cussing the management of flooding, as connected with placenta praevia, your attention shall be fully directed to the therapeutics of these cases. Tlie Cervix in the Primipara and Multipara.—We have spoken of the two extremities of the cervix uteri, and you have noted the successive changes which occur in them ; you have also seen in what way the cervical canal commences and continues to shorten, until at the completion of utero-gestation it is reduced to a simple circle or ring. It now remains for me to point out certain differences in these modifications depending upon whether they occur in a primi- para or multipara, and it is important that you should understand the nature of these variations. In a primipara, all the changes to which we have alluded progress much more tardily than in the female who has borne one or more children. The softening of the uterine tissues is slower, so is the tumefaction of the anterior and posterior lips of the os tincae ; and another essential characteristic of the os tincae in the primipara is, that it maintains more or less a conoidal form, and is not dilated so as to permit the introduction of the finger. Again: the internal surface of the two lips is uni- form,, uninterrupted by elevations; and also in the primipara, the shape of the cervical canal is fusiform. In the multipara, there is a more rapid development in the modifications of the gravid organ. The lips of the os tincae are more protuberant, and the finger can be readily introduced, for the reason that they never assume their original shape after childbirth; so true is this, that you will per- ceive a very striking contrast in the form of the vaginal extremity of the cervix when compared with that in the primipara; in the latter, it is more or less conoidal, while in the multipara it has been very properly compared to an inverted funnel. In the multipara, also, the internal surface of the lips is irregular; and this irregu- larity is owing to the circumstance that, during the passage of the child through the os uteri, there have been slight lacerations of the mucous membrane; these lacerations heal, and form afterwards so many cicatrices, which are easily recognised by the touch. Development of the Uterine Annexce and External Genitalia.— The general growth of the tissues, consequent upon fecundation, is not limited to the uterus; the appendages of the organ participate more or less in the effect of this increased nutrition ; the ovaries nearly double in size, with an augmented volume of their blood- vessels ; the same fact is observed with regard to the fallopian tubes; and there is also a marked development in the muscular 170 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. fibres of the broad and round ligaments ; the vagina and external organs likewise undergo important changes; the former, as preg- nancy advances, becomes wider and shorter, and there is a very evident increase in its spongy tissue. The vagina assumes another modification in the latter period of gestation, as has recently been pointed out by Rouget. He has shown that distinct muscular planes can be detected with the naked eye; and this will at once explain the contractile power displayed by this canal during the passage of the foetus through it. The mucous follicles become larger, and pour out more or less mucus. There is an interesting circumstance connected with this development of the mucous fol- licles, and it is this—in carrying your finger along the Avails of the vagina, you will occasionally have imparted to it a sensation, as if you are touching numerous granulations; and if you do not recol- lect the reason of this temporary change in structure, you might possibly confound it with a very important affection of the vagina —granular vaginitis, first described by Deville. The external organs, especially as the final term of gestation approaches, are more or less engorged, and there is an evident relaxation of their tissues. In a Avord, gentlemen, you cannot but appreciate, as you contemplate these different modifications in the reproductive apparatus, the simple motive, which has so obviously influenced nature—every change, you perceive, has been made tributary to the successful accomplishment of the great act in the reproductive scheme—the birth of the child. How does the Gravid Uterus Enlarge?—Thickness of its Walls. You have seen that, as the necessary consequence of gestation, the cavity of the uterus enlarges in order to afford accommodation to the germ ; and the question arises, how is this enlargement of the uterine cavity effected ? The opinion entertained by the old school- men upon this subject AA'as a singular one—they taught that the cause of the increase in the size of the organ Avas altogether mechanical; that, as the embryo gained in development and size, its pressure against the walls of the uterus occasioned a distension equal to its requirements. They, in fact, compared the gradual enlargement of the organ, and supposed it to be accomplished upon the same principle, to the distension of a bladder when filled by air or water.* But the fallacy of this and kindred hypotheses must be apparent to all of you. The uterus grows and becomes developed through the same influence precisely that imparts to the foetus its growth and development—increased nutrition. Prior to the second * It is well to remember that this question of the manner in which the gravid uterus becomes enlarged was determined, not by human dissection, for this was one of the precious elements of trutnful inquiry from which the ancients were debarred; but from the inspection of the impregnated organ in animals, in some of which, it is conceded, the uterus does enlarge through mechanical distension. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 171 month, the embryo is dependent for its nourishment on other sources, as we shall in the proper place indicate; but after this period it derives its elements of growth from the placenta. The uterus, on the contrary, becomes developed, because of the afflux of fluids and increased circulation setting toward it from the first moment of fecundation until the completion of gestation. So you perceive, gentlemen, that both the uterus and the embryo it con- tains pass respectively through their phases of increase, by the simple agency of a more active nutrition. If any argument be required to demonstrate the utter absurdity of the ancient theory of mechanical distension, you need only recollect the interesting circumstance that, in extra-uterine pregnancies, the cavity of the uterus undergoes more or less dilatation.* Thickness of the Watts of the Gravid Uterus.—There has also been much difference of opinion as to the absolute thickness of the walls of the organ during gestation; some contending that they become extremely attenuated, while others maintain that they increase in bulk only at the disc on which the placenta is inserted ; and again it is affirmed that the entire increase in the thickness of the parietes is due exclusively to the engorged state of the blood- vessels ; this latter fact being attempted to be demonstrated by the circumstance that, in women who have died of uterine hemor- rhage, the walls are always less in volume. Now, there is no doubt that the latter statement is true; but admitting its truth, what does it prove ? Absolutely nothing, so far as the solution of. the point in controversy is concerned; for, while it cannot be denied that there is a relative increase in the thickness of the uterine Avails, in consequence of the more active circulation, yet the cardinal fact for you to remember is, that the principal cause of the increased bulk of the gravid uterus is found in the changes of the muscular tissue of the organ ; and, as I have already remarked to you, in a previous lecture, these changes are brought about in two ways: 1. By an enlargement of the pre-existing muscular elements ; 2. By a new formation of them. So that, while it may be conceded that, after fatal hemorrhage, there is a diminished thickness in the uterine parietes, it must also be recollected that this loss is relative and not absolute, being proportionate only to the amount of dis- gorgement Avhich the blood-vessels have undergone. As a general principle—although there will be more or less marked variations in different women—it may be affirmed that, during the period of pregnancy, the thickness of the walls of the uterus is about the same as in the unimpregnated organ. It is greatest at the fundus, especially where the placenta is attached, * For further details on this subject, the reader may consult with profit an elabo- rate paper on " The Uterus and its Appendages," by Dr. Arthur Farre (Cyclopaedia of Anatomy and Physiology, p. 645. London, 1858). 172 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and gradually diminishes towards the cervical portion. Taking twelve lines to the inch, it may be said that, at the fundus, the thickness is from four to five lines, slightly less in the body, and from tAvo to three lines in the cervix ; another interesting fact is, that, for the first five or six months of gestation, the thickness rather increases, and after this period its tendency is gradually to diminish. Let me here direct your attention to an important circumstance with regard to the os uteri at the time of labor. In making a vagi- nal examination, when labor has fairly commenced, it will be ascer- tained that the os is oftentimes characterized by extraordinary thinness; and it is this fact Avhich, no doubt, has originated in the minds of some writers the idea that the entire surface of the uterine Avails participates in this attenuated condition. So much, you see, for determining a principle by a single circumstance. It is bad logic, and has been fruitful in the spread of unsound lessons. The Avhole of the testimony or none, is a fundamental maxim in law, and it is not without its application in our profession. Discoloration of the Vaginal Walls. — Among the changes occurring in the sexual organs consequent upon pregnancy, much importance has recently been attached by certain observers to a discoloration of the internal surface of the vagina; and men of high eminence are disposed to regard it as an evidence of very great value that gestation actually exists. There has been some differ- ence of opinion as to whom belongs the merit of having first called attention to this peculiarity in the color of the vaginal walls, but I think the credit is due to Jacquemin, of Paris, whose opportunities for investigating this subject were of no ordinary limits, having been appointed by the police to examine the generative organs of the prostitutes of the French metropolis—certainly a wise regula- tion ; for if it be an admitted principle that, for the protection of the community, prostitution must be countenanced, then, I say, let it be freed, as far as may be, from the dreadful scourge entailed upon those who indulge in it—I mean the syphilitic taint; and how can this be so effectually accomplished as through the vigilant examinations, made under the police regulations, of the genitals of the prostitutes, who are to be found in such fearful numbers in the great city of Paris. It would be well, indeed, if some such municipal law obtained in New York, which is but the younger twin sister of Paris in all that contributes to the formation of the true greatness of a people, and at the same time panders to the lowest and most degrading vices. Jacquemin, in describing the discoloration of the vagina, calls it a violet hue, not unlike the lees of wine; and he broadly affirms that, irrespective of any of the other evidences of gestation, this sign alone would be sufficient for him to pronounce upon the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 173 existence of pregnancy. Kilian, of the University of Bonn, a good observer, and a man of much experience, regards the discoloration as one of the " most constant signs of gestation." This opinion is also sustained by Kluge of Berlin, Ricord, Parent-Duchatelet, and others. There can be no doubt that the color of the vagina, in the great majority of cases, does undergo a remarkable change during pregnancy, presenting a sort of bluish tint, and this is altogether the effect of the vascular congestion of the parts. Many of you, who reside in the rural districts, and who, perhaps, are more or less familiar Avith that primitive but honorable occupa- tion of man, agriculture, and its kindred pursuits, must recollect the practice usually resorted to by breeders Avith a view of ascertaining whether the female of many of the lower animals be in a state to receive the male—or, in other words, whether she be in heat. The practice to which I allude is to inspect the outer opening and internal surface of the vagina, which, in season of heat, will be found to exhibit a very dark color—and I am quite satisfied that this same character of discoloration takes place at the advent of the catamenia in woman.* I have closely watched this latter circumstance, and in the many vaginal examinations Avhich I have made just before the menstrual eruption, I do not knoAV that I have failed in a single instance, in a normal menstruation, to detect this discoloration of the vagina. It seems to me that the true Avay to arrive at the real value of this sign, as a diagnostic evidence of pregnancy, is to determine, in the first place, the two following inquiries: 1. Is the discoloration of the vagina a universal accompaniment of gestation; 2. Is it ever present, Avhen pregnancy does not exist ? I have no hesitation in stating, from my own personal observation, that pregnancy will occasionally pass through its various stages without the slightest cognizable change in the ordinary color of the vagina, and this is more likely to occur in women remarkable for pallor of skin, and especially in those Avhose pallor is traceable solely to an anaemic condition—Avhether the anaemia be dependent upon an original deficiency of the red corpuscles, or upon a sudden or long-continued drain upon the system. In reply to the second point, AAmether the discoloration is ever present Avithout pregnancy; or, in other words, whether any other cause can produce it, I am quite confident that there are numerous instances, Avhich will amply support the affirmative of this question ; and it is with no little surprise that I find so valued an authority as Huguier positively affirming that " this change of color in the vaginal Avails is not found in any other condition of the uterus than * Some interesting facts as to the color of the vagina in domestic animals at the time of heat and during gestation, have been recorded by M. Rainard [Traite complet de la partirition des principales femellesdomestiques] 174 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. that of pregnancy." Now, gentlemen, Avhat are the facts? In the first place, I have told you that the real cause of this bluish aspect of the vagina is vascular congestion, and consequent partial inter- ruption in the ordinary current of the blood. If this be true—and the fact is very generally conceded—it should follow that Avhenever this vascular congestion is present, no matter from what cause, you may very naturally look for the effect—discoloration of the vagina. You will, therefore, notice the change of color in the case of intra- uterine tumors, in chronic sanguineous engorgement of the uterus, etc. In a word, it is one of the not unusual accompaniments of congestion of the uterus, whether from gestation, or from some morbid influence, with which pregnancy has no possible connexion. From what has just been said, it is very evident that the value of this sign as a proof of pregnancy, is subject to more or less qualification; and it is also well to mention that delicacy on the part of the female Avill oftentimes prevent the accoucheur from availing himself of the means of ascertaining whether or not it be present. LECTURE XII. Evidences of Pregnancy continued—Quickening—Ancient Theory—Law of England in regard to Quickening—What is Quickening?—Opinions of Authors—Nervous and Muscular Development—Muscular Contractions of the Foetus—Sensible and Insensible Muscular Contractions—Quickening not a Psychical Act, but the result of Excito-motory Influence—Spinal System—Its Physiological Importance— When does Quickening take Place ?—Does not always Occur—Delusive Quickening —Illustration—Contraction of Abdominal Walls mistaken for—Final Cessation of Menses and Supposed Quickening—Attempted Imposition—Queen Mary of Eng- land—Manipulations to Detect Quickening—Influence of Cold on Movements of Foetus—Illustration—Ballottement or Passive Movement of Foetus—Rules for Detecting—Positions of Foetus and Ballottement—Pulsations of Foetal Heart;— Auscultation—Mayor of Geneva—Average Beats of Foetal Heart—Not Synchro- nous with Maternal Pulse—Auscultation, how Applied—Auscultation and Position of Foetus—Twin and Extra-uterine Pregnancies—How ascertained—Placental Souffle—Uterine Murmur—Kergaradec—Conflict of Opinions—Souffle not always Dependent upon Pregnancy—Uterine and Abdominal Tumors; Cause of—Souffle no Evidence of Life of Foetus—Pulsations of Umbilical Cord—Dr. Evory Ken- nedy. Gentlemen—We shall now proceed to an examination of the evidences of gestation derived from other sources. Thus far Ave have considered those signs only, which are either so many sympa- thetic phenomena, or the direct result of increased vital action. The order of signs, to which your attention will now be directed, is not only of special interest, but some of them, Avhen recognised, are conclusive as to the existence of pregnancy. They may be enumerated as follows: 1st, Quickening; 2d, The passive move- ment of the foetus, termed by the French, Ballottement, by the English, Repercussion; 3d, Pulsations of the fcetal heart; 4th, The Bruit placentaire, placental souffle, or uterine murmur; 5th, Pulsations of the umbilical cord. 1st. Quickening.—This term is employed to designate the parti- cular period of gestation at Avhich, through the movements of the foetus, the mother becomes for the first time aware that she carries within her a living being. The anoient theory upon this subject was not only singular, but the very essence of absurdity; it incul- cated the principle that quickening was the simple evidence that, at that very moment, vitality was imparted to the foetus ; and that, therefore, prior to this event, the foetus aa as an inanimate mass, without individuality. In those days, Avhen physiology Avas not a science, and when crude hypothesis oftentimes was substituted for 176 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. truthful and scientific research, it is not strange that such opinions should have obtained. But that this hypothesis, false, and, in every sense, adverse to facts, should, almost in our own times, have been adopted by one of the most enlightened countries in the world, and made the basis of an important law, is a matter which, were it not for the unerring evidence of the Statute Book, Avould scarcely fall Avithin the range of credibility. The Ellenborough act, of 1803, holds the folloAAring inconsistent and unworthy language: "If an individual shall Avilfully or maliciously procure abortion in a Avoman, not quick with child, the crime shall be declared felony, and the offender may be fined, imprisoned, set in the pillory, publicly whipped, or transported for any term not exceeding fourteen years; but if the offence be committed after quicken- ing, it shall be punishable with deaths Now, gentlemen, allow me to ask—Why this distinction in the award of punishment for a crime which, as physiologists, you know to be nothing short of murder, Avhether committed before or after the period of quick- ening ?* What is the difference betAveen the ovule secreted by the ovary, which passes from the system Avith the menstrual blood, and the ovule on Avhich is exercised the specific influence of the spermatic fluid of the male? The broad, unequivocal, true physiological difference is, that the former is dead, deciduous matter, and, like all things dead, has no inherent pOAver of development. The latter, on the contrary, is vitalized ; the very act of fecundation infuses life into it, and it proceeds on its mission of development until, prepared by successive increase for independent life, it is expelled from the organs of its parent. You see, therefore, physiologically speaking, the embryo is as much aliAe in the earliest stages of fecundation as at any future period of its intra-uterine existence. The mould of the future being is there, Avith all the necessary elements, through progressive development, for perfect physical organization. Like the little acorn, Avhich, falling from the parent tree, if it find shelter beneath congenial soil, and be allowed to pursue uninterrupted its natural phases, will become matured into an oak as majestic and sturdy as the one to which it owes its own exist- ence. Away, then, Avith the absurdity, and, in the exercise of your prerogative as medical men, whether in the chamber of sickness, or on the Avitness-stand in courts of justice, remember that he who, * Within a few 3rears, this law has been modified, and stands as follows: " Who. soever, with the intent to procure the miscarriage of any woman, shall unlawfully administer to her, or cause to be taken by her, any poison or other noxious thing, or shall unlawfully use any instrument, or other means whatsoever, with the like intent, shall be guilty of felony, and being convicted thereof, shall be liable, at the discretion of the Court, to be transported beyond the seas for the term of his or her natural life, or for any term not less than fifteen years, or bo imprisoned for any term not exceeding three years." [1 Victoria, c. lxxxv. s. 6.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 177 from sordid motives, or Avith a vieAV to conceal his own crime, shall produce abortion is, in the eye of heaven, equally guilty of murder, whether the act be perpetrated before or after quick- ening. The true Import of the Term Quickening.—Let us now inquire what it is that gives rise to the movement, known as quickening. Is it really the movement of the foetus, or is it attributable to movement of some other organ ? You will observe, in the course of your reading, various theories upon this subject. Some main- tain that the seat of the sensation of quickening is not to be re- ferred to the foetus, but will be found to be in the abdominal walls of the woman* Others, with Royston, attribute it to the sudden passage of the uterus from the pelvis into the abdominal cavity; while again, it is said that quickening is nothing more than the " evidence of the contractile tissues of the uterus being so far de- veloped, as to admit of the peristaltic actions of the organ." It really seems to me that much time has been uselessly Avasted in the. attempted explanations of a circumstance which, in my judgment, is in no Avay difficult of comprehension. The sensation first imparted to the parent, no matter how slight, which makes her conscious that she is pregnant, and that the pro- duct of conception is alive, is a sensation traceable to nervous and muscular development. As soon as the nervous and muscular tissues of the foetus have received sufficient growth to enable them to enter upon their specific and legitimate functions, it is through the agency of one of these functions—muscular contraction—that the mother becomes sensible of her situation. Quickening, then is nothing more than the ordinary result of progressive increase— in other Avords, the physical organization of the foetus has reached a state of development, which imbues it with the power of move- ment—a movement dependent upon muscular contraction. This contraction may be divided, for practical purposes, into two kinds —sensible and insensible. In the former instance, it is sufficiently strong to impart the sensation to the mother; in the latter, so feeble that she does not become cognizant of it. So you perceive, gentlemen, that while the sensible muscular contractions of the foetus may be said to constitute quickening, yet the insensible mus- cular contractions may take place some time previously to the period at which quickening usually occurs. Again, the accoucheur, with skilful manipulation, will occasionally be enabled to recognise the active movements of the foetus before they have become ap- parent to the mother. I have met with more than one instance of this kind, and it is of importance to remember the circumstance. * Eggert says, the foetus has nothing whatever to do with the movements known as quickening—they being exclusively confined to the abdominal and uterina pariotes. [Rust's Magazine ; vol. xvii., p. 62.] 12 178 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Dr. Montgomery* states that he has had several similar examples; and the fact is confirmed by other observers. I haA-e just stated that the quickening of the foetus in utero is the result of muscular contraction of the foetus itself. This is un- doubtedly true, but as intelligent students, avIio should not be content Avith the simple affirmation of a fact, but Avho, in the true spirit of philosophy, have a right to seek its explanation, it is quite reasonable that you should ask AAThat it is that gives rise to this action of the muscular system. Is it the result of Abolition, or, in other words, is it a psychical act; or does it depend upon some- thing beyond the control of the will ? The muscular movements of the foetus in its mother's womb are reflex phenomena, the products of excito-motory influence, an influence not dependent upon the brain, but traceable exclusively to Avhat has been deno- minated the true spinal system. This system is not only the source of muscular moA^ement, but it is the very fountain of life itself. Those of you Avhose attention has not been particularly directed to the subject, might, perhaps, express surprise, if indeed you did not manifest more than ordinary incredulity at the statement that an infant born Avithout cerebrum or cerebellum, or Avithout both, is capable of breathing, crying, taking its parent's breast and per- forming other acts connected with life. But while the researches of the physiologist have established the fact beyond a peradventure —they have gone further, and demonstrated that, without the spinal cord, no matter how perfect may be the cerebral mass, life cannot be maintained, for the reason that the two essential func- tions of the economy, respiration—and, consequently, circulation— on which the various organic functions depend, are the results of reflex action of the medulla spinalis. You cannot, therefore, but appreciate the importance of this nervous centre, not only as the source of those forces constituting life, but also as the source from Avhich emanate, either directly or indirectly, many of the disturbing influences, which derange and impair the human mechanism. I shall have occasion to call your attention to the physiology of the spinal system in connexion with the subject of parturition, and you will plainly see that child-birth is but another of those opera- tions of the physiological law, which are constantly presenting themselves to our observation. Period of Quickening.—A pregnant woman usually quickens about the middle term of pregnancy, say the fourth and a half month. But there is no uniform rule on this subject. I have knoAvn quickening to occur as early as the fourth month, sometimes not until the end of the fifth, and you will, in the course of your practice, occasionally meet with cases of gestation in which the * Signs and Symptoms of Pregnancy, p. 119. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 179 mothers have experienced no sensation of life during the entire term of pregnancy, and yet bring forth healthy and fully developed infants. If you ask me to explain this, I must acknoAvdedge that I cannot. It is no doubt due to some idiosyncrasy, either on the part of the parent or child, which I do not comprehend, and which, therefore, it would be useless to attempt to elucidate. It may, peradventure, be that these foetuses are a species of " Lazy Law- rence," too indolent even to be made to move. We have many examples of this indomitable love of repose in both boys and men, who have long since left their mothers' womb. They have no object in life—they simply vegetate and die, and history keeps no record of either their advent or departure. Simulated Quickening.—But, gentlemen, what is especially inte- resting to you as accoucheurs, and more urgently so in reference to the diagnosis of pregnancy, is, that married Avomen, who are not in gestation, will sometimes imagine they feel life, and this hallucination Avill occasionally be so marked that it may possibly convert you to their mode of thought, and lead to serious error of judgment. On the principle that a medical man should be as ready to acknowledge his delinquencies as to proclaim his triumphs, and with the sincere hope that the recollection of it may hereafter admonish you of the necessity of caution, I shall cite the folloAving interest- ing case, Avhich occurred to me some years since : A married lady, the mother of eight children, came from British Guiana, for the pur- pose of placing herself under my professional care—her health had been quite infirm for two years previously to my seeing her. On an examination of her case, I discovered that she Avas laboring under asthenic dropsy, from chronic disease of the liver. In communicating my opinion to her, she very courteously remarked that it was quite possible she was affected with dropsy, but she knew very well that she was also pregnant. I asked her Avhy she thought so, and how far advanced she imagined herself to be in gestation, to A\rhich she replied that she had, for six weeks pre- viously, very distinctly felt the movements of her child, and that, according to her calculation, which had never failed her in previous pregnancies, she Avas in her sixth month. Although I had suspected uothing of this kind previous to the positive declaration of the patient, yet such was her inexorable conviction on the point, that I immediately proposed t o institute an examination, for the pur- pose of satisfying my own mind. This she strenuously refused, saying that " It would be nonsense, as she was as fully convinced of her situation as she Avas that she was a liAdng woman." Under these circumstances, I was content to submit the question of pregnancy to the future, and proceeded to do all in my power to relieve the formidable disease Avith which she was affected. So 180 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. dilapidated was her general health, and such the character of her malady, that I found my efforts limited to the mere temporary palliation of symptoms. She continued to increase in size, which circumstance she constantly referred to her pregnancy; and every day that I visited her, she declared she felt more and more distinctly the movements of her child. She would often, as she reposed on her couch, take my hand, place it on her abdomen, and exclaim; "There, Doctor, do you not feel it?" I must confess I never did feel it, but courtesy, contrary to conviction—so positive was this lady of her situation—frequently Avrung from me an equivocal, but reluctant assent. There Avas another conviction which had taken a strong hold of the mind of this estimable Avoman, and it consisted in the full belief that, as soon as she should give birth to her child, she Avould regain her health. Well, gentlemen, things passed on in this way until, according to her OAvn computation, she Avas, as it were, on the borders of confinement; and, at her urgent request, I engaged for her a monthly nurse, who immediately entered upon duty. A singular feature in the case Avas, that the very day corresponding with the period when she expected her labor, I Avas sent for in great haste, and on entering the room, my patient observed : " Doctor, you see I am not mistaken." This lady assured me, and the statement was confirmed by the nurse, that for an hour previous to my arrival, labor pains had commenced. On making a vaginal examination, you may readily imagine my embarrassment on discovering that the uterus was unchanged, and that no pregnancy existed ! Still it occurred to me that it might possibly be a case of extra-uterine fcetation. I soon, however, after due exploration, decided in my own mind that this Avas not so. I need scarcely tell you that I stood self- rebuked. I had neglected my duty. I Avas bound by every prin- ciple of self-respect, by the very reasons I have so repeatedly urged upon you, to have insisted—Avhen this lady first placed herself under my care, and disclosed to me her well-settled conviction that she was pregnant—upon an examination, which would have enabled me to decide the question; or, in the event of my failing to obtain her consent, it was an obligation which I owed both her and myself, to AA'ithdraw from the responsibility of the case, for I maintain that the medical man, when denied jurisdiction, should not assume responsibility. I must confess, gentlemen, my conduct on this occasion Avas not at all in keeping with my usual mode of doing things, for I usually insist—and succeed too—as it is termed, " in having my own Avay" in the sick room. But let us return to the patient. For the instant I was at a loss what to do. Knowing the ardent hope she entertained of her recovery as soon as she should give birth to her child, and Avell aware, also, of the extreme infirmity of her health, I was apprehensive that a sudden and THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 1ST positive assurance on my part that she Avas not pregnant, Avould result most disastrously to my suffering patient. Accordingly, under the circumstances, I thought it most judicious to invoke counsel, and I requested my distinguished friend, the late Dr. John W. Francis, to visit her with me. He, after an examination, corro- borated my opinion, and the lady was then made acquainted with the conclusion at Avhich we had arrived. Such is the operation of mind upon matter, so sovereign the influence of the mind over the body, that, almost from the moment the disclosure was made to her, she began to sink, and in four days her sufferings Avere at an end. There are various conditions of system in which women will be apt to imagine they feel the motions of the foetus, and, therefore, it requires more than ordinary caution on the part of the practitioner, in order that error may be avoided. For example, women of extreme nervous susceptibility, hysterical women, Avho are usually more or less annoyed by a flatulent state of the intestinal canal, will sometimes mistake a movement in the abdomen, dependent entirely upon a morbid condition, for the active movement of the child. Married ladies Avho have not borne children, and Avho, at the approach of the period of the final cessation of the catamenia, usually enlarge in the abdomen from a deposit of adipose matter, Avill occasionally suppose themselves pregnant, and they will assure you that they have distinctly "felt life."* Again, women, from avaricious or other motives, will feign pregnancy, and, among their other devices, will attempt to impose upon the judgment of the practitioner, by simulating the moAre- ments of the foetus, through the contraction of their abdominal muscles. When I held the Professorship of Obstetrics in Charleston, South Carolina, Dr. Bennett, of that city, kindly afforded me an opportunity of presenting to my class a very interesting case, in the person of an old colored Avoman answering to the name of "Aunt Betty." She Avas well-known in Charleston as "the old •Some ludicrous blunders have been made in these cases: females who have been married for many years, and who, notwithstanding every legitimate effort on their part—faithfully aided, no doubt, by their devoted consorts—having failed in the con- summation of their wishes—the production of offspring—are extremely prone to mistake, as the era of the final cessation advances, the phenomena usually accom- panying this important climacteric for so many evidences of gestation. The cessation of the menses, the increased size of the abdomen, together with the numerous nervous perturbations consequent upon this transition state of the eco- nomy, are readily treasured up as so many indications that "hope deferred" is at last to be gratified; and what is worth recollecting is, that it is generally extremely difficult to persuade these good ladies that what they have regarded as so many evidences of their pregnancy, are but the emphatic, yet sad declarations of nature that the springtime of life has passed, and they are about to lapse into the cold shades of winter. 132 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. woman who had been pregnant for fifteen years,'' and I was informed that she had accumulated some money by showing the curious how actively her little child "jumped in the Avomb." She was in good health, and quite corpulent. As " Aunt Betty" sat before me, there Avas considerable movement in the abdomen, which I very soon noticed she should cause at pleasure. She Avas fifty-five years old, and had not menstruated for ten years. Aftei presenting her to my class, and, under the full conviction that she Avas not pregnant, I succeeded, Avith much coaxing, in obtaining her consent that I should examine her, Avhich privilege she posi- tively declared she had never previously granted any one. The uterus Avas not enlarged; she was not pregnant, and the deception, which had been practised on the credulous, Avas quite evident— she had, from long habit, accustomed herself to cause the abdo- minal muscles to contract, Avhich so closely simulated the moAre- ments of the foetus that she successfully carried out her scheme. Before I left Charleston, the good old Avomau died, and I was enabled, by a post-mortem examination, at which Drs. Francis Y. Porcher, J. B. Whitridge, and Dr. Bennett, were present, to con- firm the accuracy of the diagnosis. There was nothing remarkable revealed by the autopsy except that the omentum was loaded Avith fatty matter, which accounted in part for the enlargement of the abdomen. Sometimes young, unmarried women will apply to you for professional advice, and beg you to give them medicine to make them regular. They will tell you, apparently, a very consistent story. It is not unusual for them to have a protuberant abdomen, and if you inquire about it, they will say, "It is only a swelling they got since they caught cold," or something equally satisfactory. Should you place your hand on the abdomen, and recognise the movements of the foetus—not unlikely to occur in some of these cases—and ask the Avoman if she has ever noticed this peculiar motion, you will be surprised, gentlemen, at the ready coolness with which she will oftentimes reply, " Oh ! yes, doctor, I am dreadfully troubled with it—it is wind in my stomach !"* You must be on your guard—a woman who has fallen is generally well versed in the Avily tricks *Dr. Keiller reported to the Edinburgh Obstetrical Society, March, 1850, the particulars of a very remarkable case not only of spurious pregnancy but spurious parturition: " He was sent for to what was regarded a very painful and protracted labor in which, according to the opinion of the attending accoucheur, the Ccesarean section ■was imperatively demanded. He was astonished to find that all the symptoms of parturition were spurious, and the uterus was unimpregnated. The friends ridiculed the idea that it was not real labor, as the motions of the child could be not only felt, but seen through the walls of the distended abdomen, and the patient herself insisted that the child's movements were so violent that she feared " it would leap through her side." The symptoms were referable in a great measure to hysteria." THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 183 of life—and she will bring every subterfuge to bear in the hope that she may conceal from the public view the evidences of her own shame! Queen Mary, of England, is a striking example of how far imagination, excited by the earnest desire to have issue, may some- times impose on good sense and moral Avorth. She was so confident that she felt the movements of the child in utero, that public proclamation was made of the interesting circum- stance, and the intelligence sped with the Avings of lightning throughout the courts of Europe. Eager, indeed, was expectation, and high the hopes of the Queen—her people rejoiced, and national oblations offered for the coming event, Avhich was to make so many of her subjects happy. But, alas! the future threw a gloom over this cherished anticipation. The supposed quickening \A~as but the result of impaired health and incipient dropsy.* How can Fcetal Movements be Excited ?—We noAv come to a very important question—How can the movements of the foetus in utero be excited ? It is quite obvious that, in many cases of supposed or doubtful pregnancy, the accoucheur A\ill be most anxious to decide the question by ascertaining, through certain manipulations, whether or not the child moves in its mother's womb. This fact being positively settled, places the existence of gestation beyond all contingency—it does more, for Avhile it demonstrates that the Avoman is pregnant, it establishes also that the child is alive. Most authors recommend, in this exploration, that the patient shall be placed in the recumbent posture, with the thighs flexed, and the chest gently elevated for the purpose of relaxing the abdominal walls. In my own judgment, it is much better, for the object will be more readily attained, to allow the abdominal muscles to be on the stretch, rather than in a state of relaxation, and therefore—although it may sometimes be incon- venient to the patient—I Avould prefer conducting the examination either in the standing or sitting position. If, in the latter, the * Hume makes the following allusion to the case: "The Queen's extreme desire to have issue had made her family give credit to any appearance of pregnancy; and when the legate was introduced to her, she fancied she felt the embryo stir in her womb. Her flatterers compared this motion of the infant to that of John the Baptist, who leaped in his mother's belly at the salutation of the Virgin. Dispatches were immediately sent to inform foreign courts of this event; orders were issued to give public thanks; great rejoicings were made; the family of the young Prince was already settled, for the Catholics held themselves assured that the child was to be a male • and Bonner, Bishop of London, made public prayers. He said that heaven would pledge to render him beautiful, vigorous, and witty. But the nation still remained somewhat incredulous, and many were persuaded that the Queen labored under infirmities, which rendered her incapable of having children. Her infant proved only the commencement of a dropsy, which the disordered state of her health had brought upon her." [History ot England, ch. xxxvi. j 184 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. patient should place herself upright in the chair, with her head and shoulders inclined slightly backward. Now, gentlemen, let us understand ourselves—what is it you Avish to discover ? Simply whether the child moves in utero. I have told you that the move- ment is an excito-motory act; it is obvious, therefore, that you will be most likely to succeed in your investigations by having recourse to those means best calculated to promote the physiological or excito-motory influence. Excito-motory action, in physiological language, consists of tAVO distinct influences—one of these influences commences at the circumference, and travels to the centre, from Avhich emanates, and as a consequence, an action called reflex. The phenomena are pro- duced exclusively through nervous agency. You know very well that a capital remedy in severe uterine haemorrhage is the cold dash applied to the abdomen—it is capital, because it will very generally produce contraction of the womb, and thus arrest the flooding. But, what is the modus in quo of this agent thus applied—on Avhat principle does it cause uterine contraction ? On the principle clearly of reflex or excito-motory influence. For example, the peripheral extremities of the nerves distributed upon the abdominal walls become primarily stimulated by the cold ; this impression is instantly conveyed, through these nerves, to the medulla spinalis, Avhich imparts to the motor nerves passing from it to the uterus a new impulse; and it is to this impulse, transmitted by these nerves to the muscular tissue of the uterus, that the con- tractions of the organ are to be referred. Upon the same principle precisely, will you sometimes observe the magic effects, in uterine haemorrhage, of a piece of ice placed in the vagina. I have many times had recourse to this simple remedy, efficient only on the ground of a sound physiological principle, and Avith the happiest results. Now, then, for the movements of the foetus—they may be excited in various Avays. Sometimes, the placing of the hand on the abdomen of the mother, and gently pressing it, will ansAver the purpose. At other times, place one hand fiat on one side of the abdomen, and, Avith the fingers of the other, percuss the opposite 6ide, as you Avould in attempting to detect fluctuation. Again, thrust the hand into a vase of ice water, and suddenly apply it to the abdomen. It is necessary here to state, as has been pointed out by Prof. Simpson and Bischoff, that the movements, which occur on the application of the cold hand to the abdomen, are movements in the first place of the uterus itself through a reflex action; but this very movement of the Avomb causes it to press against the foetus, and thus induces action in the latter.* * It should be remembered that these movements of the uterus may be observed before the foetus can move, or even after its death; and also in cases of uterine enlargement from the presence of some morbid growth. T THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 185 Some Avomen Avill tell you that, on experiencing pain in one point of the abdomen, they will make pressure on the affected part, and immediately feel the movement of the foetus. This pain is often- times produced by the pressure of some portion of the foetus against the abdominal Avails, usually one of the extremities, and as the mother, to relieve herself, pushes the extremity from the painful part of the abdomen, she excites the movement of the child. If any of you have ever witnessed an arm presentation when the arm has passed from the uterus into the vagina, you, perhaps, have noticed that on touching the protruding hand the child will move. This is an interesting example of reflex or excito-motory action. An old author, whose name I do not now recollect, recommended as a sovereign remedy in arm presentations, to prick the palm of the hand Avith a needle, which, as he alleges, Avill cause the child to withdraAV its arm into the uterus. No doubt, the recommendation Avas based upon the circumstance I have just stated; but it will prove utterly nugatory so far as the effect mentioned is concerned ; and I may also remark that the author who suggested the remedy Avas entirely ignorant—for the physiology of reflex action Avas then unknoAvn—of the true explanation of the movement following the pricking the palm of the hand. 2d. Ballottement or Passive Mot ion of the Foetus.—Ballottement or repercussion means nothing more than the passive movement of the child in utero—and differs, therefore, from quickening in the essential fact that the latter is the result of muscular contraction, while the ballottement is purely passive, a movement in no Avay connected Avith any inherent action of the foetus itself. For example, Avhen a pregnant Avomen suddenly turns from one side to the other in the recumbent posture, she may tell you she distinctly feels something fall, as it Avere, to the side on which she reclines. This is the foetus which, obedient to the laws of gravity, and floating in a quantity of amniotic fluid, follows the impulse given to it by the change of position assumed by the mother. The ballottement, when recognised, possesses great value as a sign of pregnancy. As a general rule, it does not occur earlier than the fourth month, and, according to my experience, it is most readily detected between the sixth and seventh months. Later than this, owing to the increased growth of the foetus restricting its playground, it is more or less difficult of recognition. It is worthy of recollection that sometimes it evades the most skilful manipulation, during the Avhole course of pregnancy; and I am inclined to the opinion that, in such cases, one or two circumstances will exist to account for the failure—either an unusually small quantity of liquor amnii, or a cross presentation of the foetus. This is not a mere speculation of mine—it is substantiated by accurate and well attested data. I have on several occasions failed in detecting the passive movement 186 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of the foetus; and, in acquainting myself with the actual history of the cases at the time of parturition, I have found one or other of the above circumstances to be present. The folloAving case, I think, is in point: A lady from North Carolina, consulted me in December, 1858, for Avhat she supposed to be a morbid growth in her womb. She had been married eleven years, Avas 39 years of age, and had never become pregnant. Her menses had always been regular as to time, but not free in quantity, until July previous to seeing her. With a very thorough examination of her case, although 1 failed com- pletely to detect the ballottement, after repeated and careful trials, I pronounced her pregnant. My opinion Avas based upon unexcep- tionable testimony. 1st. The active movements of the child. 2d. The presence of the true areola. The lady Avould not believe that I was right in my opinion—but being an intelligent Avoman, she accepted the compromise Avhich I proposed to her—if, at the end of a few months, she did not proAre a mother, that I Avould consent to be denounced, not only as a false prophet, but as unworthy of all confidence. The emphatic and positive manner in which I spoke tended to remove her doubts, and she soon surrendered her previous conviction. She returned to Carolina, and, on the 15th of the folloAV- ing April, was delivered of a healthy living son, for the safety of which she Avas indebted to the skill of her physician, Dr. Shepperd, Avho Avas compelled to perform version in consequence of a shoulder presentation. It Avas this form of presentation, no doubt, Avhich prevented my recognising the ballottement. Mode of Detecting Ballottement.—The rules for delecting this movement are simple. In the first place, the examination may be made either in the erect or recumbent position. The index finger of one hand is to be introduced into the vagina, and carried upAvard and backAvard to the portion of the uterus at which the neck and body of the organ unite— the other hand is to be applied expanded over the abdomen, for the purpose of grasping the fundus of the womb. You are then gently and suddenly to press Avith the index finger from below upward, and from behind forward, against the body of the uterus; this pressure will usually cause a momentary ascent of the foetus, Avhich immediately again descends, and rebounds, as it were, against the finger. This sensation, once experienced, is quite con- firmatory of the condition of the female ;* for you must remember * I was requested by a medical gentleman of this city to visit his wife, in consul- tation with his friend and family physician, Dr. Freeman. The lady had suffered, Dr. Freeman informed me, for more than a year from ovarian disease; for two months previous to my seeing her, she had been voiding quantities of pus per rectum. The patient was much emaciated from this circumstance. On an exami- nation, I found the right ovary much enlarged, and it was evident that it had taken THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 187 that the relation of the embryo to the uterus is peculiar; though lodged within the Avomb, yet it enjoys great capacity for motion, either active or passive, for the reason that it is surrounded by more or less amniotic fluid, Avhich enables it to rebound to any impulse which it may receive. I know of no other condition of the uterus, either healthy or morbid, other than pregnancy, capable of produc- ing this sensation of rebound, and therefore, when the latter is really recognised, it is an indication of pregnancy of very great import. 3d. Pulsations of Fcetal Heart.—One of the striking evidences of the progress of science, developing, as it proceeds, new facts, calculated, by their proper application, for the benefit of the human family, is exhibited in the discovery published in 1818, by M. Mayor, of Geneva, that, by the aid of auscultation, the heart of the foetus can be distinctly heard to beat in its parent's Avomb. What a precious discovery, and how inestimable its value in many cases in which the true condition of the female is shrouded in mystery—and how important, too, in instances in which, from pelvic or other defor- mities, the alternative of choice between the Ctesarean section or embryotomy may depend upon the solution of the question—Is the child alive or dead ? The pulsations of the fcetal heart are not in accordance, or, in other words, synchronous with those of the mater- nal heart. While the maternal heart will average from seventy-five to eighty beats in the minute, the former will vary from one hun- dred and ten, to one hundred and sixty.* This latter variation in the fcetal pulsations, may be ascribed to some occasional disturbance experienced by the mother, in her circulatory and respiratory func- tions, and thus transmitted to the child through the influence of the changes in the maternal blood. After these pulsations have been once detected—and they are usually not recognised until betAveen the fourth and fifth month—they Avill be found gradually to increase in force; but as the period of gestation approaches its close, there will be a marked diminution in their frequency. Cazeaux maintains the contrary of this ; I think he is in error. Tyler Smith describes them on suppurative action, the matter passing out through the rectum, in consequence of ulceration, as will sometimes happen in these cases. In addition to the enlarged ovary, I thought I discovered also, an enlargement of the uterus—and on making a vaginal examination, I very distinctly detected the ballottement. I at once pro- nounced the lady pregnant; her condition had never been suspected—her menstrua- tion had been uniform and regular; and no vaginal examination had been previously made, for the reason that its necessity was not indicated. This lady was placed upon tonic treatment, with a view of meeting the waste from the constant discharge of matter. In four months after I saw her, she was delivered by Dr. Freeman of a healthy little girl, and what is extremely interesting entirely recovered her health. * According to Frankenhauser, in the male foetus the heart beats one hundred and twenty four, and in the female one hundred and forty-four in a minute on an average. 188 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. as declining in frequency and continuous with the diminution which follows after birth.* Auscultatioti.—The double action of the foetal heart—for in it, as in the adult, there are two distinct sounds, unequal in duration —is ascertained by means of auscultation. This, you are aware, is divided into mediate and immediate. In the former, the stetho- scope is employed ; in the latter, on the contrary, the ear is applied directly to the part at which the sound is sought for. It is quite evident that the foetal pulsations cannot readily be mistaken for any other species of vascular action, for the important reason that, on counting them, it Avill be found there is no correspondence in fre- quency between them and the throes of the maternal heart. In having recourse to auscultation, the patient may assume either the recumbent or standing position. It is not necessary to expose her person; the chemise may intervene—although the ear or stetho- scope, applied directly to the naked abdomen, would be more likely to be followed by a successful investigation. The chemise should be made as smooth as possible, and perfect silence observed in the room; after the seventh month, the ear may be employed, if found desirable; but previous to this period, the stethoscope itself Avill be more advantageous. At Avhat portion of the abdomen will the pulsations of the foetal heart be most frequently found ? To ansAver this question it will be necessary to revert to what we have said, in a previous lecture, touching the relative frequency of the various presentations of the foetus. The head is, out of all comparison, most commonly found to pre- sent with the occiput either in correspondence with the left or right acetabulum; the former constituting the first, the latter, the second presentation of the vertex.f In these respective presentations, you are to ask yourselves with Avhat portion of the maternal abdo- men is the spine of the foetus in relation, for it is to be borne in mind that the beats of the heart will be more easily detected by auscultating on the back than any other part of the foetal surface— and for obvious reasons, as suggested by Velpeau ; in the first place, the natural curve of the foetal body is on its anterior plane, thus moving the cardiac region further from the abdomen of the mother, while at the same time the upper extremities are usually folded on the chest; and secondly, the anatomical relations between the spine and heart afford another motive for selecting the back of the foetus in this character of exploration. It, therefore, follows from what has been said of the relative frequency of cranial positions, that the back of the foetus will be found most commonly either on the left * P. 143. f The student should not forget what has already been said in regard to the change of the head, as indicated by Naegele, from the right sacro-iliac symphysis to the right acetabulum. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 189 or right lateral portion of the abdomen, at some point between Poupart's ligament and the umbilicus. Occasionally, however, in consequence of change in the attitude of the foetus, the pulsations may be detected in various portions of the abdominal cavity. Of course, in pelvic presentations, the sound will be recognised in the upper portion of the uterus. The facility for recognising the pulsations will be much enhanced by the escape of the liquor amnii; as soon as this passes off, the walls of the uterus coming in close contact with the body of the foetus, there is, if I may so term it, a more positive directness given to the sound, and consequently an increased poAver of perception to the auscultator. In addition to the proof of pregnancy and the life of the child, these pulsations, when recognised, Avill also indi- cate the position of the foetus in utero. If, in your exploration, you should hear the beatings of the foetal heart in tAvo distinct por- tions of the abdomen, the irresistible conclusion will be that it is a case of tAvin pregnancy ; and again, after detecting the pulsations, if, on a vaginal examination, you should ascertain that the uterus has undergone but slight enlargement, it is very manifest that it cannot contain a foetus, and, therefore, the gestation is extra-uterine. Sometimes, with the best directed efforts, and Avith all the skill you can bring to bear, it Avill be impossible to recognise the action of the heart, and yet the Avoman may be pregnant; and, at the full term, bring forth a well-developed and healthy child. So you see, gentlemen, that Avhile the pulsations of the foetal heart, once posi- tively heard, constitute an unerring evidence that pregnancy exists, their absence is by no means a proof that the female is not preg- nant. 4th. Bruit Placentaire, Placental Souffle, Uterine Murmur.—In 1823, Kergaradec called attention to what he denominated the Bruit placentaire—the placental souffle—a peculiar sound which he maintained was disclosed during pregnancy through auscultation, and Avhich he attributed to the passage of the blood from the uterus into the placenta—the utero-placental circulation—and hence the name placental souffle. Since that time, however, although the general fact is almost universally conceded that a peculiar sound is emitted, yet authors differ as to its cause and seat. Some agree in opinion with Kergaradec, while others maintain that the sound is produced, not by the utero-placental circulation, but through pressure exer- cised upon the adjacent blood-vessels by the gravid uterus. Dubois restricts the cause and seat of the souffle to the circulation going on in the substance of the uterus itself. It is quite evident that the opinion of Kergaradec is not tenable, and, among others, for the following reasons : 1st. This sound is sometimes heard after the birth of the child, and expulsion of the placenta. 2d. It is not confined to any given 190 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. point of the uterus, but will be heard in almost every portion of its surface at different times. 3d. It will oftentimes be recognised when pregnancy does not exist, in cases of abdominal or uterine tumors. The uterus, during pregnancy, is in an extremely hyper- aemic condition, the vessels are turgid Avith blood, and consequently the local circulation will be more or less labored ; may not this be the simple explanation of the uterine murmur during gestation—and Avhen it is heard after delivery, may it not be explained upon the hypothesis that the sudden emptying of the Avomb has left the vas- cular and other tissues of the organ in such a relaxed state, that the circulation, for a short period after parturition, continues to be sluggish, or, if you choose, labored, and hence the murmur? When you detect, through auscultation, the bellows sound in the heart, is it not accounted for on the principle that the circulation, through valvular or other disease, is interrupted in its ordinary round ? But hoAv, you may ask, is this souffle produced when pregnancy does not exist—in cases, for example, of abdominal or uterine tumors ? I have no doubt it is the result of pressure upon some of the surrounding vessels. The hypothesis has obtained that the souffle may be occasioned by the peculiar condition of the blood in pregnancy, producing, as is sometimes the case in chlorosis, certain abnormal sounds. That distinguished physiologist, Dr. Brown- Sequard, supposes that these sounds in chlorosis occasionally ema- nate from a tremor of the muscles peculiar to Aveak and aged per- sons ; and he has shown that there is a sound produced in the gravid uterus, which is generally mistaken for the placental souffle, and which is evidently due to the muscular sound; it co-exists with the local contractions of the uterus. There is much diversity of opinion as to the particular period of pregnancy at which the souffle can be first recognised. Some say they have detected it at the eleventh week, others at the third month. But you will find, gentlemen, that these early periods, admitting there is no error, constitute rare exceptions to a very general rule. It is more, I am sure, in accordance Avith correct observation, to say that it is not until the expiration of the fourth month that it can be detected. The souffle differs in one important particular from the pulsations of the fcetal heart—it is synchronous with the maternal pulse, and, therefore, is connected with the blood- vessels of the mother. It possesses rather a coquettish propensity —after being once heard, it will sometimes bid defiance to the most accomplished auscultator, and will so completely intermit, that several days will often elapse before it again reveals itself. Occa- sionally, the whole period of pregnancy will pass without its ever being detected. From Avhat has been said, it is manifest that its value as a sign of pregnancy is not of a high order, for it may exist where there is no gestation; and while its presence is no THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 191 indication of the life of the foetus, it may be detected when the latter has ceased to five. 5th. Pulsations of the Umbilical Cord.—Dr. Evory Kennedy, Avho has written so well on the subject of utero-fcetal auscultation, says that he has been enabled distinctly to feel, through the abdo- minal Avails of the mother, the convolutions of the umbilical cord, and also, by aid of the stethoscope, to hear its pulsations. But it has only been, he states, in cases in which the walls of the abdo- men and uterus were characterized by unusual thinness. I have, after repeated attempts under the circumstances indicated by Dr. Kennedy, never succeeded in attaining either one or other of these objects. If the cord were distinctly felt, or its pulsations heard, it would certainly be unequivocal proof of pregnancy. But it seems to me that if the pulsations alone were detected, it would be diffi- cult to demonstrate that they proceeded from the cord and not the heart, inasmuch as they, like those of the latter, are not in cor- respondence with the maternal pulse. It is true that the beatings of the cord might, from its extent, be heard in different portions of the uterine surface—but this, again, would be apt to give rise to the suspicion of Twin-pregnancy.* * A Funis souffle is sometimes heard. Five instances, in five hundred cases of labor, have been reported by Scanzoni. The source of the souffle does not appear to be clearly established, but its presence is supposed to be indicative of danger to the foetus. LECTURE XIII. Examination of the Female to Ascertain the Existence of Puegnancy—Tho Three Senses, Feeling, Seeing, and Hearing, to be employed—The "Toucher;" what ia it?__External Abdominal Examination; its Objects; how to be conducted—Va- rious Causes of Uterine Enlargement; how to be distinguished—Examination per Vaginam; Rules for—The Vagina; its Position and Relations—Position of the Female—Relation of the Vagina to the Cervix Uteri—Examination per Anum; when indicated—Retro-Version of Uterus—Prolapsion of Ovary into Triangular Fossa—Vaginal Ovariotomy—Auscultation—The Metroscope; its Uses. Gentlemen—The examination of a female, for the purpose of ascer- taining whether or not she is pregnant, requires on the part of the accoucheur, in the first place, a thorough knowledge of the various evidences of gestation, together Avith a full appreciation of the mor- bid phenomena known to simulate this condition; and, secondly, he must bring to the examination a facility of tact, which can only be acquired by a long and Avell-cultivated experience. To arrive at a just diagnosis on this subject will oftentimes constitute, from the complication of the surrounding circumstances, one of the most difficult duties in the entire curriculum of the physician's practice. But, great as is the embarrassment, it may be overcome by an enlarged knowledge and due attention. In our discussion of the numerous signs of pregnancy, you Avill not have failed to notice that they are of different grades, and pre- sent various shades of value. The great majority of them are, to say the least, only equivocal, and will not, therefore, when any important interest, such as life or character, is involved in the decision, form data sufficiently broad to enable you positively to affirm that gestation exists. I admit that a married Avoman, espe- cially if she have previously borne a child, will generally be enabled to understand that she is pregnant, from the symptoms Avhich ordinarily accompany this state, such as the suppression of the catamenia, morning sickness, mammary sympathies, and other phenomena. But these signs, as they may be dependent on other influences than pregnancy, are utterly insufficient in numerous cases in which the counsel and judgment of the physician will be invoked, and upon Avhose opinion must depend all that is sacred to the individual. The accoucheur, in his analysis of evidence, will have to bring into requisition the three senses, feeling, seeing, and hearing • THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 193 therefore, his means of exploration are divided in obstetric lan- guage into—1. The toucher; 2. The revelations made by the eye; 3. Auscultation. The adroit application of these resources, and a judicious appreciation of their deductions, will rarely fail in enabling the practitioner to evolve an opinion in accordance with the truth. The toucher consists of an external and internal examination—in the former, it is restricted to an exploration of the abdominal walls; in the latter, the finger is introduced into the vagina or rectum, for the purpose of sundry investigations, to Avhich we shall presently more particularly allude. The eye is more especially employed in examining the state and peculiarities of the mammae, Avhile the ear is engaged in testing the various auscultatory phenomena. 1. External Examination.—In this examination, the chief objects are to ascertain whether there is any abdominal enlargement, and if so, on Avhat it is dependent; also to recognise, if possible, the movements of the foetus. If from distension of the uterus, the increased volume of the abdomen will usually be more or less in the centre of the hypogastric region, pyramidal in shape, Avith the base upAvard and the apex downward ; and the enlargement Avill present to the touch uniform hardness, Avhile on the sides there will be an absence of fulness, and the abdominal walls at these points Avill yield more or less to pressure. The upper portion of the pyramid will represent the fundus of the organ. By causing the abdominal muscles to relax, Avhich can readily be done by flexing the thio-hs on the pelvis, and gently raising the head and shoulders of the Avo- man, the hand is enabled to grasp the fundus; this will determine the point of its ascent in the abdominal cavity, and thus enable you to approximate, all things being equal, the period of pregnancy. But, gentlemen, supposing the uterus to be distended, how do you knoAv that it contains a foetus ? You will probably answer me, by means of the ballottement, quickening, or the pulsations of the foetal heart. These phenomena, however, cannot be detected in the earlier months of gestation, and sometimes—although pregnancy may exist—the accoucheur fails altogether in recognising them dur- ing the whole period of the gravid state. Your diagnosis, there- fore, must be determined by other circumstances; and this brings us briefly to consider the different causes, other than gestation, capable of inducing enlargement of the uterus. They may be enumerated as folloAvs : A. Intra-uterine growths, including fibrous, polypoid tumors, and hydatids ; B. Hydrometra, or dropsy of the uterus; C. Retention of the menses; D. Physometra, or a flatulent distension of the organ; E. Hypertrophy; scirrhus. A. Intra-uterine Groicths.—-These, constituting pathological states of the organ, are usually accompanied by phenomena Avhich, to the intelligent observer, will unmask their true charaoter. For 10 O 19-1 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. example, in cases of an intra-uterine tumor, whether simply fibrous, occupying the entire cavity of the organ, or polypoid, and pedicu- lated to a given point, there will almost always be hemorrhage with more or less bearing-down pain—the bleeding and pain gene- rally increasing about the advent of the catamenial evacuation. Again: in these formations, the growth of the tumors is ordinarily sloAver, and in this way, too, they may be distinguished from preg- nancy, which you know is rapid in its development, for the reason that there are but nine months allotted to the accomplishment of that chef d'ceuvre of nature—the perfect organization of the em- bryo ! Occasionally, Avhen the uterus is enlarged from an intra- uterine growth, auscultation will reveal a souffle;* this may be mistaken for an evidence of pregnancy; but if this latter condition really exist, in addition Ave should recognise the pulsations of the foetal heart, together Avith the movements of the foetus itself. Nor, in this connexion, should it be forgotten that these growths will sometimes coexist with pregnancy. Pathologists are not of accord as to the special structure of these tumors; it has been generally said that they are composed of a fibrous tissue ; recently, however, Lebert and C. Robin seem to have demonstrated that they consist of a simple hypertrophy of the fibro-muscular element of the uterus. YirchoAV is also of this opinion, maintaining that the fibrous or fibroid uterine tumor pos- sesses in every respect the same structure as the Avails of the hypertrophied uterus, consisting not only of fibrous connecting tissue and A'essels, but also of muscular fibre cells, f In uterine hydatids there will also be occasional bearing-down pains, and more or less discharge of blood; and, in addition, there is a symptom which I consider pathognomonic of these growths, viz. a periodical discharge of water per vaginam. B. Ilydrometra, or Dropsy of the Uterus.—In this affection the constitution is usually more or less involved, it being rarely a local disease ; and, in percussing, distinct fluctuation will be revealed. C. Retention of the Menses.—This is a most important derange- ment of the female, and has more than once resulted in false and cruel opinions, affecting not only the happiness, but leading from a broken heart to the death of the individual. Retention of the menses is that peculiar condition in Avhich the menstrual blood is poured out regularly every month into the uterine cavity; through its accumulation, it gives rise to distension of the organ and certain sympathetic phenomena, which have sometimes been mistaken for pregnancy, and formed the basis of most erroneous decisions. Sec * The souffle is not at all incompatible with an intra-uterine fibrous growth, for it may result from the fact of the tumor being situated over the aorta or other large vessels; and sometimes, also, the increased vascularity of the uterus may produce it. f Virchow's Cellular Pathology, p. 443. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 195 hoAV easy a thing it is, by a careful examination, to arrive at the truth on this subject. Why is the catamenial fluid retained in utero ? Simply because there is an obstruction to its free passage ^ and this obstruction may consist either of an occluded os tincae or an imperforate hymen. Therefore, if either of these be found to exist, your diagnosis is at once arrived at.* D. Physometra.—This is a rare affection ; it consists in the accumulation of flatus within the cavity of the uterus, and I believe is almost always traceable to the extrication of gas from some decomposed substance within the organ—such as a retained pla- centa, mole, or foetus. In physometra, there will be revealed, under percussion, a sound of distinct resonance, and the uterus * Among several cases of retained menses in which I have operated, the follow- ing is not without interest: A respectable woman, the wife of a thrifty mechanic, married about six weeks, requested my professional advice. Her husband, a month after marriage, had begun to treat her cruelly in consequence of suspicions in regard to her fidelity. When I saw her, she had the appearance of being about five months pregnant; she remarked that some of the female relatives of her husband had impressed him with the belief that she was pregnant when he married her; hence his cruel treatment. The poor woman was in deep distress, and supplicated me to satisfy her husband that she had been true to him, assuring me, at the same time, that she would cheerfully submit to any examination I might suggest. She informed me that she was twenty-seven years of age, and had never menstruated; her health had been wretched from early girlhood. On visiting her the following day, I ob- served there was an indistinct and circumscribed fluctuation perceptible at the anterior portion of the abdomen, and extending upward within one inch of the umbilicus. The finger being introduced as far as the cervix, I soon appreciated an entire absence of the os tinea, the lower and central portion of the cervix being quite smooth and uniform on its surface. With the other hand applied to the abdomen, I grasped the fundus of the womb, and thus embraced this organ between the hand externally, and the finger introduced into the vagina. The diagnosis was plain; viz. that the fluctuation was the menstrual blood contained within the uterus; in consequence of there being no outlet, this fluid had accumulated, causing a dis- tension of the womb, and giving rise to the suspicion of pregnancy. I stated my opinion very fully to the husband—told him his wife could be relieved by an opera- tion, at the same time assuring him that his suspicions were without the slightest grounds. Having obtained his consent, assisted by two of my office pupils, Drs. Burtsell and Morris, I introduced a speculum into the vagina, and brought distinctly to view the cervix-uteri. This I penetrated at its lower and central portion. Soon, not less, I am sure, than two quarts of grumous blood were discharged from the uterine cavity. It is as well to mention that the perineal strait of the pelvis was somewhat contracted in its transverse diameter. The operation was attended with very little pain; the uterus assumed its ordinary size, and the patient recovered in a few days. I was much gratified with a visit from both herself and husband, the latter appearing truly contrite, while the former assured me of the happiness she experienced in being restored to his confidence and affection. Nearly thirteen months from the day of the operation, I was called to attend her in her confinement; after a severe labor of twenty-eight hours, I deemed it necessary to apply the forceps, and delivered her of a fine living son, assisted by two of my pupils, Messrs. Meriweather and Whipple, of Alabama. 196 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. will be found characterized by unusual lightness. Its volume, too, will be apt to vary in consequence of the occasional escape of flatus through the "os timae. In addition, the antecedent history of the case will aid essentially in a correct diagnosis. E. Hypertrophy and Scirrhus of the Uterus.—Here, too, the history of the case, besides the peculiar hardness of scirrhus imparted to the touch, will enable the practitioner to avoid all doubt. I may also, at this time, mention some of the ordinary causes of abdominal enlargement, which might possibly, through unpardon- able negligence, be mistaken for pregnancy—such as abdominal tumors without the uterus, whether simply fibrous, pediculated to the external surface of the organ, or in the form of a steatomatous mass, encysted dropsy, tympanites, ascites, etc., etc. Abdominal Tumors.—Fibrous growths, attached by a pedicle to the outer portion of the uterus, are, according to my experience, by no means uncommon. Usually, there are several of them; their groAvth is sometimes rapid ; most generally, hoAvever, slow. They are not malignant, and when they destroy life, they do so in con- sequence of their pressure on the digestive apparatus, so as to interfere Avith the healthy and necessary play of the nutritive func- tions. I have seen them from the size of an egg to the weight of thirty pounds. In my museum, you have examined several extremely interesting specimens of this character. These tumors are generally characterized by great mobility; and, under ordinary circumstances, they can be made, by judicious manipulation, to revolve slightly upon their axis, which consists of the pedicle by which they are attached to the external surface of the uterus; and if you gently press the ulnar portion of the hand dowmvard, you will frequently be enabled to pass it between these tumors, showing at once their separate and individual existence, and also proving hoAV entirely they are unconnected with increase of the abdomen, the result of gestation. Enlargement of the Ovary.—An enlarged ovary has oftentimes given rise to the suspicion of pregnancy; and while, with proper attention, it is not difficult to make the necessary distinction, yet it must not be forgotten that occasionally this form of tumor coexists with, and constitutes one of, the complications of gesta- tion.* In these latter cases, more than ordinary vigilance will be needed to elicit the truth. It Avould be proper to inquire whether a tumor had been observed in the abdomen for some time before the suspected pregnancy. But as a means of diagnosis in these cases, you will find auscultation, perhaps, the most efficient, pro- vided you can succeed in detecting the pulsations of the fcetal * For an interesting example of tliis kind, see Diseases of Women and Children,. p. 258. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 197 heart. In simple ovarian enlargement, you will discover, on inquiry, that the tumor commenced not in the lower and central portion of the abdomen, as is the case in enlargement of the uterus, but in one or other of the iliac regions; and for the very substantial reason that this is the location of the ovaries in their natural and healthy state. As the tumor increases in development, its ascent is more or less oblique; and, on a vaginal examination, the uterus will be found to have increased, if any, but very slightly in volume. Should it be a case of dropsy of the ovary, which is by far the most common form of morbid action assumed by this body— percussion Avill enable you to ascertain the fact, for fluctuation, more or less distinct, will be recognised. This form of dropsy is called encysted, because the fluid is contained in one or more cysts—in the former case, known as unilocular ; in the latter, multilocular. Tympanites.—The abdomen will not unfrequently become dis- tended from a collection of flatus Avithin the intestinal canal; and this is apt especially to occur in nervous, hysterical women. One of the prominent diagnostic evidences of this character of disten- sion is the alternate increase and diminution of the volume of the abdomen—and this depends upon the quantity of flatus Avhich escapes, either through the oesophagus or rectum. In these cases, too, the uterus will not be enlarged. Ascites.—Ascites, or peritoneal dropsy, cannot Avell be con- founded with pregnancy, if the following diagnostic guides be borne in mind : 1. It is the result of some previous derangement— such, for example, as inflammation, disease of the liver, kidneys, or heart; 2. In Avell-developed ascites, there is always more or less distinct fluctuation—and the fluctuation in this differs from that in hydrometra and encysted ovarian dropsy, in the important fact that it is not confined to any one portion of the abdomen, but is general; 3. The uterus, unless as a rare complication, "will be found unchanged in size. Phantom Tumors—Accumulation of Fazcal Matter.—In hys- terical and anaemic Avomen you will sometimes meet Avith Avhat are termed phantom tumors, the pathology of which appears to be an irregular contraction and relaxation of the abdominal walls. A careful vigilance Avill prevent the possibility of mistaking these enlargements for pregnancy; so also Avith regard to the occasional distension of the abdomen from accumulated faeces. 2. Internal Examination per Vaginam,.—It needs no little tact to conduct this examination in a manner at once acceptable to the patient, and profitable to the accoucheur. Indeed, I know of feAV positions more embarrassing to the youug practitioner than to be called upon to institute this kind of exploration, Avithout due knowledge and experience. It can scarcely be necessary, gentle- 198 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. men, to remind you that your patient is always entitled to a full measure of delicacy and refinement—it should never be forgotten that it is at a heavy sacrifice that she consents to have you by her side in the hour of her trial—and the richest equivalent, therefore, you can offer her for this sacrifice is the high-toned bearing, which every cultivated gentleman knows so Avell how to exercise tOAvard a female under these circumstances. You should accustom yourselves to conduct this examination with either hand, and whichever one you employ the index finger only is required. It should be extended fully, the thumb brought into the palm of the hand, and covered by the other three fingers. (Fig. 43.) If you have a scratch or sore on the finger, never intro duce it into the vagina, for you incur the serious hazard of inocu- lating yourself with the venereal poison, if any exist; or the absorption of acrid leucorrheal matter may prove disastrous. The finger should always be lubricated with some mucilaginous or oily material; what I find to ansAver every purpose is a little soap and Avater. Unless there be some personal or other objection to it, I usually prefer making this examination with the patient on her back, and in the recumbent position ; the abdominal Avails should be in a state of relaxation, as in the external examination, in order to facilitate the accoucheur in his manipulations—for, if they be tense and resisting, he will be unable to feel the uterus with the hand applied externally. A very proper and necessary precaution is, to precede the examination by causing the bladder and rectum to be evacuated of their contents. A neglect of this precaution will be apt to interfere more or less with the thoroughness of the exploration, and add no little to the discomfort of the patient. Preliminaries to the Examination.—You are to remember that there is not the slightest necessity for, nor will any thing justify, the exposure of your patient. Your coat and shirt sleeve should be turned over at the Avrist, and a napkin properly pinned over them, so as to protect you from any mucus or other secretions in the vagina—and besides, it is more in keeping with neatness and refinement, two attributes ahvays appreciated in her physician by a delicate and cultivated female. How are you to find the vagina ? This may appear to you a very unnecessary question—but, gentle THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 199 men, it is full of sterling import to you as practitioners. What would be the measure of your mortification if, in attempting an examination of this kind, the patient, after more than Christian forbearance, should exclaim, " Doctor, \A-hat are you about; do you not know better than that?" and you should discover that the rebuke Avas prompted by the painful circumstance that, instead of the vagina, you had introduced the finger into the anus! And yet, gentlemen, strange as it may seem to you, this blunder has been committed, for want of proper knowledge, much to the chagrin of the practitioner, and the outraged feelings of the patient. It is with a view, therefore, of guarding you against the possibility of such an error, that I shall proceed in a few words to point out in what way it may be avoided. The hand, arranged as I have already described, is to be placed under the sheet, and, Avithout the consciousness of your patient, you should at once carry the index finger to the central and internal surface of the knee corresponding Avith the side of the bed at Avhich you are sitting; then conduct the finger carefully along the median line on the internal surface of the thigh as far as the vulva ; this will bring your finger to the central portion of either the right or left labium externum, and as soon as it has reached this point, all that is necessary Avill be to push the finger a little to the right or left, depending upon which labium it may be, and it is at once in the vagina. Relations of the Vagina—Deductions.—As the finger passes into the vagina, ahvays have its radial border looking toward the symphysis pubis. Noav, before proceeding further, let us pause for a moment, and make one or two observations with regard to the shape and anatomical relations of the vagina. It is, you knoAv, called the vulvo-utcrine canal, because it extends from the vulva to the uterus, receiving, as it were, into its upper portion the cervix of the latter organ. The vagina posteriorly, in its three middle fifths, is in relation, through the medium of cellular tissue, with the rectum, giving rise to the recto-vaginal septum ; anteriorly, it forms, through the same sort of inten-ention, a union with the urethra and bladder, thus constituting for the accoucheur two important septa, Adz. the urethro-vaginal, and vesico-vaginal. In addition to these relations, it must be borne in mind that the vagina is a crooked canal, Avith its concavity forward, and its con- vexity backward ; so that it corresponds Avith the curves of the pelvis, the upper extremity being parallel to the axis of the superior, while the lower is in relation Avith the axis of the inferior strait; the ordinary position of the uterus is such that its long axis is more or less in correspondence Avith the axis of the upper strait of the pelvis ; and it, therefore, follows, that the junction of the. upper portion of the vagina and cervix of the organ will form with the outer opening of the vagina an angle of about 45 degrees. The 200 THE PRINCIPLES ANI) PRACTICE OF OBSl'ETRICS. object of my directing attention to these important facts is, that they may serve as a guide for the direction of the finger after it has reached the vagina. Without special attention to the subject, the young practitioner—I do not think I exaggerate it—in ninety cases out of one hundred, will, as soon as the finger enters the vagina, direct it from before backward! In doing this he will not succeed in reaching the os uteri, which is one of the important objects of his search, either in exploring for the evidences of preg- nancy or at the time df labor—and hence his examination is Avith- out profit, he forms no diagnosis, and is stultified by his OAvn io-norance ! In carrying the finger from before backAvard, he reaches, not the os uteri, but the rectum—and if it should chance to be filled with masses of fiecal matter, by pushing and poking— as he Avould be likely to do—it is not impossible that he might mistake the pieces of excrement for some anomalous condition of things—perhaps a presentation of the nates, supposing the movable lumps to represent the testes—and in his confusion, he would reveal his diagnosis, and request an immediate consultation ! In order, therefore, to avoid all error on the subject, as soon as the finger has passed about three inches into the vagina, the Avrist is immediately to be depressed, and an opposite direction imparted to the finger—and for the obvious reason that, at first, the direc- tion should be parallel to the axis of the inferior strait. You will sometimes meet with cases in Avhich the cervix uteri is situated so high up that it will be extremely difficult to reach it Avith the finger. Under these circumstances, you will find it good practice to examine your patient in the standing position ; in this Avay, by giving the uterus all the advantage of gravity, the diffi- culty will generally be overcome.* Well, you have reached the neck of the uterus—Avhat next ? You are now to ascertain its exact position; is it normal ? Has it descended lower into the pelvic excavation than usual—is the os tincse tumid and moist—is there any shortening of the cervix—is the body of the organ enlarged—does the enlargement indicate disease, or is it the result of pregnancy ? Can you distinguish the foetus by the ballottement ? These, gentlemen, are so many inquiries Avhich will necessarily present themselves to the atten- tion of the accoucheur in conducting an examination with a vieAv of ascertaining whether or not pregnancy exists. I should have mentioned that, during this exploration, the other hand is to be applied to the abdomen of the female for the pur- pose of gently grasping the fundus of the Avomb, and thus judging of its volume and exact position in the abdominal cavity. * In cases, also, m which, from disease or otherwise, the breathing of the patient becomes affected in the recumbent posture, she should be examined in the upright position. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 201 The vaginal examination, if properly conducted, will reveal to the observant practitioner much interesting information, uncon- nected with the mere question of pregnancy. For example, he can ascertain the existence of pelvic deformities; the condition of the soft parts, whether normal or otherwise, and thus decide between a pathological and healthy condition of the parts he traverses Avith his finger. In one word, gentlemen, the examination per vaginam is a precious resource for the Avell-educated practitioner; it is a field rich with disclosures, which may serve as his guide in an infinity of ways. 3. Internal Examination per Anurn.—Under certain circum- stances, it may become necessary to examine the female per anum; for instance, in cases in which there may be exquisite sensibility, or much contraction of the vagina ; Avhere there are tumors developed in the posterior wall of the canal; or in cases of retroversion of the uterus complicating gestation ; or Avhere there has been pro- lapsion of the OArary or small intestines into the triangular fossa, bounded anteriorly by the posterior surface of the uterus, and pos- teriorly by the anterior surface of the rectum—sometimes called the recto-uterine fossa. This is a mode of examination extremely repugnant to the female, but, when indicated, it is fruitful in light to the practitioner. You Avill sometimes be consulted by women, who will complain of extreme and painful pressure on the rectum, giving rise not only to great physical suffering, but oftentimes interfering seriously with the act of defecation. This pressure may arise from tAvo very different conditions: either from retroversion of the uterus, or a prolapsion of the ovary into the triangular fossa. In either event, an examination per anum Avill greatly assist in elucidating the true nature of the case. The ovary, too, may be distended, exhibiting an example of encysted dropsy of the organ. Suppose such a case to complicate labor; you see how important it would be to arrive at a proper diagnosis, in order that prompt and effi- cient means might be devised to overcome the obstruction to the passage of the child. In such case, the remedy would be to per- forate the ovary through the vagina, Avith a vieAV of alloAving the fluid to escape, and thus diminish the bulk of the tumor.* 4. Auscultation.—It has already been stated that the pulsations of the foetal heart and uterine murmur are to be sought through auscultation ; and this is accomplished either by the ear or stetho- scope. It requires much tact, patience, and experience to become an efficient auscultator. Xauch some years ago suggested an instru- ment—the metroscope—which he introduced into the \ragina for * On f.nc occasion I performed the operation of vaginal ovariotomy in a young girl under extremely distressing circumstances. ■ See Diseases of Women and Chil- dren, p. 297. 202 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the purpose of detecting, as early as the third month, the foetal movement, and he also affirms that he has been able to satisfy him self Avith the metroscope of the important fact that the placenta is attached over the mouth of the Avomb. The instrument consists of a wooden tube flexed nearly at a right angle ; one extremity is introduced into the vagina, and carried to the cervix uteri, Avhile the other is applied to the ear. It can scarcely be necessary to remark that the metroscope has not met with much favor, and is noAv but little used. LECTURE XIV. Extra-uterine Pregnancy; its Varieties—Ovarian, Fallopian, Abdominal, and Interstitial—Characteristics of each Variety—Causes of Extra-uterine Pregnan- cy—Opinion of Astruc—Objections—Progress and Phenomena of Extra-uterine Pregnancy—Placenta and Membranes; the Germ inclosed in a Cyst—Exponent of tho Uterus; Cyst; how formed—Cyst affords no Outlet for Foetus—Rupture of Cyst from Increased Growth of Foetus—Hemorrhage; how Produced—Enlarge- ment of Uterus—Extra-uterine Fcetation rarely extends to the Fifth Month— Exceptional Cases—Secondary Cyst; how Formed—Signs of Extra-uterine Fa'tation—Areola and Tumefaction of Breasts—Illustration—Active Movement of Foetus; Cardiac Pulsations—Malpositions of Uterus from Position of Cyst— Intermittent Pain in Extra-uterine Gestation—Dangers of this Variety of Gesta- tion—Hemorrhage from Rupture of Cyst—Peritoneal Inflammation—Termina- tions of Extra-uterine Pregnancy; Treatment—Gastrotomy; when Performed— Gastrotomy and Caesarean Section—Fearful Hemorrhage in the Former; why— Section of Vagina—Elimination of Foetus; how aided. Gextlemex—When fecundation has been consummated, and the vitalized germ does not reach the uterus, it is because of some derangement, Avhich has contravened nature; the development, therefore, takes place not within the uterine cavity, but at some point external to it; hence, this form of pregnancy is denominated extra-uterine. Pregnancy out of the uterus is unquestionably of rare occurrence in the human female ; yet, on the other hand, there are Avell-authenticated cases, Avhich give to the subject an interest well worthy the attention of the practitioner.* Authors have made numerous divisions which, it appears to me, are more calculated to perplex than aid the student in his investigation of the subject. In lieu, therefore, of arraying before you this long and varied classification, I shall content myself with presenting, for your consideration, four different kinds of extra-uterine gestation, which, for practical purposes, will embrace all that science properly recognises: 1. Ovarian; 2. Tubal, or Fallopian; 3. Abdominal; 4. Interstitial. 1. Ovarian Pregnancy.—When the embryo becomes developed in the ovary, it is called ovarian pregnancy; in reading upon this point, you will observe much discrepancy of opinion, arising out of the question whether it is possible for fecundation to take place before the rupture of the ovisac ? Those who maintain that it can- not, deny the fact of ovarian gestation, for they say that true ovarian pregnancy is where the embryo becomes developed Avithin * This variety of gestation has also been observed in the rabbit, sheep, and bitch. 204 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the ovary, and this can only oceurby the spermatozoon penetrating the o\ isac, without disturbing its integrity, and vitalizing the germ. But, as they contend that this mode of fecundation cannot be ac- complished, they reject, as a consequence, the possibility of ovarian gestation. Xow, gentlemen, it is very evident that this is a mere play of words ; it is a species of transcendental logic, whicli is not calculated either to advance the true interests of science, or subserve the requirements of the physician who, in questions of this nature, is in want of Avell-established facts, unaccompanied by any of the refinements of the sophist, or the theoretical niceties of the dis- putant. What you Avish to understand is simply this—is it possible for the fecundated germ to become developed, so as to constitute, in truth and in substance, an ovarian pregnancy ? The fact is proved beyond all peradventure, for the foetus has been found, in a state of progressive groAvth, in intimate relations Avith the organ; so that the question is not Avhether the development is within or without the ovisac, but whether, not occurring in the uterine cavity, it is possible for it to take place in connexion with the ovary. I repeat, science furnishes Avell-authenticated examples of this species of extra- uterine gestation.* 2. Tubal or Fallopian Pregnancy.—This has usually been re- garded the most frequent form of abnormal pregnancy, and is said to bear to the others the proportion of nine to three. Prof. Hecker has recently shown, from carefully collected tables, that this is not so.f For example : in all the cases of extra-uterine fcetation, which he has been enabled to gather from various sources, he has ascer- tained that, Avhile abdominal pregnancy occurred in one hundred and thirty-two instances, the fallopian variety was observed only sixty-four times. These sixty-four cases, Avith one exception, ter- minated fatally; the exceptional example has been reported by Prof. VirchoAv. It is also interesting to note that Hecker's researches have fully confirmed the opinion, which has for a long time pre- vailed, viz. that fallopian pregnancy is more frequent in the left than in the right tube. J According to his record, it occurred thirty- seven times in the former, and only twenty-seven in the latter. It should be remembered that, under the term abdominal, Prof. Hec- ker includes also, ovarian gestation. * An interesting case of ovarian gestation has recently been recorded by J. Hall Davis, M.D., in which the left ovary wa3 developed into a cyst, and contained a de- cayed foetus. [Transactions of the Obstetrical Society of London, 1860, p. 241.] ■"• Monatsschrift fur Geburtskunde, 7-ef. 1859. j Dr. Finnell, of New York, reports in the New York Journal of Medicine for March, 1857, an interesting case of fallopian pregnancy on the right side. The same gentleman has recently met with a second example of the same variety of gestation also on the right side. Few medical men in this country have enjoyed more ex- tended opportunities of pursuing autopsical examinations than Dr. Finnell, as his numerous reports to the New York Pathological Society will show. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 205 3. Abdominal Pregnancy.—In this case, the germ becomes deposited in some portion of the abdominal cavity, and passes through certain stages of development; the surest guide as to the particular part of the abdomen in which the development pro- gresses, Avill be the attachment of the placenta. This has been variously found on the broad ligaments, in the recto-uterine fossa, on the mesentery, in the iliac fossae, on the internal surface of the anterior Avail of the abdomen; in a word, more or less on all the abdominal viscera. I might cite well-accredited instances of these different points of attachment of the placenta, but, as they are generally accepted as truths, I scarcely think it necessary to con- sume time in their narration. According to Prof. Hecker, there is a very marked difference in the mortality of this and the tubal species; Avhile in the latter, one in sixty-four^ survived, in the former, among one hundred and tbirty-tAVO cases, there were only fifty-six deaths, giving a mortality of but forty-two per cent.* 4. Interstitial Pregnancy.—The embryo here is developed neither directly under the peritoneal nor mucous coverings of the uterus, but becomes located in the meshes of the muscular fibres of the organ, and there receives its growth. The question naturally arises, hoAV is it conveyed to that particular portion of the uterus, and become embedded in the midst of its very substance ? Several hypotheses have been advanced to explain the circumstance, but they are as yet simple hypotheses, Avithout the support of any reli- able data. It Avas the opinion of Breschet—Avho in 1824 Avas the first to describe this variety under the form graviditas in uteri substantia—that the embryo, as it passed into the uterus, fell into the opening of some of the venous sinuses, Avhich he supposed to exist near the uterine extremity of the fallopian tube, and thus found its way into the substance of the organ. But repeated attempts have failed to discover these sinuses, and, Avithout the proof of their existence, it is in accordance Avith true philosophy to doubt their reputed functions. Only twenty-six cases of this species of extra-uterine fcetation have been recorded; it is as fatal as tubal gestation, and, like this latter, it was observed more frequently * A very remarkable example of extra-abdominal pregnancy has been reported by Dr. Geuth. The female, from early childhood, had a small movable tumor at the external abdominal ring. After marriage, she had borne three children. Some time after the birth of the third child, the catamenia ceased, and the tumor began to en- large. Sixteen and a half weeks after the menstrual suppression, the tumor equalled the volume of two fists; it extended, by a pedicle, into the inguinal canal. The patient suffered greatly, and became much enfeebled. The tumor was laid open, and contained a foetus and placenta of between four and five months. The patient recovered, and has subsequently become pregnant. Dr. Geuth's opinion is that this was an instance originally of hernia of the ovary and fallopian tube, and that pregnancy occurred without the abdomen. [VerhadL der Ges. fur Geburtsk. Ber- lin, 1855.] 206 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. on the left than on the right side, in the proportion of seventeen to twenty-four. Causes of Extra-uterine Fcetation.—Yarious theories have been advanced in explanation of extra-uterine gestation. If Avas con- tended by Astruc that it is much more frequent in widows and unmarried Avomen.* Upon this assumption he proposed the theory, that oftentimes fright, from being detected in the very act, deter- mined the error loci of the germ. But hoAv, Avith this hypothesis, are we to understand the occurrence of extra-uterine fcetation in married women, who have not only a right to be pregnant, but are most anxious to become mothers, and who, therefore, so far from experiencing alarm or mental emotion, enter into the act of inter- course with all the earnestness and pleasure, which an honest con- viction of right can inspire ? Again : how is it consistent with the Avell-knoAvn fact that some married Avomen become pregnant, and bring forth healthy living children Avithout the slightest approach to anything abnormal, to Avhom sexual intercourse is most repugnant, and whose constant hope is that they may not prove mothers ? Is it not reasonable to suppose, that in these there Avould be strong mental emotion, bordering on Avell-developed fright, at the time of cohabitation ? In my opinion, a more plausible explanation is found in the theory, Avhich, I believe, Avas first proposed by Prof. Virchow. He has observed that this form of pregnancy is frequently accompanied by adhesions of the internal genital organs, caused by false mem- branes ; these adhesions are mostly on the left side. He, therefore, attributes to their presence an important influence in the produc- tion of the pregnancy itself, and also explains AA'hy it is that extra- uterine gestation is more frequent on the left than on the right side. It may be mentioned, en passant, that adhesions of this kind are sometimes the real, but occult cause of sterility. Progress and Phenomena of Extra-uterine Fcetation.—In a practical sense, it is essential for you to understand the progress and phenomena of this species of pregnancy, in order that you may be prepared, when it occurs, to render the necessary assistance to your patient. The development of the foetus and its appendages proceeds nearly in the same manner as when the germ is located in the uterus, although, as a general rule, the cotyledonous element or lobes of the placenta are more abundant. In closely examining an extra- uterine fcetation, you will be able to recognise the chorion and amnios; the uterus is more vascular, its fibres and mucous cover- ing are in a hypertrophied state, and the entire organ notably enlarged. It is an interesting fact, and in strong illustration of the harmony * Experience proves that extra-uterine pregnancy, in the majority of cases, occurs in women who have previously borne children. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 207 of principle Avhich characterizes the operations of nature, that very soon after the passage of the fecundated germ to Avhatever part of the maternal organs is to constitute the seat of its growth, there will be observed in that part an increase in the action of the blood-vessels; this, no doubt, is owing to the vital activity, which is so marked in the ovule as soon as fecundation has been accom- plished. So true is it that the vessels become congested, through an afflux of fluid necessary for the wants of the embryo, that if, from accident or othenvise, these vessels should become ruptured, a fatal hemorrhage may ensue even in the very first few Aveeks of the gestation. The germ is inclosed in a species of cyst, which is composed differently in the different classes of extra-uterine fcetation. For example, in ovarian pregnancy, the cyst is made up of the fibrous and serous tissues of the ovary itself; Avhile, in tubal pregnancy, it consists of the muscular tissue of the tube, in conjunction with its peritoneal tunic. In abdominal pregnancy, on the contrary, the cyst is composed almost exclusively of an exudation which," from its plastic character, forms a bond of union between the ovum and the surface with Avhich it may be in contact. The cyst represents the uterus; but, unlike this organ, it has no outlet for the passage of the foetus into the world; and this is even so in fallopian preg- nancy, for, in this case, the tube will be found obliterated on each side of the cyst. As the embryo increases in development, one of the dangers to be encountered is the rupture of the cyst, which often results in the death of the mother from hemorrhage, and it is not, I think, improbable that this may sometimes be tlie real, but concealed cause of death, in cases in Avhich females, in apparently good health, suddenly sink. In extra-uterine pregnancy, the uterus, as said before, undergoes more or less enlargement; and this circumstance occasionally com- plicates the diagnosis. Frequently, in consequence of the increased vitality of the lining membrane of the organ, the membrana decidua Avill be recognised. It is comparatively rare that this variety of gestation reaches its full term; it seldom passes beyond the fifth month, although sometimes it attains the ordinary period; and there are instances recorded of its duration continuing many years. In these latter cases, the foetus is found in a degenerated state—it is either exsiccated and shrivelled, or will present a stony hardness, and sometimes a mere mass of adipose or fatty matter. The degeneration into a stony hardness is more apt to occur in cases of abdominal pregnancy, and then, as also when the foetus is dead in utero, and becomes converted into a calcareous mass, it is called lithopadion. Even Avhen the gestation reaches the full time, it is extremely rare for the foetus to be alive—it almost always dies from Avant of sufficient nutrition. 203 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. I have told you that rupture of the cyst, containing the foetus, is usually folloAved by fatal consequences—this, hoAvcver, is not always so ; occasionally, after the escape of the embryo through the rupture—if the patient survive the hemorrhage—she may sink from peritoneal inflammation, which is extremely apt to follow the egress of the foetus from the cyst. Should, however, the inflam- mation be subdued by prompt treatment, then there will generally be the formation of Avhat is called a secondary cyst, in Avhich the foetus becomes inclosed, and Avhich is the product of the exudation consequent upon the inflammatory action. The foetus, thus embraced within its secondary cyst—and the same thing may occur Avhile in its primitive envelope—Avill, some- times, from its weight, or other circumstances, cause inflammation, which may result not only in its OAvn destruction, but also in that of the cyst, involving the neighboring parts in more or less ulcera- tion, so that there may follow a fistulous communication externally, either through some portion of the abdomen, rectum, bladder, or vagina, and through this opening, the foetus, in a state of decomposition, may be discharged fragment by fragment. This result is likely to compromise the life of the mother. It is, indeed, stated that portions of the embryo have been ejected by vomiting from the stomach. If, therefore, in the course of your practice, you should be called upon to give an opinion as to the possibility of the passage of foetal fragments, through the channels mentioned, you can, Avithout hesitation, state that such a condition of things may result from an extra-uterine pregnancy in the manner indicated. Symptoms a?id Diagnosis of Extra-uterine Fetation.—How are Ave to knoAV that extra-uterine pregnancy exists? Here, as in uterine-gestation, we have nothing specially to guide us in the com- mencement ; menstruation may or may not become interrupted; in the only case of extra-uterine gestation, Avhich has fallen under my personal notice, in which I was consulted by Dr. Cyrus M. Thomp- son, of the State of Maine, the same phenomena occurred in the breasts, Avhich are usual in ordinary uterine gestation, and the areola, especially, was fully developed with its characteristic attributes. The abdomen was more or less enlarged, but there was no suppression of the menstrual evacuation.* It is maintained, * This was the case of a lady, who married when she was thirty-three years of age. During her maidenhood she enjoyed excellent health, and continued to do so for a year after marriage; at this period, however, she suffered more or less from derangement of the system; her abdomen enlarged, the breasts became tumid, and there was nausea with occasional vomiting. Her menses were quite regular, both as to time and quantity; she had a cough, with purulent expectoration, and a pulse at 110. It was under these circumstances that she visited the city of New York, bringing with her a letter from her family physician, Dr. Thompson, who requested THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 209 by some Avriters, that the breasts undergo no change in this form of pregnancy, and that there is no secretion of milk. I cannot understand on what this opinion is founded. The phenomena, con- my opinion as to her case. The doctor had fully made up his mind as to the broad meaning of the cough, purulent expectoration, and accelerated pulse—they were the unmistakable evidences of a serious trouble, which had already marked this lady as a victim to that relentless enemy of our race—consumption. She, however, did not appear at all conscious that the cough indicated any such fatal issue, and her whole attention was concentrated upon the abdominal enlargement. Her own conviction was that she had a tumor, which would destroy her life; she did not believe it possible she was pregnant, for the reason that her menstrual flow was regular. I made a very critical examination of the case, and soon became convinced of two facts: First, that the uterus was enlarged, corresponding with a three months' gestation; second, that commencing in the left iliac fossa, and extending obliquely upwards in the direction of the right hypochondriac region, there was evidently a growth independent of the uterus. On inquiry, the lady informed me that, just six months before I saw her, she commenced to experience irritability of the stomach, and there was also an increase in the size of the breasts. Soon after this, she felt a sense of pain in the abdomen, which has continued more or less at intervals, and which, within the last two or three weeks, had occasioned her not only much physical distress, but caused a great deal of mental anxiety, from the apprehension that she labored under some serious affection, which would destroy her life. Here, then, were two conditions, which, on examination, I had distinctly recognised, viz.: In the first place, an enlargement of the uterus; and, secondly, an enlargement of the abdominal cavity altogether independent of the uterine development. What could this latter be? A very natural presumption was—that it might be an ovarian tumor. During my manipula- tions on the abdomen, I very distinctly felt a movement—at first I was not quite satisfied of its nature. I again recognised it, and so distinctly, that it could not be mistaken—it was evidently the movement of a foetus. I then had recourse to auscultation, and, after some time, the pulsations of the foetal heart were detected ; the sounds were emitted about two inches above the umbilicus, and to the right. There was no mistaking them. My pupil, Mr. F. B. Bates, a relative of the lady, heard them, and also recognised the movements of the foetus. From the point of the abdomen at which the pulsations were detected, I came to the conclusion that the breech presented obliquely downward corresponding with the left iliac fossa. Here, then, was clearly a case of pregnancy. What was its true nature ? It was quite obvious that it was not a case of uterine gestation, for this organ, although enlarged, had not yet left the pelvic excavation. I decided, after a full considera- tion of all tlie circumstances; that it was unequivocally an example of extra-uterine fetation. I have already observed that the areola was well marked, presenting its true characteristics. In reply to the most anxious inquiry of the patient regarding her condition, I told her she was pregnant, but concealed the fact of the peculiar variety of gestation under which she labored. I was unwilling to add anything to her cup of sorrow, which was already full to overflowing; and more especially as I had good reason to believe that the period of her dissolution was near at hand. She appeared delighted with the opinion, and returned home joyous and happy, little dreaming of the sad future, which was so soon to remove her from earth! In all truth, sha verified those trite but expressive words of the poet: " When ignorance 1b bliss, Tis folly to be wise." I gave my opinion to Dr. Thompson in writing; and I received a letter from him, 14 210 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sequent upon ordinary gestation, are entirely sympathetic, result- ing from the changes going on in the uterine organs; and these sympathetic phenomena are the results of that close alliance, which is knoAvn to subsist between the breasts, the uterus, and its appen- dages. It does seem to me, that the fire, so to speak, kindled in these appendages and in the uterus itself—for we have seen that it also undergoes increase of volume—is sufficient to evoke corre- sponding excitement in the mammae. As I have already mentioned, the fact of the enlargement of the uterus tends to complicate the diagnosis; but in extra-uterine pregnancy, besides the increased size of the organ, there will be discovered on one or other portion of the abdomen, usually on the side, an enlargement, and the patient will occasionally complain of a sense of pain at that point. Here, again, this may be confounded with a tumor of the ovary, or a tumor of some other descrip- tion. It is obvious that, for the first three or four months of extra- uterine fcetation, there is nothing to guide us in the expression of a positive opinion as to its existence; and the only means of arriving at a just decision Avill be the active or passive movements of the foetus, and the cardiac pulsations. These, avcII recognised, place all doubt at an end. I should mention that, although the uterus increases iu volume, yet it does not exhibit the changes Avhich avo have described as characteristic of uterine gestation. For example, the cervix does not undergo any sensible diminution in its length, nor, under ordinary circumstances, does the position of the cervix tend backward toward the sacrum, as we know is the case in true gestation, in proportion as the uterus ascends in the abdominal cavity ; and, moreover, by a proper abdominal examination, you will be enabled to recognise whether the tumor is the enlarged uterus; but all doubt upon the subject will be dissipated by placing the finger of one hand on the cervix, ami the other hand on the abdominal portion of the tumor, thus completely grasping it two months afterward, announcing the death of his«patient, under the following painful circumstances: On her return home, she rallied for the first week or two— her whole thoughts being occupied with the happy anticipation of soon becoming a mother; she quickly, however, relapsed into her former condition—the cough increasing, the pulse reaching 130, with copious expectoration and great loss of flesh. Just one month from the time she left New York she was attacked with profuse haemoptysis, which was followed by profound prostration: the haemoptysis again recurred in two weeks, and two days afterward she sank from exhaustion. The folloAving is a brief extract from the doctor's letter: "In a post-mortem examination, your diagnosis of this case was fully confirmed. There was an extra-uterine foetus, apparently about seven months developed. It was partly decomposed, having, I have no doubt, succumbed a few days before tlie mother. There was about a pint of blood in the peritoneal sac, which must have added greatly to the prostration of our unfortunate patient. As far as I could determine, it was a case of ovarian extra-uterine pregnancy." THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 211 between the two hands ; and, in this Avay, you can readily detect, by an alternate movement of the hands, whether it be the uterus or something foreign to it. The particular position of the cyst, inclosing the foetus, Avill some- times exercise an important influence on the position of the womb ; and this should be borne in mind, otherwise it might lead to the embarrassment of mistaking extra-uterine pregnancy for simply a displacement of the uterus. If, for example, the cyst should attach itself posteriorly to the uterus, in the recto-uterine fossa, for instance, it might possibly be mistaken for retroversion of the organ. But, a moment's thought on the part of the practitioner, together with a vaginal examination, Avould soon reveal the error. The fundus and body of the uterus, instead of being retroverted, would be in directly an opposite condition; they would be pushed forward, constituting Avhat is known as an anteversion; and the cervix, in place of being forward, as is the case in retroversion, Avould be turned backAvard ; this malposition would be apt also to produce more or less irritation of the bladder. The presence of the cyst in the recto-uterine cavity might mislead you in other respects in your diagnosis ; for, Ave have elsewhere remarked, that this fossa is occasionally the seat of a prolapsed ovary, or of a portion of the small intestines. But adequate care in your examination, with a knoAvledge of the antecedent circum- stances, will generally aArail in enabling you to arrive at a correct opinion. Moreover, those who have recorded examples of this peculiar location of the cyst, say, that on an examination per vaginam or anum, the foetus can be recognised by the sense of touch. Suppose, hoAvever, the cyst should occupy a reverse posi- tion, and be found just in front of the uterus. The result, in this case, would most likely be retroversion of the uterus, and more or less vesical irritation ; this latter Avould be the effect of two forces —in the first place, the presence of the cyst; and, secondly, of the neck of the uterus, which, in retroversion, would be found turned toward the lower extremity of the bladder. The female, in extra-uterine pregnancy, will, at different periods, experience more or less pain, marked by distinct intermittence. When the cyst is composed of muscular fibres, as is the case in interstitial, fallopian, and ovarian gestation, these pains will closely simulate labor pains, and are the result of the contractions of the muscular tissue of the cyst. The uterus itself often participates in these contractions, and adds to the severity of the pain.* * Professor Hohl reports an interesting case of abdominal pregnancy, in which he recognised the contractions of the cyst. The cyst was behind the posterior cul de sac of the vagina, and near the posterior wall of the pelvis. He could distinctly feel it, and during the pains, the contractions of the cyst were quite apparent. After death, there were many organic muscular fibres detected in the coat of the ovum. 212 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. The Dangers of Extra-uterine Fcetation.—Let us now, gentle- men, briefly examine in what chiefly consist the true dangers of extra-uterine fcetation. It is an important question, and embodies some interesting practical bearings. It has already been remarked to you, that this form of gestation may terminate in one of tAvo ways : First, In rupture of the cyst, which is generally the result of the increased development of the foetus, although not always so, for the laceration may be caused by Woavs, falls, etc.; Secondly, In the death of the foetus, the sac remaining undisturbed. These, I believe, may be said to be the tAvo ordinary modes of termina- tion of this species of gestation ; and there are consequences to the mother groAving out of each, which it is essential for the practi- tioner to appreciate. In very rare instances, the mother escapes the usual fatal consequences of rupture of the cyst, because of the formation of Avhat is knoAvn as the secondary sac, the nature of which we have already explained to you. But the immediate danger of the rupture is death from hemorrhage; and fatal results ensue in at least tAvo-thirds of the cases in Avhich rupture takes place. The laceration is usually preceded by pain in some point of the abdominal cavity, quickly followed by symptoms of marked prostration—cold extremities, pallor of countenance, clammy per- spiration, vomiting, and flickering pulse. This may occur at any period of the pregnancy, even in the first month. In these cases, a post-mortem examination Avill reveal more or less effusion of blood in the peritoneal cavity—the effusion being the result of the rup- ture of the blood-vessels immediately concerned in the development of the foetus and its annexse. Should, hoAvever, the female escape the ordinary consequences of rupture, she incurs the serious peril of peritoneal inflammation, caused by the irritation of the foetus on the serous lining after it has left the cyst. So you see, the two immediate dangers of rupture of the sac are: 1. Death from hemorrhage ; 2. Death from inflammation. If, however, the cyst be not ruptured, the foetus may continue to live to the completion of the full term of gestation, which fact will be recognised by its movements and the pulsations of its heart; or it may have perished, and still continue to be inclosed in the sac. In either case, as has already been stated, there will be intermittent pains simulating the throes of labor, but altogether ineffectual so far as the expulsion of the foetus is concerned. It, therefore, results that the foetus may sojourn in the system of the female, and its presence give rise to the following conditions : 1. It may destroy the life of the mother by inflammation; 2. By the derangement which its presence and pressure may occasion in the digestive and other functions; 3. By its decomposition, and passage from the maternal system, through the vagina, rectum, abdomen, bladder, etc., as have already been indicated; 4. It may degenerate into a THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 213 stony, shrivelled mass, and remain for many years in the system, without resulting in anything serious. Treatment.—With this brief review of the principal circumstances connected Avith extra-uterine pregnancy, the question has, I haA'e no doubt, suggested itself to your minds—What can be done in these cases ? Does science afford us any means of relief? These ques- tions, gentlemen, concern us as medical men deeply ; for the great object of our profession is to arrest, if possible, the shaft of death; and when we fail in this, to do all in our poAver to soothe the anguish of human suffering, and make as light as may be the pro- gress to the grave. We will suppose that your diagnosis as to the existence of extra-uterine pregnancy is either beyond all peradven- ture, or that it is a matter of great doubt.* In the latter instance, to attempt any plan of treatment would be the sheerest folly, for the substantial reason that there can be no indication as to any special medication, as long as you are ignorant of the true nature of the case. You Avould not, I imagine, deem it Avise, because a patient complains of pain in the chest, to take it for granted that the pain is necessarily the result of pneumonia or pleurisy, and, therefore, plunge your lancet into the arm and abstract blood ad eleliquium ! But we take the former example—the proof of the pregnancy is positive. In this case, some very nice considerations present them- selves : First, the mother's life is placed in great jeopardy, in the various Avays already indicated ; Secondly, The death of the foetus is reduced almost to a moral certainty. These, then, are the naked and indisputable dangers of an extra-uterine pregnancy, if left to pursue its own course ; f and the important question for the practi- tioner is—Does science possess any alternative by which the danger to the mother may be lessened, or the chances of safety to the child increased ? I assume, as a fact, amply sustained by the experience of the profession, that, as a general rule, the certainty of extra-uterine gestation cannot be arrived at before the period of quickenino-; * Some grave errors have been committed with regard to tlie existence of this form of gestation; a case which occurred in Berlin is not without its moral: In August, 1828, Dr. Heim, who, with other eminent gentlemen, had agreed that a patient was the subject of extra-uterine fetation, requested Prof Dieffenbach to per- form tlie Cassarean section. The operation was accordingly performed, but to the amazement of all present, there was no pregnancy of any kind. The woman, how- ever, fortunately recovered. [Dr. Heim's Vermischte Medicinische Schriften. p. 402. Leipzig, 1836.] f It has recently been suggested by Dr. Bachetti, of Pisa, to attempt the destruc- tion of the embryo at an early period, so that the mother may be protected from harm, through an arrest of its development. lie records a case of this kind in which he succeeded in his object by electro-puncture He implanted two needles into the tumor, and then directed into the latter an electro-magnetic current. [L'Uuion Me- iicale, p. 168. IS")7.] 21-4 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. therefore, anterior to this period, the question of treatment will not usually arise. There is a difference of opinion as to the course to be pursued after the life of the child has been fully recognised. Some recommend gastrotomy, Avhich consists in an incision of the abdominal walls for the purpose of extracting the fcetus, and thus equalizing the chances of life betAveen it and its parent. Now, this is a mode of procedure Avliich should not be resorted to without deliberate reflection, and its justification based upon the reasonable assurance that, taking all the surrounding circumstances into con- sideration, it presents the greatest chance of safety to both mother and child. There is one special danger in the operation of gastrotomy in extra-uterine pregnancy, which does not apply to the Caesarean section in uterine gestation, and it is this: In gastrotomy, besides the dread of inflammation and shock to the nervous system—com- mon to it and the Caesarean operation—tJiere is the cardinal danger of hemorrhage, and for the following reason : As soon as the cyst is opened, and the integrity of the blood-vessels encroached upon, profuse bleeding ensues—the cyst, especially in abdominal extra- uterine pregnancy, possessing comparatively such slight poAver of contraction, for the reason that its muscular tissue is not abundant; in the Caesarean section, on the contrary, the uterus speedily con- tracts, and arrests the flooding.* The records of gastrotomy, the child being alive, are certainly adverse to the operation, for it has almost always proved fatal. If, however, you should have decided that the extraction of the fcetus is justifiable, it may sometimes happen that it will be more adATisable to make an incision into the vagina, and remove it through this passage; and this will be more particularly indicated in cases in Avhich the fcetus can be felt distinctly pressing doAvn upon the vagina. Should the head present, the child may be delivered after the incision, by means of the forceps or version, as occurred in the practice of Dubois. He felt the head of the foetus through the vagina—made an incision into the vaginal Avail, and also into the cyst, with a view of terminating the delivery by means of the forceps. He soon found, hoAvever, that there Avere firm and resist- ing adhesions between the head and sides of the cyst, Avhich caused him to abandon the operation. In the course of a feAv days an extremely putrid odor was emitted through the opening, and the fcetus, having undergone decomposition, came away in fragments ; the bony structures being aided in their passage by means of small pincers, and repeated tepid injections. The mother Avas convales- cent in tAvo months from the time of the operation. * In the interstitial and fallopian varieties of extra-uterine fcetation, the cyst is Bupplied with muscular fibres—in the former, from the uterus itself; in the latter, from the muscular coat of the tube. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 215 There is another condition in Avhich the operation of gastrotomy may be resorted to. Suppose, for example, after having carried the foetus beyond the ordinary term of gestation, the mother should manifest much suffering from its presence, and her health exhibit evidences of approaching decline from this cause. Under these circumstances, the question would legitimately arise Avhether it Avould not be advisable to extract the fcetus for the purpose of increasing the chances of life to the mother. Here, again, gentle- men, it is but a question of expediency, which is to be determined by sound judgment, and Avith but one motive to govern that judg- ment, viz. the greater Avelfare of the parent. I might here mention that Mr. Adams, of the London Hospital, and Dr. Stutter, of Syden- ham, have recently succeeded, by gastrotomy, in the extraction of dead extra-uterine foetuses, several Aveeks after the completion of the full period of gestation. In both instances, the mothers sur- vived.* Should you discover, at any time, an incipient abscess in the abdomen, vagina, or rectum, etc., occasioned by the death and decomposition of the fcetus, I need not tell you that it should be promoted by Avarm fomentations, and, if necessary, opened, so that a passage may be afforded to the foetus; and its extraction assisted by the various instruments necessary for the purpose. Dr. Camp- bell, f in an excellent memoir on the subject, presents some inte- resting details. He says it is well proved by experience that, Avhen the suppurative process is established, or a breach is actually formed in the parietes of the abdomen, the integuments may, with safety, be largely incised or the pre-existing aperture freely dilated Avith success. He records thirty cases in Avhich gastrotomy was performed, or the breach dilated, and of these, twenty-eitrht recovered. In twelve cases of gastrotomy, resorted to after the suppurative process was Avell advanced, ten were successful. In nine cases operated on, Avhen the fcetus was still alive, or soon after its death, all were fatal. * Medical Times and Gazette, London, July, 1860. f A Memoir on Extra-uterine Gestation. Edinburgh, 1840. LECTURE XV. Pregnancy, although not a Pathological State, is occasionally subject to Derange- ments—These Derangements are both Physiological and Mechanical; Illustration— Dogmatical Doctrines of the Ancients in regard to the Therapeutics of Pregnancy— Bloodletting in Pregnancy; when Indicated—Cathartics and Emetics; are they admissible?—Nausea and Vomiting; how Treated—"When Excessive—Ptyalism— Constipation—How Constipation is caused in the Pregnant Female; in part through Morbid Nervous Influence; in part from Mechanical Pressure—Diarrhoea; its Dangers—Palpitation of the Heart and Syncope—Lurcher's Opinion respecting Hypertrophy of the Heart—Pain in the Abdominal Muscles; how Treated—Pain- ful Mammas—Pain in tlie Right Hypochondrium—Pruritus of the Vulva; Hemor- rhoids ; how Produced—Varicose Veins—Cough and Oppressed Breathing. Gentlemen—I have remarked, in a previous lecture, that preg- nancy cannot, strictly speaking, be regarded as a pathological or diseased state. But Avhile this fact is conceded, yet, on the other hand, it is not to be forgotten, that many of the sympathetic phenomena characteristic of gestation Avill sometimes, through exaggerated action, assume a morbid character, calling for the intervention of science. Indeed, the derangements of pregnancy may, with propriety, be divided into physiological and mechanical. Do not misunderstand me; a true and complete physiological action is nothing more than a natural function, and Avhile it keeps within the particular sphere of duty assigned to it in the mecha- nism, it cannot, by any construction, be denominated morbid. It is only when the physiological function ceases to be recognised by nature as a sound link in the chain of forces, which make up the entire Avorkings of the system in health, that it becomes converted into a pathological result. Let us illustrate this point. You knoAV very Avell, that the im- portant office of the kidneys is to secrete urine, through Avhich effete matter is more or less constantly passing from the system; so long as this secretion is performed normally, it constitutes a necessary and precious element of health. But, suppose that, in lieu of the ordinary action of the kidney, there should be an increased secretion of urine, giving rise to that dangerous, and oftentimes fatal malady—diabetes. In this case, Ave should clearly have substituted a pathological state for Avhat, under ordinary cir- cumstances, is strictly a physiological function. The same thing occurs frequently in pregnancy. For example, there is scarcely a sympathy eA'oked in the economy as the consequence of fecundation, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 217 which may not, in the manner just described, become morbid, and thus need the attention of the practitioner. Again : as the result of mere mechanical pressure, there may occur various phenomena, which, from their disturbing influences, are entitled to be termed morbid, and which, therefore, are legitimately' objects of medical treatment. The digestive, vascular, and nervous systems may all become more or less disordered, as incidental to gestation, and these de- rangements will assume various types. The nausea and vomiting, ptyalism, depraved appetite, constipation, diarrhoea, etc., are all so many consequences, which, under certain circumstances, may require therapeutic management. Bloodletting in Pregnancy.—I have already alluded to the dog- matical and dangerous lessons, inculcated by the early fathers regarding the management of the pregnant woman ; and these les- sons have, I fear, ripened into a maxim which, even at the present day, is too often regarded Avith scrupulous fidelity. The old- school men taught that pregnancy is a peculiar state, calling for periodical medication; and that the only security for a safe and healthy gestation Avas the strict observance, on the part of the practitioner, of certain prescribed rules of treatment. In fact, so far from regarding pregnancy a natural condition of the system, they described it as an abnormal state, and hence Avere predicated upon this basis their vieAvs of its management. For example, the doctrine very generally obtained, that one of the universal charac- teristics of gestation is plethora ; and hence the maxim that blood should be abstracted from the arm of the pregnant Avoman in the fourth, seventh, and end of the ninth month—these being the respective periods in Avhich the gravid uterus is most disturbed by this vascular fulness of the system. You have seen that plethora is not necessarily an accompaniment of pregnancy, and, therefore, any rules of treatment founded upon such an assumption, cannot be sustained according to the laws of rigid analysis; and, more- over, if you Avere to act in blind obedience to this precept, you could not fail to do a vast deal of harm. It oftentimes happens that many of the phenomena of pregnancy, Avhich are supposed to emanate from plethora, are directly traceable, not to an engorged condition of the vessels, but to an exalted vitality in the uterine organs, and its transmission to the various portions of the economy with Avhich these organs are more or less in close sympathetic alli- ance. Then, gentlemen, so far from teaching these crude generalizations of the ancient school, Avhich all bedside experience proves to be erroneous, I shall enjoin upon you the sound principle, that you are to employ the lancet in pregnancy, not because of the fact that pregnancy exists, but because of the incidental occurrence of some 213 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. circumstance complicating that condition, Avhich broadly indicates the necessity of loss of blood. For instance, in all acute diseases, in cases of actual plethora, as shoAvn by the bounding pulse, flushed countenance, headache, etc.; in threatened abortion, Avith marked weight and uneasiness about the hips, accompanied with fulness of the system, blood may be abstracted in quantity, according to the judgment of the practitioner, Avith good effect. Cathartics.—It Avas a favorite maxim of Hippocrates, that cathar- tics should be administered to the pregnant female only from the fourth to the seventh month, and that, in all cases, the administra- tion of the cathartic should be preceded by the abstraction of blood ; and, again, it was maintained by Puzos and others, that purgatives were essentially necessary during the ninth month of gestation, for the reason that they protected the female from many of those post- partum difficulties, Avhich were supposed to be due to a constipated state of the boAvels. The only remark I shall make on the subject is, that, unless there should be some special reason, such as the presence of inflammation, the necessity for preceding a cathartic by the use of the lancet is one of the fanciful notions founded upon nothing stable in therapeutics; and as to limiting cathartic medi- cines to the fourth, seventh, ninth, or any other period of gestation, is about as philosophical as to enjoin upon a navigator, starting from ~New York to Liverpool, the absolute necessity of steering north, east,- southeast, or due east, on stated days. Like the skilful navigator, the physician must be governed by circumstances; and when, in his judgment, cathartics are indicated, they must be given, not according to any stereotyped rule, but for the special object which may present itself at the time. Emetics.—You Avill find, in the course of your future experience, that there is a very general prejudice existing, not only among the profession, but also in the public mind, against the employment of emetics during gestation; and this prejudice is founded upon the apprehension that their direct tendency is to produce contraction of the uterus, and, therefore, premature expulsion of its contents. It might appear, a priori, that this apprehension is not Avithout force; but it seems to me that, in reality, it is not entitled to much consideration. I have paid some attention to this question, and I am clearly of opinion that the prejudice against the use of emetics in pregnancy is not only unfounded in fact, but has occasionally been productive of bad consequences. I do not knoAV hoAv I can better illustrate the truth of this latter remark, than by the brief narration of an interesting case in point, which came under my observation a feAv months since : A married lady, aged tAventy-seven years, one year married, Avas in her seventh month of gestation. Her health had ahvays been good, and particularly so since her marriage. Xothing of any im- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 219 portance occurred during her pregnancy, with the exception of the ordinary phenomena incident to this condition, until the night of Dec. 23d, Avhen, being in her seventh month, she Avas suddenly attacked, while in bed, Avith vertigo, followed by loss of conscious- ness, and s/ertorous breathing. But a few minutes elapsed before I Avas by her side. Here, evidently, was a case of apoplexy. What was to be done? In the hurry of the moment, and his mind fixed upon the two prominent symptoms—the loss of consciousness and stertor—the physician would most likely plunge his lancet into the arm for the purpose of relieving the brain of its pressure! He has read in the books, and heard, ex cathedra, that, in apoplexy, blood- letting is the heroic remedy. This is a case of apoplexy, and, therefore, he bleeds. Now, gentlemen, this may be a syllogistic argument, and so far as the logic of the schools is concerned, it may have impressed upon it the seal of approbation. But the question is too naked—it is too abstract. In one Avord, it lacks the necessary collaterals for the medical man in the sick room ; and it is precisely this want of completeness which oftentimes paralyses science in its practical ministrations, and exposes both practitioner and patient to the broadest empiricism. It is very true that, in many instances, prompt and full bleeding is the remedy for apoplexy—but not ahvays. We have, for example, apoplexy from gastric repletion— the stomach is filled with indigestible food, thus causing mechanical obstruction to the circulation. In this case, bleeding would be so much time lost, and the last spark of life might become extinct during its performance. As soon as I approached the bed of my patient, I observed, on a chair, a basin, in Avhich I Avas informed she had several times at- tempted to vomit. I noticed in the basin some small pieces of salad, which had evidently been ejected from the stomach. On inquiry, I learned that she had spent the evening at a friend's house, and had partaken very freely of lobster salad and ice cream. Without de- lay, I mixed twenty grains of ipecacuanha in half a tumbler of Avarm Avater, and, Avith some little difficulty, caused her to SAvallow it. In a fe'\v moments it took effect, and you Avould have been amazed to see the quantity of undigested food thrown from the stomach. As soon as this offensive material was ejected, the patient evinced marked and gratifying evidences of returning reason—the stertor ceased, and her consciousness was shortly in full play. She Avent on to her full term ; and I had the pleasure, in two months from that time, of presenting her Avith a fine little boy, alive and in good health. One moment's hesitation, on my part, or the too ready adoption of the routine practice of bleeding, AA-ould have sacrificed two lives, and thrown into the deepest grief a devoted husband, whose anxiety on the occasion bordered almost on beAvilderment. To show you that emetics are not incompatible Avith a healthy 220 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. gestation, and do not necessarily provoke premature action of the uterus, I may recall to your recollection a very common practice, among young unmarried women, who, finding themselves pregnant, have recourse to these substances in the hope that they may rid themselves of their burden, and thus, through the destruction of the evidence of their guilt, find shelter against the withering storm of public opinion. But their hope most frequently ends in disappoint- ment—the remedy has not the desired effect. Again: how often are pregnant women exposed to that unearthly sensation, sea-sick- ness, and yet to miscarry under the most violent and repeated attacks of vomiting, is but an exception to the general rule. There- fore, I have no hesitation in stating, that emetics, during pregnancy, are to be employed, Avhen indicated, Avith as little reserve as under any other circumstances. I shall noAv briefly allude to some of the disorders of pregnancy, AA'hich will, occasionally, call for the interposition of science : 1. Nausea and Vomiting.—It is conceded that nausea and vomit- ing are the usual, and, so to speak, the natural sympathetic accom- paniments of gestation, and, therefore, under ordinary circumstan- ces, do not require the attention of the physician ; but sometimes, it may become necessary to resort to remedies for the purpose of keeping them Avithin reasonable limits. A great variety of agents has been suggested for this purpose. Opium, in its various prepara- tions, may be given internally, a quarter or half a grain at a dose; tAvo or three drops of the solution of morphia, in a teaspoonful of cold water ; small pieces of ice internally, or a piece of ice laid on the epigastric region, will sometimes have good effect. Dr. Simpson speaks favorably of the inhalation of laudanum from a small ether inhaler, hot water being used to promote evaporation. I have, occasionally, derived much benefit from the application to the epigastrium of a cloth saturated Avith laudanum ; chloroform, em- ployed in the same Avay, has been found useful. Equal parts of lemon juice and cold Avater, say a tablespoonful of each, or the same quantity of lime water and milk, tAvo or three times a day; tAvo or three drops of tincture of nux vomica, every tAvo or three hours, is a remedy much extolled by Lobach ; but, he observes, that after the arrest of the vomiting, severe cramps are apt to ensue, which, how- ever, readily yield to the tincture of the acetate of copper, one drop each hour, gradually increasing to six drops an hour. The extract of belladonna, in ointment, applied to the cervix uteri, first sug- gested, I believe, by Bretonneau and Cazeaux, is sometimes very efficacious. I have employed it Avith very striking benefit. Its strength should be 3j. of belladonna to 3 i. of adeps; a small por- tion to be smeared on the cervix once or twice a day, as may be indicated. It should be applied Avith the finger, and not through the speculum, for the reason that this instrument may, especially THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 221 :n sensitive Avomen, induce premature action of the uterus. The following, knoAvn as the potion of RiA'iere,has been in much repute, and may be resorted to oftentimes with advantage: I*. Acid Citric.........gr. xxxvj. Syrup. Sacchar........f. 3 viij. Potassas Bicarbonat......gr. xxxvj. Aquae Destillat........f. 1 iv. The citric acid to be dissolved in one half of the water, and then add the syrup; the bicarbonate of potash to be dissolved in the remaining portion of Avater, and a tablespoonful of each adminis- tered successively. Should the vomiting be aggravated by a con- stipated condition of the bowe's, which is often the case, though it may elude the vigilance of the practitioner, one or two of the fol- lowing pills may be given as occasion may require: 3. Pil. Colocynth Comp., ) _ _ _ aa gr. xxiv. Extract Hyoscyam., ) Pil. Hydrarg........gr. xij. Ft. Massa in pil. xxiv. dividenda. Dr. Simpson commends highly the nitrate of cerium in one or tAvo grain doses in water. If the patient should eject bile or vicious secretions from her stomach, then a slight emetic will be indicated ; nothing better, perhaps, than 10 or 15 grains of ipecacuanha. You Avill occasionally, gentlemen, meet Avith cases of rebellious vomiting, accompanied by a distressing Aveight in the vicinity of the uterus, Avith flushed countenance and an excited pulse. In these cases, you will find the abstraction of blood from the arm, from ij. to iv. ounces, repeated as may be necessary, a most efficient remedy. Indeed, if it be not had recourse to, miscarriage will be A*ery apt to follow.* 2. Ptyalism.—Salivation cannot be said to be a very common attendant upon pregnancy, yet it does sometimes occur, and will occasionally give rise to annoying consequences from the more or less constant dribbling of saliva, and in quantities so great as to weaken the patient. I have seen but few cases of excessive ptyalism during gestation, and, although there are many remedies recom- mended, I have not found anything so effectual as occasional small doses of Epsom salts—say, a teaspoonful in half a tumbler of water * Dr. Clay, of Manchester, calls attention to increased pain and tenderness of the neck of the womb as an occasional cause of persistent vomiting in pregnancy; the increased pain and tenderness being the result of inflammatory action. The slightest irritation of the part induces violent vomiting, and this is arrested as soon as the irritation is removed. Ho recommends such a position of the patient as shall relieve the cervix from direct pressure by the head; and, if necessary, a resort to leeches, to reduce the indViimation. His treatment was adopted with complete success in three cases. [Midland Quarterly Journal, Oct 1857.] 222 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. every alternate morning; or, if necessary, daily. It produces serous discharges from the boAvels, and thus to a certain extent antagonizes the excessive secretion of saliva. 3. Constipation.—I think it may safely be affirmed that regu- larity of the boAvels during gestation is the exception, Avhile a ten- dency to constipation is the general rule ; and if this be so, the true reason of this circumstance is certainly Avorthy of a moment's thouo-ht. Xot to speak of those examples of constipation, which are to be attributed simply to carelessness on the part of the female, there are numerous others continually occurring during the preg- nant state, which need some other explanation. The uterus, it is admitted, under the influence of gestation awakens in the economy various sympathies, and these cannot be evoked Avithout occasion- ally bringing about more or less derangement in the healthy or natural functions of the particular organs with Avhich they are con- nected. For example, we have seen that nothing is more common in pregnancy than disturbance of the stomach; so likewise do the heart, lungs, liver, kidneys, and the nervous centres, etc., become more or less deranged in their respective functions. These sympa- thetic influences are produced through the ganglionic system of nerves, which, becoming to a certain extent the seat of irritation in the uterus, transmit this irritation, through the ganglia and plexuses, to other organs of the system. I believe that, to a certain degree, the constipation of pregnancy may be explained in the same way—the regular action of the intes- tinal canal being modified in consequence of a want of healthy nervous power from the ganglionic nerves; this, at all events, in my opinion, is the true explanation of the torpor of the boAvels in the earlier months of gestation. But, at a later period, there is an additional cause brought into operation, viz. pressure of the uterus against the intestines ; this develops itself more sensibly during the last four months of gestation; for, at this time, the uterus com- presses the large intestine just as it passes from the left iliac fossa to the sacrum, and hence there is more or less obstruction at this point to the descent of the faeces into the rectum. You may very naturally ask why, when the impregnated uterus becomes largely developed in the abdominal cavity, the whole intestinal canal does not suffer from compression ? The simple reason is, that the intes- tines above the pelvis enjoy great mobility, and are, therefore, from this cause, enabled to accommodate themselves to the distended uterus. It is very desirable to assist nature, during gestation, in removing the usual torpor of the intestinal canal; for, if it be permitted to continue, headache, fever, and loss of appetite At-ill be apt to ensue. For this purpose, I am in the habit of ordering a simple enema of warm water early in the morning, or what will frequently answer THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 223 an excellent purpose, a tumbler of cold water drunk as soon as the patient leaves the bed. Sometimes it may be necessary to give a little manna dissolved in Avater, and again one or two of the follow- ing pills may be administered according to circumstances: S.MassaeHydrarg., ) ^a gr. xij. Saponis, ) Assafoetidae, gr. vj. Ft. Massa in pil. vj. dividenda. You will sometimes find that, in the attempt to administer an enema, the fluid is immediately returned. This will probably be owing to the circumstance that the rectum is clogged up Avith lumps of faecal matter, which will be likely to give rise to various local symptoms, such as more or less bearing down in the back passage and tenesmus, which, if continued, may result in premature deli- very ; pains throughout the pelvis and lower limbs, Avith indications of paraplegia from undue pressure on the sacral plexus of nerves. Now, this is a very important condition of things, and a little inattention on the part of the accoucheur may result in serious trouble to the patient. Therefore, in all such cases, I would advise you particularly to inquire how long a time has elapsed since the evacu- ation of the boAvels; Avhetherthe pain and tenesmus have continued for several days; and if you have reason to believe the rectum to be filled with fieces Avithout the ability to expel them, it will be your duty to proceed at once to remove the offending masses. This may be done in one of two ways—either introduce the index finger into the rectum, and thus giving it a hook-like form, bring away, piece after piece, the faecal matter, or, if you prefer it, you ma}r introduce a small spatula, and thus rid the rectum of its contents. 4. Diarrhoea.—Pregnant Avomen are occasionally subject to an opposite condition of the boAvels, viz., diarrhoea; and it is Avell to remember that the same causes capable of producing diarrhoea, when pregnancy does not exist, may also display their action during this state, such as improper food, cold, etc.; and again, diarrhoea in pregnancy, as in other conditions of the system, will sometimes be the direct consequence of constipation. HaATe you never, for example, seen a case of protracted constipation followed by severe diarrhoea ? If you have not, such instances will undoubtedly occur to you in practice. In these cases, the intestinal canal becomes irritated by the presence of fiecal matter, and more or less profuse diarrhoea Avill be the result. One word as to the treatment of this latter form of diarrhoea. Give an astringent, and you will most probably destroy your patient. On the contrary, administer a good cathartic medicine, SAveep the Avhole intestinal canal, remove the offending cause—the accumulated fiecal matter—and you -will not only arrest the diarrhoea, but restore your patient to health. There 22-1 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. is, however, gentlemen, Avhat may be called the diarrheea of preg- nancy—that is to say, it will sometimes supervene upon pregnancy almost simultaneously with the inception of this state, produced by a peculiar condition of the ganglionic nerves ; so that, although far less frequent than constipation, yet diarrhoea may be regarded an occasional accompaniment of gestation, and may, by debilitating the system, give rise to unpleasant results ; but what is most to be apprehended is its tendency in women of great nervous suscepti- bility to produce miscarriage. The diarrhoea must be treated on general principles; should it result from improper food or consti- pation, a purgative Avill be indicated; if the food be still in the stomach, administer ten or fifteen grains of ipecacuanha; if from nervous irritability, calming enemata, etc. A tablespoonfid of the folloAving mixture may be given Avith good effect tAvo or three times a day: IJ. Cretae Mistura3, f 3 vj. Tinct. Opii, 1 " Catechu, > aa f3 j. " Kino, ) M. 5. Palpitation of the Heart.—In women of great nervous sus- ceptibility, palpitation of the heart is not an unusual attendant upon pregnancy during the earlier months. It sometimes resolves itself into quite a disturbing symptom, and will need attention. If not controlled it may lead to miscarriage. When it is found to be due simply to nervous irritability, gentle tonics and antispasmodics judiciously employed will be folloAved by good results. Small doses of quinine with nourishing and digestible food; and, as an antispasmodic, thirty or forty drops of the tincture of hyoscyamus will prove valuable. If the palpitation, as will sometimes be the case, should be occasioned by a plethoric condition of system, the broad indication is the lancet, together Avith the use of saline cathartics and moderate diet. The quantity of blood to be abstracted must rest Avith the judgment of the practitioner. In the latter months of gestation the female will oftentimes complain of distressing palpitation, Avhich arises neither from nervous irritability nor plethora, but from the mechanical pressure of the elevated dia- phragm, thus encroaching upon the capacity of the chest, and, therefore, giving rise to functional disturbance of the heart. The most certain remedy in this case will be patience, for the difficulty will terminate with the delivery. But something maybe gained by position; the patient usually experiences more or less relief in the sitting or demi-recumbent posture. It is highly important that the bowels be kept in a soluble state, for constipation will tend to aggravate this particular form of palpitation. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 225 Larcher* has endeavored to show that, during pregnancy, there is a normal hypertrophy of the heart, which consists in a thicken- ing of the left ventricle, the Avails of which are increased in volume from one-fourth to one-third over their ordinary dimensions ; this increase is confined exclusively to the left ventricle, no other por- tions of the organ participating in it. The statement of Larcher is deduced from several hundred post-mortem examinations. The interesting practical fact connected Avith this opinion is, that the hypertrophy of the left ventricle will explain the belloAVS sound so frequently detected in gestation, and Avhich, therefore, is not to be regarded, in this case, as necessarily connected Avith fatal organic lesion of the organ. 6. Syncope.—Young married women, in their first pregnancy, are very apt to be attacked Avith syncope. Indeed, according to my experience, this is much more frequent than is generally admitted by writers. I have known it to occur as early as the second Aveek of gestation. It is usually confined to the earlier months, but in some cases it exhibits itself at the time of quicken- ing. It will develop itself in women of good health, as well as in those of delicate constitution. Sometimes, its duration is quite brief and evanescent, Avhile again it will continue for a longer period, producing much disquietude on the part of friends. It may take place at any time, and Avithout the slightest premonition. Syncope cannot, I think, as a general rule, be regarded a dangerous complication for the mother. I have never seen fatal consequences ensue from it, except in one case, Avhere it was Avell ascertained that organic disease of the heart had previously existed.f It is, hoAvever, not Avithout danger, under certain circumstances, to the child ; for example, Avhen the syncope is long continued, the inter- ruption of the proper supply of healthy blood to the fcetus may result in its destruction. AUoav me, here, to call your attention to an important distinction betAveen syncope, strictly speaking, and a sudden loss of consciousness, unaccompanied by suspension or dimi- nution in the heart's action ; this latter seems to have an analogy with epilepsy; and, of course, its treatment must depend, as far as may be ascertained, upon the particular cause producing it. In an ordinary case of fainting, the treatment is simple; the patient should be placed instantly in the recumbent position, her head on a plane with her body, in order to facilitate the passage of blood to the brain; the dress loosened, fresh air admitted, cold water dashed in the face, and, if necessary, salts of ammonia applied to the nose. It should also be recollected that simple mechanical excitement of the heart by manual pressure is a valu- * Gazette M6dicale de Paris. 1857. p. 258. f It is proper to mention that there are some few oases recorded of sudden death from syncope during pregnancy, tlie syncope being the result simply of emotion. 15 226 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. able means of re-establishing its rhythmical movement. It can scarcely be necessary to remark that a proper supervision should be exercised by friends in cases in which the female becomes sub. ject to these fainting turns. # 1. Pain in the Abdominal Parietes.—In women with their first children, more especially, there will occasionally be experienced exces- sive pain in the abdominal walls from the sixth to the ninth month of gestation. The true cause is, no doubt, the great distension to which these parts are subject, and the firmer resistance which they offer in a primipara. Sometimes, the pain amounts to intense suf. ferine, and the practitioner must be careful not to confound it Avith inflammation. The diagnosis is very clear—in mere pain of the abdominal muscles from distension, there is no fever; pressure and frictions relieve, instead of aggravating, the distress. In inflam- mation, on the contrary, the slightest pressure increases the pain, and there i3 high fever, with an accelerated and hard pulse. I have found in these cases of severe abdominal pain much benefit from the application, by means of gentle friction, of equal parts of laudanum and SAveet oil; soap liniment, or camphorated oil is also useful. For the purpose of relaxing and soothing the stretched integuments a large slippery-elm poultice, applied Avarm, will be very servicable. 8. Relaxation of t/ie Abdominal Parietes.—You will, in Avomen who have borne several children, oftentimes observe an opposite condition of the abdominal parietes. Instead of being excessively tense from distension, they will present an aspect of relaxation, being absolutely as it were, flabby, and utterly unable to afford the necessary support to the developing uterus. This necessarily exposes the gravid organ to the displacement knoAvn as anteversion, Avhich, if not remedied, Avill, during the pregnancy, occasion much disturbance about the bladder, and at the time of labor present serious obstruction to the delivery of the child, as will be more particularly mentioned Avhen speaking of the causes of obstructed delivery. The remedy for this relaxed condition of the abdominal wallo is proper support; it can be afforded by the employment of a broad elastic belt Avhich, if properly adjusted to the person, will prove quite sufficient in preventing the displacement to which I have referred. Before applying it, the accoucheur, if the uterus be already anteverted, should gently grasp the fundus of the organ, through the abdominal coverings, and direct it upAvard and back- ward with a view of restoring it to its normal position. 9. Painful Mammce.—The breasts, particularly in the primipara, sometimes become the seat of distressing pain. As pregnancy advances, they enlarge, the lacteal glands and ducts undergoing more or less constant development—the consequence is, occasionally, treat local distress, producing at times fever, and other consti- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 227 tutional disturbance. In these cases, you Avill find, especially if the bowels be confined, much benefit from the derivative action of Epsom salts given in small quantities in solution, and as circum- stances may indicate. Benefit will also be derived from local appli- cations; gentle frictions Avith some liniment, camphorated oil, laudanum and sweet oil, or a poultice of crumbs of bread, saturated Avith a small quantity of tincture of belladonna. If the patient be plethoric, the abstraction of a few ounces of blood will be of advan- tage ; and I have known great good accrue from tolerant doses of tartarized antimony. 10. Pain in the Right Side.—About the sixth month of pregnancy, women are often attacked Avith pain in the right side, which may possibly, through inadvertence, be mistaken for inflammation. The pain usually arises from the fact that the ascending uterus begins to exercise a pressure on the liver. As a general rule, the pain will continue more or less until after delivery, although it may be miti- gated by the occasional use of a mercurial pill at night, followed in the morning by oil, or Epsom salts. 11. Pruritus of the Vulva.—A most distressing itching of the external organs Avill sometimes manifest itself during pregnancy, and, in its aggravated form, it will constitute one of the most pain- ful affections Avith which the pregnant female has to contend, caus- ing her literally to lacerate the parts by the constant scratching to which she has recourse in the hope of temporary relief. Ulcerations often result, requiring very nice attention on the part of the prac- titioner. You will meet with pruritus of the vulva in other cases than pregnancy, but when it is found to complicate gestation, it calls for more than usual vigilance, for, if not controlled, it may lead to abortion. The female, from motives of delicacy, oftentimes conceals the fact of her suffering, and, on this account, the physi- cian is generally not consulted until the malady has reached one of its most aggravated phases. The characteristic feature of the disease is intense itching; sometimes small vesicles, containing a sero-sanguineous fluid, will be observed on the inner surface of the parts, Avhere, in some cases, deep ulceration will be provoked. I have just stated that other causes than pregnancy will produce pruritus of the vulva; such, for example, as the final cessation of the menses, inattention to personal cleanliness^e presence of what are termed the pediculi pubis, known as the small parasite insects, which occasionally infest these parts, discharges from the vagina, ascarides in the rectum, etc. In some instances the Avorms will pass from the rectum to the vagina, and two cases have recently been published by Dr. Yollez, in Avhich pruritus pudendi resulted from the presence of ascarides exclusively in the vagina, none hav- ing been found in the rectum. In these instances, mercurial oint- ment will prove an efficient remedy. 228 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Treatment.—The treatment of pruritus must depend upon the particular condition of the parts, and also upon the cause to which it is traceable. When there are no ulcerations, I have generally found, if there be nothing to contra-indicatc it, the abstraction from 3 iv. to 3 vi. of blood from the arm, together with saline cathartics, and a lotion applied freely of § i. of the borate of soda to Oj. of water, Avith 3 i. of Magendie's solution of morphia, to be folloAved by good results. When the parts are ulcerated, I ahvays touch the ulcerated surface Avith the solid nitrate of silver, and this should be repeated every fourth or fifth day, as may be indicated by the progress of the disease. The parts to be cleansed Avith Castile soap and Avater, and, as far as possible, rest enjoined on the patient. This malady is apt, especially when suffered to continue for some time, to result in emaciation, and in such case, if you limit your remedies to local applications, you Avill fail in affording relief. Tonics, together Avith nutritious diet, will be indicated. There will occasionally be developed a form of pruritus of the genital organs, assuming the character of eczema, Avhich is extremely difficult to manage, often proving obstinately rebellious to remedies. In this particular condition of things, the folloAving treatment has been proposed by M. Tournie, and Avhich I have found very efficient for the purpose. He recommends, as topical applications, calomel ointment, and a powder of camphor and starch. Should the parts be covered Avith scabs, emollient poultices are first to be employed; when the scabs are removed, the ointment is to be applied tAvice a day, 3j. of calomel to "fj. of lard; after each application, a poAvder, consisting of four parts of starch to one of finely powdered cam- phor, to be freely used. 12. Hemorrhoids.—Hemorrhoidal tumors, or piles, are not uncommon during pregnancy, and frequently give rise to much distress. When large, they may, by the excessive pain they induce, occasion premature action of the uterus. In the pregnant Avoman, there are tAvo causes in operation which tend directly to the forma- tion of these tumors: in the first place, pressure exerted by the gravid uterus on the venous trunks, thus obstructing the free return of blood to the heart, and secondly constipation, which is so fre- quent an attendant upon gestation. These hemorrhoidal tumors may be either external or internal; in either circumstance, they are exceedingly apt to be accompanied by much pain and irritation. If they bleed, which is sometimes the case, the patient, for the time being, is relieved, for their disgorgement is ahvays followed by a diminution in their volume, and consequently a lessening of the irri- tation and pressure. Occasionally, hoAvever, the bleeding Avill be so frequent as seriously to affect the health, resulting in an anaemic condition of the system, and imposing upon the female the various nervous and other derangements consequent upon this bloodless THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 229 state. Iii such cat once a day for the purpose of cleansing it. After the fourth month, its use may generally be dispensed Avith, for the uterus, having as- cended above the superior strait, Avill usually remain in the abdomi- nal cavity, Avithout the necessity of support. The tenesmus may be partially relieved by the use of injections of warm soap suds into the rectum, and, in order to facilitate the admission of the fluid, the practitioner will sometimes find advantage in the introduction of the index finger into the intestine for the purpose of gently pressing the uterus forward, so that the pipe of the syringe may meet Avith no obstruction. Introduction of the Catheter.—For the relief of the bladder, suf- fering from retention, resort must be had to the catheter. You will readily understand that, in the second variety of uterine dis- placement—the cervix of the uterus pressing upon the vulva—the natural position of both the bladder and urethra will be modified__ the bladder, of course, is prolapsed, sometimes protruding slightly beyond the vulva, and the urethra, instead of being oblique from beloAv upward, will be so changed in its direction, that, from the meatus to a little beyond its central portion, it will be horizontal while its vesical extremity will be drawn downward. You per- ceive, therefore, that Avithout a recollection of this circumstance. 234 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the successful introduction of the catheter would not be an easy- thing to accomplish, to say nothing of the serious consequences AA'hich would most likely ensue from a forced attempt to overcome the difficulty. The catheter, under these circumstances, should bo introduced at first horizontally, from before backAvard, and then the outer extremity of the instrument elevated, while the internal ex- tremity is correspondingly depressed, for the purpose of following the altered direction of the urethra, and thus entering the cavity of the bladder, which you must remember is downward and forward, and not upward, as it is in its normal position ; it must also be remembered that, in this case, the convex border of the instrument should be turned upward, and its concavity downward. When the gravid uterus is in a state of complete procidentia, the complications become much more aggravated. The difficulties about the rectum and bladder are necessarily much increased, and the patient is exposed to additional suffering. There are well- authenticated instances of women having passed the period of gestation Avith the uterus protruding beyond the vulva. You can readily imagine the distress and danger consequent upon such a condition of things. When procidentia of the gravid uterus ex- ists, the first duty of the practitioner is to attempt its reduction, by grasping it gently Avith the fingers, and making pressure from before backward, parallel to the axis of the inferior, and then upAvard in the direction of the axis of the superior strait. When reduced, it should be retained in place by means of the sponge-pes- sary and T bandage. It may, in cases of procidentia of the impregnated womb, become a question hoAV far it is justifiable to promote premature delivery; and this question will necessarily present itself in instances, in which the local irritation or constitutional disturbance is such as to involve, in more or less hazard, the safety of the patient. The ultimate decision must depend upon the accompanying circumstances of each individual case, and the sound judgment of the practitioner. II. Ante-version*—Ante-version of the uterus is comparatively of rare occurrence in early pregnancy ; although you occasionally meet Avith it in Avomen Avho have borne many children, and whose abdominal Avails are consequently so much relaxed as to be inade- quate to afford the proper support to the ascending organ, and it, therefore, falls forAvard, giving rise to two conditions: 1st, Ante- version ; 2d, An increased promineuce to the abdomen. If ante- * There is a broad difference between ante-version and ante-flexion of tho uterus. In the latter, the uterus is, as it were, curved on itself in such way that the two upper thirds of the organ are thrown forward on the bladder, but the cervix is undisturbed in its relations with the pelvic cavity. So, also, in retro-flexion, while the superior portions of the uterus are curved backward the position of the cervix remains unchanged. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 235 version occur in early gestation, before the uterus has left the pelvic excavation, it can readily be replaced by passing the finger into the vagina, and pressing the anterior surface of the organ backward ; sometimes, it may be reduced to its normal position by gently drawing the cervix forward, the tendency of AA'hich will be to place the body and fundus in a position parallel to the axis of the superior strait of the pelvis. In a more advanced period of gesta- tion, when the uterus is ante-verted, because of relaxation of the abdominal parietes, the practitioner should, in the first place, restore the organ to its normal position by righting it with the palm of his hand applied to the abdomen, making the pressure from below upward, and from before backAvard ; and secondly, an ab- dominal brace, or bandage, is to be applied for the purpose of retaining the uterus in situ. III. Retro-version.—Retro-version is much more frequent than ante-version, and may occur in the virgin, in the married Avoman, who is not pregnant, and it may also complicate pregnancy itself. It is most common Avhen the uterus is in a state of vacuity. It is quite obvious that this form of displacement must take place during the earlier months of gestation, for, after the fourth and fifth months, the longitudinal diameter of the uterus is so much in excess of the antero-posterior diameter of the superior strait, that it is physically impossible for the organ to become completely retro- verted. Retro-version of the uterus implies a displacement of the organ, by Avhich it rests more or less horizontally in the peh-ic excavation, the fundus being directed toward the sacrum, and the cervix regards the internal surface of the pubes. This displacement, Avhen complete, divides, as it Avere, the cavity of the pelvis into two com- partments, an upper and lower—for the former, it constitutes the floor, and for the latter, the roof or superior boundary. The term retro-version was, I think it is generally conceded, first applied to this character of mal-position by Dr. Wm. Hunter. There are numerous causes capable of producing retro-version • among which may be enumerated an enlarged pelvis, a relaxed con- dition of the ligaments of the organ—the round and broad ; undue pressure Avhether against the anterior surface of the uterus, or upon its fundus; the efforts of vomiting, straining in the attempt at defecation, a distended bladder, and any sudden or A-iolent move- ment may also produce it. Retro-version will, sometimes, be con- genital ; it is almost ahvays, however, the result of accident. It is sometimes very gradual in its occurrence, and again it is quite sudden. In the latter case, it is the consequence of some extraneous physical violence experienced by the female, such as a fall, blow, or the lifting of a heavy Aveight. When this displace- ment has taken place, it is accompanied by symptoms, which, to the 236 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. vigilant practitioner, AA'ill generally indicate its nature—for example, there Avill be more or less uneasiness experienced about the loins, and oftentimes a dragging sensation, irritation of the bladder and rectum, Avith difficulty in evacuating either; sometimes, it will bo almost impossible to evacuate the rectum in consequence of the extreme pressure exercised upon it by the retro-verted organ. All these results are very much increased in the gravid uterus, and occasionally fatal consequences ensue from its complete hori- zontal impaction between the sacrum and pubes, giving rise, in the first place, to severe pressure, resulting subsequently in inflamma- tion, ulceration, and its consequences. In this case, also, there may be rupture of the bladder from the continued retention of urine, and the ini] os-ibility of drawing it oft* by means of the catheter.* The rectum, loaded with faecal matter, will occasion a tenesmus which, provoking on the part of the female excessive efforts to expel the contents, may result in rupture of the vagina, thus causing the fundus of the womb to pass through the opening. A case of this kind, Avhich proved fatal, is mentioned by Dubois, as having been communicated to him by Dr. Mayor. There are examples of this displacement, in Avhich death occurred from the severe local inflam- mation, and consequent constitutional disturbance, resulting from pressure of the retro-verted Avomb. It will sometimes happen that the uterus, from the serious irritation to Avhich it is exposed, will be thrown into premature action, thus ridding itself of its contents. This, in cases in Avhich it becomes impossible to reduce the mal- posed organ, should be regarded as a most fortunate issue, for it Avill prove the means of saving the life of the mother, and enable the practitioner to restore the uterus to its normal position. In- deed, when this early evacuation of the uterus is not accomplished by nature, it is, under certain circumstances, the only resort left for the accoucheur. The diagnosis of a retro-verted womb is, ordinarily, not difficult. In addition to the local disturbance, to which allusion has already been made, a vaginal examination will soon dissipate all doubt. The finger will readily recognise a change in the position of the * A woman, aged thirty five years, had enormous distension of the abdomen, which, on examination, had all the characters of ascites; there was dulness over the greater part of the cavity, extending high up above the umbilicus, and evidently due to the presence of fluid. A medical practitioner had been on the point of per- forming paracentesis so urgent was her distress. Fortunately, this was deferred, and she was taken to the Westminster Hospital. On inquiring into her history, it was learned ttiat she was three months pregnant. A catheter could not be intro- duced, aud on examination, a retro-version of the womb was detected, which had probably existed three weeks, the duration of the swelling. A few ounces of urine dribbled away daily. The fundus of the womb was pushed up, and immediate relief given, upwards of a gallon of urine flowing away without the aid of the catheter. The woman recovered. [Lofld. Lancet, April 30, 1859.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 237 organ, the cervix being in front, and the fundus behind, pressing, more or less, upon the rectum; and, in complete retro-version, the posterior surface of the organ will form the upper boundary of the pelvic excavation, being distinctly felt by the finger, extending horizontally from before backAvard. When pregnancy does not exist, retro-version of the uterus can- not be said to be a dangerous complication, although it is one of much annoyance to the patient, and oftentimes, from the difficulty of retaining the organ in situ, of embarrassment to the accoucheur. Very different, hoAvever, is the case during the period of gestation, for here, as you have just seen, the most formidable and, occasion- ally, fatal results ensue. Two of the earliest, most constant, and distressing symptoms of this displacement will be irritation of the bladder and rectum ; and this very irritation is frequently the first indication that there is anything Avrong. Having told you in Avhat retroversion consists, and spoken of the consequences of this form of displacement, the next point for con- sideration is, as to the remedies to be employed. One of the most imperious demands Avill be the evacuation of the bladder and rectum, more especially the former. But this is not al\A'ays readily accom. plished, for the reason that the distended bladder ascends obliquely upAvard into the abdominal cavity, and so changes the position of the urethra as sometimes to render it physically impossible to intro- duce the catheter. This constitutes one of the most serious and painful complications of retro-version; and, under such circumstances, as death Avill be inevitable Avithout relief to the bladder, the A'ery important question arises: What is to be done? We have the authority of Sabatier, in these cases, to perforate the bladder above the pubes; and, if the necessity of the operation be indicated, I should not hesitate to have recourse to it; for the double reason that relief must be had, and, secondly, the operation itself does not necessarily involve any danger. The rectum should be evacuated by means of enemata, or, if required, the fseces may be scooped out Avith a small spoon or spatula. These two viscera being emptied of their contents, an effort should next be made to restore the uterus to its proper position ; for this purpose, various plans have been suggested. In the event of inflammation having arisen from the severe pressure of the uterus against the adjacent organs, any attempt at reduction should be preceded by means best calculated to remove inflammatory action, such as leeches, hot fomentations, and emollient injections into the vagina. Minute doses of tartarized antimony, given to tolerance, will frequently be folloAved by good effects in subduing the local excitement. This being accomplished, efforts may be 238 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. made to reduce the organ to its usual axis. For this purpose, the index finger of one hand should be introduced into the rectum, Avith the view of pressing the fundus of the Avomb upward and forward ; at the same time, the finger of the other hand is to be carried through the vagina to the cervix of the organ, and a movement made precisely counter to the other—that is, the cervix should In- brought a little downward and backAvard. This simple manipula- tion, adroitly performed, Avill sometimes result in the restoration of the retro-verted uterus, but not ahvays. Much will sometimes be gained by the position of the patient; for example, if either on the back, or resting on her left side, you should fail in accomplish- ing the object, it will be found useful to direct your patient to place herself on her knees and elbows—this will tend to facilitate the attempt at reduction ; but the position is an unpleasant one, and oftentimes there will be objection made to it. Evrat suggested the introduction into the rectum of a tampon prepared in the folloAving manner : a small rod about tAvelve inches in length has fastened to one extremity a sort of mop made of fine old linen, and Avell smeared Avith oil or fresh lard; this tampon is then gently introduced into the rectum; of course, it is soon brought in contact Avith the loAver surface of the malposed organ, and Avith a uniform but judicious upAvard and forward pressure, Evrat and others have succeeded in giving to the uterus its natural position. It is, hoAvever, to be recollected that, Avhile pressure is made upward and forward by means of the tampon, the finger of the accoucheur should be introduced into the vagina for the pur- pose of making doAvmvard and backward traction on the cervix. If it prove impossible to reduce the organ, then it has been pro- posed to perforate the uterus through its posterior wall Avith a view of affording escape to the liquor amnii, and Avith the hope of so far diminishing the bulk of the gravid uterus as to facilitate the reduc- tion. This, however, is a dangerous expedient, and should not be resorted to except in those cases in Avhich it is absolutely impossible to rupture the membranes through the cervix, Avhich, although difficult in this form of mal-position, may, with due care and pefse- verance, be accomplished. It has been suggested by Halpin,* in cases which have resisted the ordinary attempts at reduction, to pass into the vagina an instrument, the object of Avhich shall be the exercise of a uniform pressure simultaneously on the entire loAver surface of the uterus. Thus he contends, by means of a bladder, he can completely fill the pelvis, and elevate into the abdominal cavity the different viscera contained within the excavation. For this purpose, he plo,ces an empty bladder between the fundus of the womb and rectum ; he * Arch. Gen. 1340, p. 88. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 239 then cautiously inflates it, and, as the bladder becomes distended, the retroverted uterus is replaced. A plan very similar to this has been suggested by Gariel. He introduces one of his vulcanized india-rubber pessaries into the rectum; it consists of a dilatable air pessary, Avith an air reservoir, and a tube, to each of which are attached small taps. The collapsed pessary, having been previously placed in Avarm water, is introduced by means of a probe into the rectum, immediately behind the uterus; then the tube of the pes- sary is adjusted to the air reservoir; the taps are opened, and by simple pressure of the hand the air is made to escape from the reservoir into the pessary; in this Avay the pessary presses upon, and raises the retro-verted uterus from the hollow of the sacrum; thus the natural position of the organ becomes restored. This is an ingenious contrivance, but the proper application of the instru- ment requires much care in order that it may prove efficient. It is not at all uncommon for the inattentive practitioner to sup- pose that retroversion exists, Avhen, in fact, there is no displace- ment Avhatever; and, I think, I shall perform an acceptable service by directing your attention briefly to the causes of error. I have more than once been consulted by medical gentlemen, Avho haA'e treated their patients for this supposed mal-position, Avhen, upon examination, I have discovered that the symptoms, Avhich had been mistaken for those of retro-version, Avere due to circumstances Avith Avhich dislocation of this viscus had no sort of connexion. Two of the most prominent causes of error will be: 1st. A collection of fiecal matter in the rectum ; 2d. A prolapsion of the ovary into the recto-uterine fossa. You will perceive that either of these contingencies will necessarily, to a greater or less extent, give rise to the same local disturbances, which usually characterize a retro-version of the uterus—such, for example, as pain about the hips, distressing pressure on the rectum, Avith fre- quent desire to defecate, together with tenesmus. Hoav, then, is the diagnosis to be determined—and in AA'hat Avay is the true nature of the difficulty to be ascertained ? If it be a collection of fiecal matter in the rectum, this can readily be appreciated, almost in all instances, by a vaginal examination. Let the accoucheur, as he passes it into the A'agina, run his finger carefully along the track of the rectum, with a vieAv of ascertaining, whether or not it is unusu- ally distended—if the distension be due to faecal matter, he Avill be enabled to recognise the fact by slightly pressing upon the rectum, Avhich Avill enable him to separate the different pieces of hardened firces, and thus become satisfied that it is their presence, Avhich has caused the symptoms to Avhich we have just alluded. Again, in retro-version, Avhile the fundus is thrown backAvard into the holloAV of the sacrum, the cervix of the uterus inclines toward the pubes; this will not be the case when the rectum is simply loaded with 21:0 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. excrement. But, in order to remove all doubt on the subject of the diagnosis, let the rectum be freely evacuated by enemata; if this cannot be accomplished by these means—as is sometimes the caSe—then the finger, or a small spatula, should be introduced, and the faeces brought away, as has been previously suggested. The rectum being relieved of its distension, it will folloAA', as a necessary result, if there be no retro-version, that the patient will, at once, experience an absence of the distressing local disturbances. Hoav are Ave to proceed in our diagnosis of prolapsed ovary ? In this case, if the ovary haAre not undergone enlargement from disease, it will not be difficult to displace it from side to side by means of the finger, indeed, in some instances it may be pushed upAvard AA'ithout difficulty, but as soon as the finger is withdrawn, it again prolapses; the most positive demonstration that it is a prolapsed ovary, will be the introduction of the uterine sound. Let the accoucheur carry the sound into the uterus, which must ahvays be done with great caution; as soon as it is sufficiently introduced, the uterus, should it be retroverted, will, of course, while the sound is within its cavity, become righted in its position ; if, under these circumstances, the finger of the accoucheur be intro- duced into the vagina, he will not feel anything pressing upon the rectum—but, on the contrary, if, after the introduction of the sound, the tumor be felt, then it is evident that it is occasioned by the presence of the ovary in the recto-uterine fossa. Hernia of the Gravid Uterus.—Hernia of the impregnated or- gan is extremely rare ; still there are some recorded examples of it. Dr. Evory Kennedy, in his Avork on obstetric auscultation, cites the instance of an umbilical hernia of the uterus in a female, Avho had previously borne several children. It appears that Avhile in labor Avith her second child, she Avas attacked Avith an ordinary umbilical hernia; this continued gradually to increase, Avhen, in a subsequent pregnancy, the gravid organ passed completely out of the abdominal cavity through the umbilical opening, so that, at the end of the ninth month, it extended to the knees. Madame Boivin has recorded a case of ventral hernia of the impregnated Avomb, the organ passing out through an opening above the pubes, Avhich opening Avas the result of a large abscess. Other varieties of hernia have also been mentioned as having occurred, such as inguinal and crural.* * I find, in the Obstetrical Transactions of London, for 1856, p. 77, the following interesting case of umbilical protrusion of the impregnated organ, having occurred in the practice of Mr. Gr. C. P. Murray: Mrs. M. A. J., thirty years old, mother of three children, observed some blood issuing from her navel; on examining the abdomen, Mr. Murray observed a large tumor the size of a gravid uterus in the latter months; the head of a fcetus could be distinctly fell, at the right and upper portion of the umbilical tumor, the body of the foetus extending downward on the left side. There LECTURE XVII. The Annexse of the Foetus; The Decidua—-Huntor's Theory of its Formation; The Decidua, an Hypertrophied Condition of tho Uterine Mucous Membrane—The Reflexa; how formed—Coste's Views—Uses of the Decidua—The Chorion and its Villi—The Uses of each—Nourishment of the Embryo through the Villi— Professor Goodsir—The Amnion; its Uses—The Liqifor Amuii: Origin of—Is it derived from Mother or Foetus?—Casts of the Uriniferous Tubes found in Liquor Amnii—Uses of Liquor Amnii—Various—Does it contribute to Nourish- ment of Foetus?—The Placenta—Peculiar to the Mammiferous Class—How Divided, and Dimensions of—Two Circulations in Placenta—Distinct and Inde- - pendent—Red Corpuscles—Difference in Size of in Foetal and Maternal Blood— When does Placenta begin to Form ?—What is the Connexion between Placenta and Uterus ?—Do the Blood-vessels of the Mother penetrate the Placenta ?— Hunter's Opinion confirmed by Dr. Reid and Professor Goodsir—Professor Dalton, his Injection of the Utero-Placental Vessels by Air—Fatty Degeneration of the Placenta—Is it Normal or Pathological?—The Umbilical Cord; how Composed— Its Uses—Nomenclature of the Anatomist and Physiologist—Difference between— Variations in Volume and Length of the Cord—Twisting of the Cord around the Fcetus—Dr. Weidemann's Statistics of—Does the Cord possess any Trace of Nervous Tissue—Dr. Simpson on Contractility of the Cord—Scanzoni's Opinion— Vtrchow. Gextlemex—We shall to-day speak of the annexse, or appen- dages of the fcetus. These consist of the membranes, the liquor amnii, placenta, and umbilical cord. Each one of these appendages has its oAvn special duty to perform during the progress of the reproductive evolution ; Avhenthis latter is completed, their presence ceases to be necessary, and they are, therefore, expelled from the uterus at the time of childbirth. The membranes are three in num- ber: 1. The decidua, or caduca; 2. The chorion; 3. The amnion. These three membranes constitute so many concentric layers, and form the coque, or, if you please, the shell of the fcetus. The was still excoriation of the skin around the navel, but no division of the linea alba whatever, the continuity of the ring being perfect. The coverings of the hernia were composed of skin, fascia, and peritoneum. The tumor consisted of more than two- thirds of the uterus, the lower part lying within the grasp of the umbilicus. The patient being placed in the most favorable position for reduction, gentle manipulation was exercised, after which, to the astonishment of those present, the whole pro- truding organ was returned, with comparative facility, into the abdomen, the ring yielding equally all round to allow of the return of the hernial mass. No portion of intestine had protruded with the uterus. A bandage was applied to the seat of the hernia, which aeted well; the patient went on to the full time, and, after a favor able labor, gave birth to a healthy female child. 16 242 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mode of their origin, together with their particular uses, is not unworthy of attention. 1. Membrunu Ih vidua.—Until quite recently, it Avas very gene- rally conceded that the membrana decidua Avas produced in the manner originally explained by Dr. William Hunter. He main- tained that this membrane Avas a new formation, and resulted in the folloAving manner: At the time of fecundation, the internal sur- face of the uterus becomes the seat of increased vital action, which results in the exudation of coagulable lymph ; this coagulable lymph constitutes a closed sac, and is the veritable decidua, or, as it is sometimes called, caduca; this membrane Dr. Hunter termed the decidua A'era, in contradistinction to another fold, the decidua reflexa. This latter is produced, according to his theory, as fol- Ioavs : the caduca vera forming a closed sac, and occupying the entire cavity of the uterus, it follows that the three openings of the uterine cavity are completely occluded ; these three openings being the os tinea?, and the two superior and lateral angles, Avhich are • continuous Avith the tAvo fallopian tubes. Under this arrangement, it Avould become a necessary consequence that nothing could enter the cavity of the uterus, unless it either perforates or pushes before it this closed sac, or membrana vera. Hunter, therefore, attempted to show that, as the fecundated OA'ule is impelled by the fallopian tube toward one or other of the lateral and superior angles, as soon as it reaches this angle, it secures its entrance into the uterus by pushing before it a fold of the membrana vera, and it is this fold Avhich he has denominated the membrana reflexa. This Avas the exposition of Hunter ; and, as I have already remarked, until Avithin a very short time, it Avas the accepted theory. Such, hoAVCA'er, is the progress of mind, as is constantly deve- loped in the revelations of scientific research, that Avhat Avas formerly regarded as the true description of the decidua, is now found to be utterly at variance with facts. It has been satisfactorily demon- strated by Coste, Professors E. II. and Ed. Weber, Sharpey, and others,* that, so far from this membrane being the product of a neAv formation, it is simply the result of a modified or hypertrophied condition of the mucous lining of the uterus. They have shown that the decidua is not a closed sac, but is continuous with the mucous covering of the fallopian tubes ; and still more, that its structure is similar to that of the mucous membrane of the uterus itself, containing the same glands and the same layers; and, there- fore, Hunter's theory of the reflexa is as fallacious as is that of the original formation of the decidua vera itself. A very short time after fecundation, the tubular surface of the mucous membrane of the uterine cavity becomes thickened, and its * Midler's Elements of Physiology, pp. 1574-80. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 243 vascularity much increased. The entire internal surface of the organ is covered with a soft, pulpy tissue, in which may be observed numerous cellular elements. It is in this peculiar tissue that the ovum becomes imbedded; and it is this modified mucous lining, . which constitutes the decidua vera. Under the microscope, the mouths of the tubes can be distinctly recognised, as also their white epithelial lining. The follicles become much enlarged, and there is poured out from them into the cavity of the uterus a fluid, Avhich serves, as we shall afterward see, through the absorption of the villi of the chorion, for the nutrition of the embryo during the earlier periods of its existence, previous to the formation of the placenta. Decidua reflexa.—There has been much difference of opinion as to the mode of origin of the decidua reflexa. It is now admitted, as I have told you, that the explanation of Dr. William Hunter is not the correct one; and, perhaps, the views of Coste upon the subject are the most reliable of any that have been advanced within late years. According to him, as soon as the ovum enters the uterus, it becomes partially imbedded in the soft, pulpy mucous membrane, constituting the decidua; the particular portion of the decidua with Avhich the ovum thus comes in contact is immediately the seat of increased nutrition, which causes it to groAV or spring up around the ovum, not unlike the fleshy granulations, Avhich are observed to arise around the pea put into an issue for the purpose of increasing the purulent discharge. This increase of a small part of the decidua vera continues until the ovum is completely enve- loped by it; and this growth is Avhat Coste denominates the reflexa.* These tAvo layers of decidua, the vera and reflexa, approach nearer to each other as the ovum increases in deArelopment, so that, at about the end of the third month, there is absolute contact between them, forming but one membrane. At the time of partu- rition, the membrana decidua is expelled from the uterus, and hence its name. The blood-vessels of this membrane gradually cease to be supplied with blood, and, at the period of delivery, the quantity is so exceedingly slight, that no hemorrhage accompanies its expulsion. Uses of the Decidua.—There can be no doubt that the chief uses of the decidua are to provide, as it Avere, a bed for the ovum in the earlier periods of its development, and, through the nume- rous glands distributed on its surface, to afford the necessary nourishment previous to the organization of the placenta, which, we shall tell you, has no existence at the commencement of gestation. II. The Chorion.—It has just been shown that the membrana decidua is nothing more than a modification in structure of the mucous investment of the uterus, and, therefore, it is, strictly speak- * Comptes Rendus, 1817 244 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ing, furnished by the mother. The chorion, on the contrary, together Avith the amnion, appertains exclu>ively to the fietus, and, hence, these membranes are, with propriety, denominated its pro- • per tunics ; the chorion is the most external membrane of the ovum, and forms one of its constituents from the earliest appreciable moment of fecundation. It is a thin, transparent investment, not unlike a small hydatid ; it passes over the fcetal surface of the pla- centa, and also affords an external sheath to the umbilical cord. The chorion is intended to discharge, in the earlier periods of embryonic life, a most important and necessary oflice, Avhich is the nutritiou of the embryo itself; and, hence, for this purpose, one of the first changes it undergoes is the production over its cellular surface of villous prolongations, giving to it the peculiar shaggy appearance, Avhich forms, in the first periods of conception, one of its prominent characteristics. These villi constitute so many absorb- ing radicules, through Avhich the fluids furnished by the parent are conveyed from the decidua vera to the embryo, thus supplying the latter Avith the necessary elements of development; and this mode of nutrition continues, as I have told you, until the formation of the placenta. It has been demonstrated by Professor Goodsir, that each one of these villi or tufts is composed of numerous nucleated cells in differ- ent stages of development, inclosed Avithin a layer of basement membrane. At first, the chorion and villi bear no evidences of vascularity, being entirely composed of cells, covered on their external surface by a delicate structureless membrane; soon, how- ever, vessels, conducted by the allantois, give rise to vascular loops in these villi. On that portion of the chorion, from Avhich ema. nates the placenta, the villi increase very much in number, while on the other portion they preserve their original condi- tion. Each of these placental villi is supplied Avith a vascular loop, betAveen Avhich and the umbilical vessels there is a direct continuity ; and the blood of the foetus is forced through the ves- sels in the villi by the agency of the fcetal circulation. III. The Amnios.—This is the most internal membrane of the Fig. 44. ovum ; it is smooth and trans- The Amnios enclo.ing the Foetus. parent (Eig. 44), and is ill slight adhesion with the chorion, by means of the mucous filaments cover- ing its outer surface. The internal surface of the amnios is separated THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 245 from the foetus through the intervention of a fluid- -the liquor amnii—to the origin, and special uses of which we shall presently refer. Like the chorion, this membrane passes over the foetal por- tion of the placenta, and also aids in forming the sheath of the umbi- lical cord. Bag of Waters.—These tAvo membranes, together Avith the decidua, constitute the envelopes of the foetus during the term of gestation, and, at the time of parturition, they possess an import- ance Avell worthy the consideration of the accoucheur. For exam- ple, they, in conjunction Avith the liquor amnii, form what is knoAvn as the membranous sac, or, in more popular phraseology, the " bag of Avaters." This " bag of waters," as we shall have occasion to explain Avhen speaking of the phenomena of natural labor, dis- charges a very important office in the influence it contributes toward inducing a proper degree of dilatation of the mouth of the womb. As a general principle, it is not characterized by much poAver of resistance, and, consequently, becomes ruptured at the proper time by the simple contractile efforts of the uterus. But it will occasionally happen that, OAving to a greater degree of tenacity, it proves rebellious to every effort of the contracting Avomb, and the accoucheur is called upon to rupture it Avith his finger during a pain, and sometimes, indeed, it will be necessary to incise it, such being the nature of its resistance. The Liquor Amnii.—The origin of this fluid is a question, Avhich has called forth much difference of opinion. Some observers main- tain that it is the production of the foetus; others, that it is fur- nished by the mother; and, again, there are some Avho argue that it is the joint production of mother and child. It is admitted that the quantity of liquor amnii is relatively greater in the earlier months than at the latter periods of gestation ; and, in addition, it is Avell to remember that the general quantity of this fluid at the time of childbirth is subject to remarkable variations. Sometimes) after the rupture of the membranes, the escape of fluid will be so slight that this circumstance gives rise to what the old Avomen denominate a " dry labor;" at other times, there will pass from the uterus several quarts. In these latter cases, it will have been observed that the patient suffered during her gestation from more than ordinary distension of the abdominal Avails. This sudden gush of fluid has more than once struck terror into the young practi- tioner, causing him to mistake the discharge of the amniotic liquor for a case of fearful flooding; and, occasionally, under this delusion, inducing him to request a consultation, imagining the patient to be in imminent danger! With a moment's forethought, all embarrass- ment will at once cease, for it is only necessary to make a slight examination of the clothes to ascertain at once that the dischai o-e, in lieu of blood, is colorless. 24(3 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Source of tike Liquor Amnii.—The true source of the liquor amnii appears to be derived from the parent; and it is claimed to be nothing more than an exhalation, or, as Yelpeau terms it, a vital imbibition, requiring no special canals for its passage. This fluid is found, at times, mixed with meconium, and there is no doubt, that there is an excretion of urine from the fcetus commingling Avith the liquor amnii. Under the microscope, besides other materials, clear, transparent, elongated cylindrical bodies—the casts of the urini- ferous tubes of the kidney of the fcetus—have been distinctly recog- nised and the detection of these substances is very conclusive evidence that there is a mixture of the urinary secretion, and the amniotic liquor. Again: there are facts recorded upon perfectly reliable authority, in which the death of the foetus, Avhile in utero, Avas occasioned by rupture of the bladder from over distension, in consequence of an imperforation of the urethra, thus preventing the escape of the urine. According to Vogt, the liquor amnii contains common salt, lactate of soda, albumen, sulphate and phosphate of lime ; and even the presence of urea has been detected in it; Bernard has recently observed glucose in this fluid. Vogt has also shown that the ele- ments vary during the different periods of gestation ; for example, the chloride of sodium is in greater proportion during the first months, being the period Avhen cell-development and groAvth are more active. Whether the liquor amnii be engaged in affording nourishment to the embryo, Ave shall examine Avhen speaking of the nutrition of the fcetus. Uses of the Liquor Amnii.—The uses of this fluid are various: 1. During gestation, it serves to protect the foetus against the effects of any sudden concussion, AA'hich may befal the mother ; 2. It pre- vents the adhesion of those parts of the fcetus, which are intended to remain separate; 3. It affords facility for the fetal movements in utero; 4. It protects the umbilical cord from undue pressure, thus ensuring a free circulation of blood from the fcetus to the placenta; 5. At the time of labor, the liquor amnii performs the important double office of aiding materially, by its uniform and gentle pres- sure, in the dilatation of the mouth of the womb, and, after the rupture of the " bag of waters," it lubricates the vagina and vulva, thus facilitating the ultimate distension which they are so soon to undergo. Placenta.—The placenta, or after-birth, the latter name being given to it for the reason that, as a general rule, it is expelled from the uterus after the fcetus, is a flat, spongy mass, generally circular in shape, but sometimes assuming the oval form. It is the medium of communication betAveen the mother and child—its special office being to supply nourishment to the fcetus, during its intra-uterine existence. The placenta is peculiar to the mammiferous class, but in THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 247 these it presents much variation, both in its form and dimensions. In the ruminating animals, it assumes the appearance of small unequal masses, and is consequently multiple. In the mare, it exhibits a reddish, granular layer, Avhich is found to coA'er the entire surface of the chorion. We, however, are to examine it as it pre- sents itself in the human subject. The term placenta is derived from its supposed resemblance to a flattened cake—this name leav- ing been applied to it by Fallopius. It usually measures from six to eight inches in diameter, and, at its centre, is from one inch to one inch and a half in thickness, gradually becoming less so toward its border or circumference. But while these may be considered the standard measurements, it must be remembered that there are occasionally exceptions ; for example, the after-birth at full term Avill sometimes greatly exceed these dimensions, while again it will fall short of them. Jtirisions of the Placenta.—The placenta is divided into two surfaces—the fcetal and maternal. The fcetal surface (Fig. 45) is sometimes called the membranous, because the chorion and amnios both pass over it; it likeAvise has received the name of arbores- cent, for the reason that the distribution of the tAvo umbilical arte- ries, and one vein, give to it that peculiar appearance resembling the branches of a tree. This surface of the placenta is smooth, and, as it were, glistening. The maternal portion, sometimes denominated uterine, is in contact Avith the uterus; and, Avhile the integrity of the contact is preserved, this surface is also smooth, its lobes or cotyledons being more or less in close juxtaposition. But. if the after-birth be examined, subsequently to its detachment from the uterus, the maternal surface will exhibit an irregular, broken aspect, and distinct separations recognised among the various lobes composing it. (Fig. 46.) Blood-vessels of the Placenta.—Physiologically speaking, it may 24S THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be said that the placenta is divided into tAvo distinct portions; one appertaining to the fcetus, and the other to the mother ; for, as avc proceed further in the examination of this subject, it will be shown that there arc two distinct, independent circulations in the organ ; one on the fcetal surface, composed of the vessels in the umbilical cord; the other, on the maternal surface, composed of the utero' placental vessels. BetAveen these two orders of vessels there exists no continuity of canal, and, therefore, the tAvo circulations are independent of each other. I think there is no fact better esta- blished than this absence of continuity of vascular connexion betAveen the parent and fcetus. A contrary opinion has been attempted to be proved by the result of injections thrown into the vessels of" the umbilical cord, and Avhich have been alleged to pass directly into the blood-vessels on the maternal surface of the placenta; but on a close analysis of these experiments, it has been most satisfactorily sIioavii that, in every case in Avhich the injection has been recog- nised in the vessels of the mother, it Avas through simple extrava- sation. An additional proof, if one be necessary, is furnished by the fact of the marked difference in the size and relative number of the red corpuscles, and, also, in the amount of fibrin and albu- men, as found in the blood of the parent and fcetus. These circumstances, noAV accepted as Avell-demonstrated facts, surely prove the Avant of continuity between the vessels on the maternal and foetal surfaces of the placenta; and the fact, thus established, involves an important consideration connected with the passage of blood from the system of the mother to the foetus, to Avhich your attention will be directed under the head of the foetal circulation. Flourens and others, it may here be stated, have recently shoAvn that if madder be given to a pregnant animal, the bones of the foetuses become colored by it as much, if not more, than those of the mother, thus proving the permeability of the maternal and fcetal blood-vessels in the placenta. It is not until the second month that the formation of the pla- centa commences. Although the circulations on the foetal and maternal surfaces of this bod)' are not carried on through continuity of canal, yet it must be borne in mind that these two portions of the ovum are mingled, the one Avith the other, in close alliance throughout their whole substance ; and, in this respect, the human after-birth differs essentially from the placenta of some of the lower classes of ani- mals, in which the uterine or maternal portion consists of the hypertrophied decidua, Avhile the foetal surface is composed of the vascular tufts of the chorion, Avhich, as it were, are found to dip doAA'n into the thickened decidua. So that, in this latter case, there is no difficulty in separating these tAvo portions of the organ. Fcetcd and Uterine Surfaces of the Placenta.—According to the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 249 most recent observations, the following appears to be the mode of origin of the foetal surface of the placenta: The villous tufts, which spring from the chorion, and to Avhich allusion has already been made Avhen speaking of this latter em-elope, are composed, accord- ing to Prof. Goodsir, of numerous nucleated cells. There is observed at the terminal extremity of each of these villi, a sort of bulbous expansion, and, through the development of additional cells, the villi become elongated, and dipping down into the decidua, absorb from it nourishment, Avhich is carried to the germ, this is what occurs in the earlier stages of fcetal development, for, at this time, as the villi contain no vessels, the nourishment is derived simply through the process of" absorption. But soon the villous tufts are supplied with a vascular apparatus; each villus is furnished with one or more capillary loops, which communicate Avith an artery on one side, and a vein on the other. In this Avay, through the increase and extension of the vascular villi of the cho- rion, the foetal portion of the placenta is formed ; while the maternal or uterine originates from the enlargement of the vessels in the hy- pertrophied decidua, betAveen which, as has already been remarked, these villi dip down. Prof. Goodsir says, " these vessels assume the character of sinuses; and at last SAvell out (so to speak) around and between the villi; so that, finally, the villi are completely bound up or covered by the membrane, Avhich constitutes the walls of the vessels, the membrane folloAving the contour of all the villi, and ■ even passing, to a certain extent, over the branches and stems of the tufts. BetAveen the membrane or Avail of the large decidual vessels, and the internal membrane of the villi, there still remains a layer of the cells of the decidua.1'* This, then, appears to be briefly the mode of origin of the maternal portion of the placenta. But a very natural question hoav arises—hoAV is the blood con- veyed from the system of the parent to the uterine surface of the after-birth, and Avhat is the particular mode of union bStAveen this latter and the uterus itself? It is brought through Avhat are termed the curling arteries of the uterus, and deposited into the placental cavity, and it is afterward returned through the large veins, gene- • rally called the sinuses.f * Anatomical and Pathological Observations, p. 60. f It has been, for a long time, a controverted point, as to the particular mode of connexion which exists between the internal surface of the uterus and the mater- nal portion of the placenta. It is quite evident, however, that the original opinion of Dr. William Hunter has been fully demonstrated by the experiments of Dr. Reed and Prof. Goodsir. Hunter maintained that the blood-vessels of the uterus passed into the substance of the placenta, and formed a portion of its mass; but repeated attempts have been made to show that his opinion was erroneous, founded, as it was. upon the injections, which were made to pass from the uterine vessels into the maternal portion of the placenta—it being alleged that these injections reached the placental mass, not through continuity of vessels, but because of extra- 250 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Thus, gentlemen, you have seen that the placenta not only pre- sents tAvo surfaces—one belonging to the fcetus, and the other to the mother—but you have also observed that these two surfaces pos- sess two circulations, distinct and independent; the one carried on by the two arteries and one vein of the umbilical cord, the other by the maternal arteries and veins, sometimes designated the utero- placental vessels. Under this arrangement, the fcetus derives from the placenta the elaborated blood necessary for its nourishment and growth in the manner avc shall presently explain. Fatty Degeneration of the Placenta.—It is worthy of note that, as pregnancy draAvs tOAvard its close, the placenta becomes more hard, and its capillary vessels undergo a peculiar alteration, Avhich consists in the appearance of numerous oil globules in the coats of the vessels, constituting Avhat is termed fatty degeneration of the fcetal tufts. This change in the physical condition of the placenta, has been regarded as an evidence of diseased structure ; but recent observation proves that, in the great majority of cases, this fatty substitution occurs in the placenta as one of the phases through Avhich it finally passes. Dr. Druit and others have called special attention to this subject. Sound pathology has unquestionably demonstrated that fatty degeneration is oftentimes the result of morbid action; but it must also be recollected, that it constitutes one of the peculiar processes to Avhich tissues are subjected, after their functional activity is at an end, and prior to their absorp- tion. This is well illustrated in the case of the muscular fibre-cells of the impregnated uterus, when the organ, having accomplished the purpose for Avhich it underAvent increase, is about to return to its original size. Dr. Barnes, of London, has recently given the profession tAvo extremely interesting papers on the subject of fatty degenera- tion of the placenta, in connexion with the pathological changes to which this mass is liable ; and he has pointed out very cleverly the relation between this metamorphosis of the placenta and abor- tion.* Umbilical Cord.—The cord is the direct channel of communica- tion between the after-birth and fcetus. One of the extremities is attached to the placenta, Avhile the other is in connexion with the umbilicus of the child. It is composed of three vessels, tAvo arte- ries, and one vein—the arteries are branches of the hypogastric or internal iliacs, and bring the impure blood from the fcetus to the placenta; the vein originates in the foetal portion of the placenta, vasation. Recently, Prof. Dalton, in an interesting paper read before the New York Academy of Medicine, fully confirms the views of Hunter, by means of air thrown from the divided vessels of the muscular walls of the uterus into the placenta itself. See Anatomy of the Placenta, by Jno. C. Dalton, M.D. * Medico-Chirurgical Transactions, vols. 34-36. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 251 and conveys arterial blood from this organ to the system of the foetus. The student is sometimes apt to become confused when told that the vein contains arterial blood, and the arteries are the chan- nels through Avhich is conveyed the impure or venous blood. But, it must be remembered that the nomenclature of the anatomist is not the nomenclature of the physiologist. The former designates every vessel an artery, without regard to its office or function, which proceeds from the heart toward a given point, and applies, in the same way, the term vein to every vessel whose direction is toward the heart. The physiologist, on the contrary, considers an artery a A'essel for the transmission of arterial blood ; and a vein, the channel through which passes impure or venous blood. As the science of anatomy is much more ancient jthan that of physiology, and, as its nomenclature consequently enjoys the precedence, it is right that the distinction, to which we have just alluded, should not be forgotten. In addition to its three blood-vessels, the umbilical cord has a sheath composed of reflections from the amnion and chorion, and a pulpy gelatinous material, knoAvn as the gelatine of Wharton. As a general rule, the volume of the cord equals in thickness that of the small finger; but, sometimes, it will be much greater, and, again, it will be less than this size. When the A'olume is increased, it is usually due to an infiltration of fluid, and by no increase of size in the vessels themselves, although this latter circumstance has occasionally been observed. On the contrary, Avhen the cord is very small or slender, it is because of the entire absence of this infiltration. The ordinary length of the umbilical cord is from fifteen to tAventy inches, Avhich is about the average length of the foetus at full term. But there are occasional exceptions. For example, cases are recorded in Avhich it exceeded in length five feet, and again it has measured not more than from four to six inches. In the former instance, although the length of the cord is actually far in excess of the normal or average standard, yet it may become comparatively shorter in con- sequence of being coiled around some portion of the fcetus.* In * According to Dr. Weidemann, the funis was found twisted around the child 3379 times in 28,430 deliveries. In these 3379 instances, it was coiled around the neck 3230 times, and 149 times around other portions of the body. In the 3270 cases, 254G consisted of a simple coil, while in 681 instances, there were several coils. As regards the causes of the coiling of the funis, it is related that in 1788 cases, occurring at the Marburg Midwifery Institution, the cord was, in 80 instances, less than 15 inches in length, and in 183 over 25 inches; in 54 cases, the liquor amnii was small in quantity; in 41 it was copious. In 165 the child weighed less than live pounds, and in 28 it exceeded eight pounds. Therefore, it is deduced, that among the causes tending to the occurrence may be mentioned a long funis, abun- dance of liquor amnii, add a small child. Among 2930 children born at Marburg, 132 were dead, and 251 were still-born. 252 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the latter case, in consequence of the extreme congenital shortness of the umbilical cord, there will be more or less hazard of its sudden rupture during the throes of labor in some portion of its extent, m of its being torn from the umbilicus, giving rise to serious, if not fatal, hemorrhage. If neither of these accidents should occur, there would still be danger of suddenly detaching the placenta from the uterus, or, if the adhesion be strong enough to resist the traction, the next evil in the order of sequence would possibly be inversion, or turning inside out of the uterus itself, a contingency full of dan- ger to the mother, as will be explained Avhen treating more par- ticularly of this form of uterine difficulty. You will sometimes recognise knotted cords, that is, there Avill be observed in the extqpt of the funis one or several knots, and these are more particularly noticed in cases in which the cord Fig. 47. exceeds its ordinary length. (Fig. 47.) It is supposed that this latter circumstance, together Avith the movements of the foetus, predisposes to the formation of these knots. I have several times Of 72.j born with coiled funis, 45 were dead, and 72 still-born. Among the 45 dead-born, in the 725 examples of coiling, in 18 only could the death be referred to this latter circumstance alone. From results derived from the Midwifery Institutions at Dresden, Cottingen, Wurzburg, Berlin, and Marburg, it appears that of 13,7*20 new-born infants, 902 were born dead; while in 1217 instances of coiling of the funis, 31 children were born dead, whose death could be ascribed to that circumstance, giving a proportion of 139 to the codings, and D19 to the number born dead. Thus, as the sixteenth child among new-born children, in general, as well as among those in which the cord is found twisted, is born dead; as the twelfth child among the new-born, in general, and the tenth among those around which the funis is coiled, is still-born; and, as in one chii'i vn forty only can this coiling be regarded as really the cause of death, it follows that this iccident is»ot entitled to prominent consideration. [Monatsschrifl fur Geburtskunde.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 253 met with them, but in no instance have I knoAvn them to interrupt the circulation betAA'een the mother and child. The placental extremity of the funis is usually attached to the central portion of the after-birth, although occasionally it will be found inserted near the edge or border of the organ. Cases are recorded in which it is alleged that the foetal extremity of the cord, in lieu of entering the umbilicus of the child, was observed attached to the limbs, head, etc. But these instances do not come to us with the seal of good faith, and I should be strongly induced to doubt the statement unless in cases of extraordinary monstrosities. Is there Nervous Tissue in the Cord?—Does the umbilical cord possess any vestige of nervous tissue ? This is an extremely inte- resting question from the fact that it is now Avell known that both the vein and arteries, composing the cord, are capable of contrac- tion. An interesting paper on this subject, demonstrating that these vessels are really imbued with contractile power, Avas pub- lished some time since* by Prof. Simpson. In that paper, he does not admit the presence of nerves in the funis, but contents himself Avith the bare hypothesis that elementary nervous tissue may in some form exist in it. Scanzoni f says, " Isolated nerve branches from the plexus hepaticus for the vein, and from the plexus hypo- gastricns for the arteries, are described by Schott and Valentin, and, according to the latter observer, they extend three or four inches from the umbilicus, as is revealed by the microscope." VirchoAV, hoAvever, does not admit these views, because he has never suc- ceeded in detecting nerves in the umbilical cord at any period of its development. * Edinburgh Jour, of Med. Science, May, 1851, p. 494. f Lehrbuch der Geburtshilfe, p. 104. LECTURE XVIII. Nutrition, a fundamental law of life—Objects of Nutrition; Growth and Develop- ment__Development physiologically considered—Nutrition of Embryo; various Opinions concerning—Yolk Nutrition—Nutrition through Villous Tufts—Liquor Amnii; has it nutrient properties ?—Does it enter the System of the Fcetus by Cutaneous Absorption or Deglutition?—The Placenta and Foetal Circulation— Adult Circulation; how it differs from that of the Fcetus—How is the Impure Blood, returned by the Umbilical Arteries, decarbonized in the Placenta ?—Endos- mose Action—Albumen cannot pass by Endosmosis; Opinion of Mialhe—Albu- minose—Influence of Parent upon Progeny—Transmission of Hereditary Disease— Change in the Circulation as soon as Respiration is established—Puer Cseruleus— Does the Fcetus Breathe in Utero?—Intra-uterine Respiration not Essential to Development or Life of Fcetus. Gentle^lex—Nutrition, whether in the vegetable or animal king- dom, is one of the absolute and fundamental necessities of life ; to pursue the topic of development, through the process of nutrition, in the various conditions and phases of animated nature, would prove, if not foreign to the purpose of these lectures, a most interesting inquiry. Such a discussion, however, \Arould divert us from our present object, and Ave shall speak, therefore, simply of the arrangements instituted by nature for the nourishment of the human embryo, from the earliest moments of fecundation until the final accomplishment of intra-uterine existence. The Objects of Nutrition.—Nutrition has no single purpose; you are not to suppose that it is for the promotion of mere growth. If this were so, the result would be simply an aggregation of the primordial elements, Avithout form or symmetry—the archi- tecture of the system would be defective—that beautiful and perfect mechanism, composed, as it is, of multiplied tissues and organs, would fail to exist, and in lieu of all this there would be substituted a sort of anomalous mass, Avithout order or arrangement. You see, therefore, that, besides growth, nutrition, in order that the great object of nature may be carried out, must subserve another most important purpose, viz. development. Development, in a physio- logical sense, may be said to be the proper adjustment or distribu- tion of growth matter for the formation of the A'arious tissues and organs of the economy; so that, when growth and development have completed the structure of the various parts of the human system, it may then be said that nutrition has efficiently performed a portion of its Avork. It, hoAA'ever, has something more to do. • THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 255 The human system, like all living things, is constantly undergoing change—every hour that Ave live there is waste of structure—this waste, if not supplied by new matter—which can only be done through nutrition, will lead to disintegration and decay. In a Avord, it may be affirmed, that the object of nutrition is three-fold: 1. Growth; 2. Development; 3. Repair of waste. Beginning Avith the simple cell, the original nucleus, if I may so term it, of the embryo, Ave perceive, through the successive stages of groAvth and development, the transmutation of that compara- tively insignificant cell into a type of the most perfect organization, as is disclosed in the mechanism of man ! The subject of embryonic nutrition has called forth many con- flicting opinions; and even in our own day, Avith all the lights which science has furnished, there still exists more or less dis- crepancy among observers. There is one fact, hoAvever, not only full of interest, but well worthy of observation, and it is this—that, throughout the whole life of man, there is no period in which nutrition results in such rapid growth and development as during intra-uterine existence; and this is still more marked in the first half of foetal life. But Avhen nature is unchecked in her operations, this rapid development interferes in no Avay with the perfection of the work in Avhich she is engaged. In the brief period of nine months, the small cell, through successive increase and develop- ment, is converted into the full-groAvn fcetus. What an extraordi- nary achievement, and Iioav demonstrative of the power of Him, to Avhosc infinite wisdom all things earthly are due! Modes of Nutrition.—In order to present the subject of fcetal nutrition in the simplest possible form, and to convey to you Avhat I believe to be the accepted opinions, at the present day, on this subject, I shall briefly consider the ovum in three different aspects: 1. From the moment of fecundation until its arrival Avithin the uterus; 2. From its entrance into the uterus, until the formation of the placenta ; 3. From this latter period, until the completion of the ordinary term of utero-gestation. These, then, a're three dis- tinct periods of development, each one requiring a supply of elements necessary for the nourishment and growth of the neAV being. From the period that the fecundated ovule becomes detached from the ovarian vesicle, until its entrance into the uterine cavity, it may be said to be dependent upon Avhat is knoA\-n as yolk nour- ishment. But this particular species of nourishment soon becomes exhausted in the case of the human embryo, so that when the latter is lodged Avithin the cavity of the uterus, a fresh source is found necessary, Avhich is promptly provided, through the absorption of juices from the decidua by means of the villous tufts on the exte- rior of the chorion, to which allusion has already been made. This 256 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tuft nutrition is in more or less actiA'e exercise until the second month, when a new arrangement is made through the vascular connexions, which subsist betAveen the embryo and uterus, as a consequence of the formation of the placenta and umbilical cord. Does the Liquor Amnii contain Nutrient Properties?—A very ancient doctrine touching the nutrition of the foetus, and main- tained with much zeal, referred the source of nourishment to the liquor amnii; the advocates of this opinion Avere divided into two sects, as to the mode in which the amniotic fluid entered the system of the foetus, Avith the view of affording it the necessary nourish- ment. One declaring that it was through cutaneous absorption, the other through the act of deglutition. It is not improbable that the liquor amnii does in reality contribute a share, during the earlier periods of embryonic existence, to its nourishment ; for it is AA'ell ascertained that it contains nutritious elements, such as albu- men, salts, etc. Nor is it beyond possibility that some portion of the amniotic fluid may be sAvallowed by the foetus. On the other hand, there are well-authenticated instances in Avhich this fluid has been recognised in the stomach and intestines, in cases of acepha- lous children ; and also AA'here there existed, from malformation, no communication between the oesophagus and stomach. These latter facts, it has been alleged, strengthen the hypothesis of cutaneous absorption. But it is quite evident that the cutaneous absorption of the liquor amnii cannot be sustained by any such testimony. In the first place, even in acephalous children, the amniotic fluid may reach the stomach through the oesophagus; and, secondly, in cases in Avhich there is an occlusion of this tube, the liquid found in the stomach cannot be the amniotic, for the important reason that, if it be absorbed by the skin, it will commingle Avith the blood, and not be taken to the stomach. Whatever influence may be exercised by the liquor amnii in affording nourishment to the embryo, it must be admitted that this influence is confined to the earlier periods of embryonic life; for, as soon as the placenta is formed, all the wants of the fcetus, as Ave shall see, are abundantly provided for through this vascular con- nexion. Nutrition by the Placenta.—The placenta, as you knoAV, is com- posed of a maternal and foetal portion, each of these surfaces having its own particular order of vessels, through Avhich a distinct circu- lation is carried on. The utero-placental vessels are engaged in the distribution of blood on the former, while the circulation on the latter is conducted by the vessels of the cord, viz., the two umbilical arteries and one umbilical vein. The blood is brought from the system of the parent, and circulated through the maternal or uterine surface of the placenta by the utero-placental arteries—it is conveyed back to the system of the mother by the utero-placental THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 257 veins. Prof. Goodsir has shoAvn, as already stated, that the uterine arteries proceed from the walls of the uterus through the hyper- trophied decidua; and, during their progress through this layer of membrane, they take a sort of tortuous or serpentine direction, and hence they have been denominated the " curling arteries " of the uterus. These arteries convey the blood from the system of the mother into the cavernous structure of the placenta, and the blood is again returned to the general maternal circulation through the large veins, which have received the name of sinuses. Thus, you perceive, nature has abundantly provided the maternal surface of the placenta with blood from the system of the parent; but, as yet, you do not understand, in the absence of all continuity of canal betAveen the two orders of vessels on the fcetal and uterine portions of the after-birth, in what way the foetus is benefited by this supply of blood, or, in other Avords, how it finds passage to the foetal system for the purpose of providing it Avith necessary nourish- ment. This, hoAvcA'er, it will be our purpose to elucidate before we complete the present lecture. Adult and Fueted Circulation.—AHoav me noAv to call your attention to the fcetal circulation. This circulation is marked by certain characteristic differences, which are not found in the case of the child or adult; and these differences are OAving to the im- portant fact, that, in the fcetus, existence is a dependent one—it has no poAver of elaborating the blood essential for its maintenance— this is done by its parent. On the contrary, in the healthy, Avell- organized child, and in the adult, Avhere life is independent, and the individual elaborates its oAvn blood, there is a peculiar arrangement in the mechanism of the vascular and pulmonary systems adapted to this condition of life. You will, perhaps, have a more accurate idea of Avhat I mean by a brief contrast betAveen the circulatory apparatus as it obtains in the adult and fcetus. In both, there is a great central organ—the heart; and in both, also, there are tAvo orders of vessels, viz. arte- ries and veins. In the adult heart there are four cavities, tAvo on the right side, and tAvo on the left. On the right side there are an auricle and ventricle, Avhich communicate Avith each other, and which are intended for the reception of venous blood ; and on the left side there are also an auricle and ventricle, communicating Avith each other, and containing arterial blood. These four cavities com- municate Avith each other only through the auriculo-ventricular openings. Noav, then, let us turn, for the instant, to the arrangement in the fcetal heart. Here, as in the adult, there are four cavities : tAvo on the right and tAvo on the left, communicating, as in the case of the adult, by means of the auriculo-ventricular openings. But, in addition, in the foetal heart, the right auricle communicates Avith 17 258 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the left auricle, through a small opening known as the foramen ovale. The only difference, then, in the arrangement of the heart proper, as it presents itself in the adult and fcetus is, that, besides the auriculo-ventricular openings, there is in the fcetus the foramen ovale, Avhich is the point of communication between the right and left auricle. In the adult, the folloAving is the route of the circulation—the veins return from the upper and lower extremities the blood which has been distributed throughout the system for the purpose of nourishment, but which, in its round of circulation, has become less charged Avith oxygen, and contains more carbonic acid, and, therefore, is in need of renovation. The veins, I say, return this blood from the upper extremities to the descending vena cava, and from the lower to the ascending vena cava—these two vessels, the descending and ascending cava1, empty their contents into the right auricle of the heart; thence it passes, through the auriculo-ven- tricular opening, into the right ventricle; from the right ventricle, it is conveyed by the pulmonary artery, Avhich bifurcates into a right and left branch, into the lungs; and here, in consequence of the absorption of oxygen and the exhalation of carbonic acid, the venous blood is converted into arterial, Avhich is conveyed through the pulmonary veins to the left ventricle ; from the latter, it passes into the aorta, through the ramifications of Avhich it is conducted to every portion of the economy, imparting sustenance to each tissue and organ.* As soon as it has completed its circuit, it again requires renovation, and for this purpose is returned to the lungs— and so the Avork of elaboration continues, in more or less perfection, from the first moment of independent existence until the final close of life. This, gentlemen, is briefly the circulation in the adult or the child, AA'hose life is independent of its mother. Let us noAv folloAV the course of the blood in the system of the fcetus. Besides the peculiarities already pointed out in the circula- tory apparatus of the latter, there is the ductus arteriosus, Avhich appears to be nothing more than an extension of the pulmonary artery, and Avhich conveys all the blood, except the small quantity going to the lungs, from the right ventricle to the arch of the aorta. Then, there are the umbilical vein, and two umbilical arteries. The blood is conveyed from the placenta to the fcetus in the fol- loAving manner : The arterial or elaborated blood is carried by the umbilical vein, which enters the system of the fcetus at the umbili- * Respiration consists essentially in the absorption of oxygen and the exhalation of carbonic acid; but this latter is not formed, as was once supposed, by the com- bination of carbon and oxygen in the lungs; a small amount of carbonic acid is pro- duced in the lungs by the decomposition of carbonates, but its chief formation takes place in the tissues—the muscles, nerve-centres, etc. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 259 cus. When this vein penetrates the umbilical opening, its course is at first from before backward, then from below upward, and from left to right. As soon as it reaches the inferior portion of the liver, it gives off a branch which distributes blood to the right lobe of this viscus ; this same blood is afterwards conveyed through the hepatic vein, and deposited in the ascending vena cava. In order that you may not be led into error, and with the view of avoiding all confusion, I beg you to remember that the instant the umbilical vein sends off the branch to the liver, it takes the name of ductus venosus. This latter vessel, then, is nothing more than the original umbilical vein, the name being changed as soon as it has parted with the branch, whose duty it is to carry blood to the right lobe of the liver. The ductus venosus throws its contents into the ascending vena cava; and you must bear in mind that the blood thus deposited in the ascending cava comes directly from the pla- centa, and is therefore pure, fitted to the nutrition of the foetus. I have just mentioned that the hepatic vein also deposits its contents in the ascending cava. Hence, then, there are three columns of blood all commingling Avith each other: 1. The blood, which is derived through the ductus venosus directly from the placenta, and which is pure ; 2. The blood, which has circulated through the liver, and Avhich is returned to the cava by the hepatic vein ; 3. The blood Avhich is brought from the lower extremities, and ultimately deposited in the ascending cava; the latter column of blood is of course less pure than the other tAvo, for the reason that it has already been distributed to the lower extremities. Well, this volume of blood, derived as you have just £een from three different sources, is conveyed by the ascending \'ena cava into the right auricle of the heart. But the upper portion of the cava, as it enters the auricle, is, through the arrangement of the Eustachian valve, rendered almost continuous Avith the foramen ovale, so that the blood it conveys into the right auricle, instead of mingling Avith that brought by the descending cava into the same chamber of the heart, passes almost entirely through the foramen ovale into the left auricle. Thence, through the auriculo- vcntrh ular opening, it is conveyed to the left ventricle, and from this cavity it passes, through the aorta and its branches, to the head and upper extremities. The branches to Avhich I allude, originate at the arch of the aorta, and are the brachio-cephalic trunk, or arteria innominata, the left primitive carotid, and left subclavian. The blood, after being distributed through these channels to the upper parts of the body, suffers a diminution in its nutritive pro- perties, and, therefore, needs elaboration; hence, it is returned by the jugular and axillary veins to the subclavians, Avhich, together with the azygos vein, empty their contents into the descending vena eaA-a—this latter conveys it into the right auricle, from Avhich, 260 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. through the auriculo-ventricular opening, it passes into the right ventricle, and from this latter cavity it enters the pulmonary artery. The pulmonary artery conveys to the lungs, during fcetal life, but a very small quantity of blood, only sufficient to supply them with nutriment, for the reason that they have no power of elaborating this fluid, as is the case in the lungs of the adult. Some provision, therefore, is needed by which the surplus blood from the right ventricle may be disposed of; for this purpose there is the ductus arteriosus, whose office it is to convey all the blood from the right ventricle, not passing to the lungs, to the arch of the aorta. This latter blood is then transmitted through the descend- ing aorta, and, with the exception of the portion of it which is distributed by the external iliacs and their branches to the loAA'er extremities, is conveyed through the two umbilical arteries to the placenta, for the purpose of undergoing fresh renovation. The two umbilical vessels, you will not forget, are formed by the internal iliac or hypogastric arteries. Before calling your attention to the special arrangement in the placenta for the elaboration of the blood, returned to it by the umbilical arteries, I wish, for the moment, to allude briefly to one or tAvo points connected with the route of the circulation in the foetus. You cannot have failed to notice, in the distribution of blood through the system of the latter, the important fact that, to a certain extent, the head and upper extremities are supplied with purer blood than the lower portions of the body. The head and superior extremities do in reality receive blood almost as pure as that Avhich comes directly from the placenta, and for the reason that their development is required to be in advance of that of the lower portions of the system. For example, a part of the blood Avhich is derived directly from the placenta passes through the ductus venosus into the ascending cava, thence into the right auricle, and through the foramen ovale into the left auricle—from this latter chamber it is sent to the left ventricle; from the left ventricle it is conveyed through the arterial branches given off at the arch of the aorta to the head and superior extremities. But you are to bear in mind that, as the blood passes from the left ventricle into the aorta, a small portion of it must, of necessity, descend and thus commingle with blood emptied into this channel by the ductus arteriosus, and Avhich you will recollect is brought there from the right ventricle, after it has been returned from the upper portions of the body. The blood thus conveyed from the right ventricle, through the ductus arteriosus, to the arch of the aorta, has, through its circuit, lost more or less of its nutrient elements; but yet, you perceive, it receives a small supply of pure blood from the left ventricle in the descending aorta—and therefore although it is true that the blood which circulates through the head THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 261 and upper extremities is purer, because a portion of it comes directly from the placenta, yet it must be recollected that the lower part of the body is not exclusively dependent for its supply upon the blood from the right ventricle—and Avhich has already partly exhausted itself in its circulation to the head, etc.—but it also receives a column of pure blood from the left ventricle as it passes to the aorta. Elaboration of the Blood in the Placenta.—Next let us examine Iioav it is that the impure blood, Avhich is returned from the system of the fcetus to the placenta through the umbilical arteries, receives a fresh supply of nutritious matter; or, in other Avords, how it is that its decarbonization is accomplished. One of the theories brought forth to elucidate this question Avas based on the supposi- tion, that the blood-vessels on the foetal and maternal surfaces of the placenta were continuous Avith each other ; and, on this assumption, it Avas maintained that the impure blood Avas conveyed directly from the foetus to the system of the mother—thence to the mater- nal lungs, from which, after having lost its carbonic acid and receiving oxygen, it Avas returned to the placenta, Avhence, through the umbilical vein, it again made its circuit in the system of the foetus. The deductions from this theory are utterly fallacious, for the assumption on Avhich it is predicated, as I have already pointed out, is Avithout foundation. The vessels of the foetal and maternal surfaces of the placenta do not communicate Avith each other—^they are distinct and independent, and so are their circulations. How, then, you may very legitimately inquire, if the blood from the foetus be not returned to the circulation of the mother, does it become purified ? The answer to this question is quite easy, and it may be regarded as one among the accepted truths of physiology. During intra-uterine existence, the aeration or decarbonization of the blood is accomplished altogether in the placenta; and this organ may, in strict physiological meaning, be denominated the lungs of the foetus* The folloAving is the process of elaboration. The impure blood, as you are aAvare, is brought from the system of the fcetus to the placenta, through the umbilical arteries; these arteries ramify, and communicate by continuity of canal Avith the radicules of the umbilical vein on the foetal surface of the placenta; although there is no direct communication betAveen the vessels respectively, on the two placental surfaces, yet there is a con- tiguity ; and, in fact, these vessels may be said to be, as it Avere, in juxtaposition, so that the impure blood in the umbilical arteries becomes liberated of its carbonic acid, and is supplied Avith oxygen from the blood of the mother by an endosmotic action—that is, the * As regards the functions of the placenta, it must be remembered that this body is, at the same time, tho representative of the digestive and respiratory organs of the adult. 262 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. oxygen percolating the AA-alls of the canals, displaces the carbonic acid which passes into the maternal system through the same kind of endosmotic process; thus, you perceive, one of the first results produced upon the blood of the fcetus is to afford an escape of its deleterious element, the carbon, Avhich, in the form of carbonic acid, passes into the vessels of the mother, Avhich it can do with impunity to her health. The parent, hoAvever, is not content with receiving into her oAvn system this element, no longer fitted to sojourn in that of her offspring; she does more—she transmits, through the same process of percolation, from her own blood, an element necessary for the continued sustenance of the foetus. What is this element ? Some say that it is albumen, Avhich is knoAvn to be essential to foetal nutrition. But Mialhe has shown that pure albumen cannot pass through membranes, and he has developed the interesting fact, that it is a substance, called albuminose, Avhich has the power of per- colating membranous tissues ; it is this substance which passes from the blood of the mother to the fcetus, and from Avhich the latter derives its nourishment. Robin and Verdeil have demonstrated that Avhat Avas supposed by Guillot, Le Blanc, and others, to be casein in the blood of pregnant women and nurses, is essentially albuminose, Avhich, after all, is strikingly similar to casein and kiesteine. As soon as these changes have been effected in the blood brought to the placenta by the umbilical arteries, the elaborated fluid is. immediately taken up by the radicules of the umbilical vein, and again conveyed to the system of the foetus, and there distributed in the manner already indicated. In this simple but efficient Avay has nature provided, by the constant escape of deleterious, and the constant addition of nutritious matter, for the groAvth and develop- ment of the foetus. In addition to the office Avhich the placenta performs toward the foetus, of giving albuminose in exchange for carbonic acid, it is supposed, by some observers—and the hypothesis is not without a degree of probability—that it also discharges, to a certain extent, the duty of an excreting organ, by removing, through the maternal blood, excrementitious material, which, if permitted to remain in the system of the foetus, Avould prove destructive to its existence.* With this supposition, it is easy to comprehend how the system of the mother may become contami- nated by disease derived from her husband; and how, also, this * Bernard has recently attempted to show, that there exists, in the placenta of the mammiferous class, a peculiar function, which heretofore has been unknown, and which appears to supply the glycogenic action of the liver during the earlier periods of embryonic existence. Indeed, he and Ch. Rouget have demonstrated that a gly- cogenic matter exists not only in the placenta and amnion, but also in all tlie new cells in the various tissues of the embryo, especially in the epithelial cells. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 263 disease may be transmitted to offspring begotten by a different father.* Transmission of Disease.—The transmission of disease, from parent to offspring, presents a most interesting subject of inquiry to the practitioner of medicine. That this hereditary transmission is more or less constantly taking place, is a fact, unhappily, too well established, and it constitutes a veritable blight upon the race. Scrofula, syphilis, phthisis, carcinoma, etc., all of which I hold to be constitutional taints, may be transmitted either by the mother or father; and this will, of course, depend upon Avhether the former or latter be affected with the malady thus transmitted. For exam- ple, a scrofulous mother Avill pass the disease to her child, through the ovule which she furnishes—that very ovule being a part of her system—containing either the elements of health or disease, just precisely as the case may be. Again: all the soluble elements in the blood of the mother—salts, fibrin, etc.—pass freely into the blood of the fcetus. Suppose, again, the mother be free from all taints of scrofula, syphilis, etc., yet, under these circumstances, either of these affections may be propngated by the father, should he have the misfortune to labor under the affliction of either of them, or of any other constitutional malady capable of transmission ; and it is propagated through the spermatozoa, Avhich he emits during sexual intercourse, and Avhich, as you knoAV, are the true essential fecundating elements of the spermatic fluid, f From what has been said of the placental circulation, it must be evident to you that when the blood of the pregnant female is im- * Attention has lately been directed to a very curious class of phenomena, which show, that where the mother has previously borne offspring, the influence of the father may be impressed on her progeny afterward begotten by a different parent; as in the well-known case of the transmission of quagga marks to a succession of colts, both of whose parents were of the species horse, the mare having been once impregnated by a quagga male; and in the not unfrequent occurrence of a similar phenomenon in the human species, as when a widow who marries a second time, bears children strongly resembling her first husband. Some of these cases appear referable to the strong mental impression left by the first male parent upon the female: but there are others, which seem to render it more likely, that the blood of the female has imbibed from that of the fcetus, through the placental circulation, some of the attributes which the latter has derived from its male parent; and that tho female may communicate these, with those proper to herself, to the subsequent offspring of a different male parentage. This idea is borne out by a great number of important facts; and it serves to explain the circumstance well known to practi. tioners, that secondary syphilis will often appear in a female during gestation or after parturition, who has never had primary symptoms, while the father of the child bIiows no recent syphilitic disorder. For if he has communicated a syphilitic taint to the fjpetus, the mother may become inoculated with it through her offspring, in the manner just described. [Carpenter's Human Physiology, p. 781.] f The reader will find some interesting facts touching the transmission of disease to the foetus, in an able Report on the Influence of Marriage and Consanguinity upon Offspring, by S. M. Bemiss, M.D., 1858. 264 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. pure, either from the accumulation in it of bile, or any other poisonous matter, the foetus, Avhich is nourished by that blood, must necessarily be exposed to more or less danger. There is another interesting feature connected Avith the condition of the blood during gestation, and it is this : It is not uncommon to find women, attacked Avith eclampsia or puerperal convulsions, bring forth dead children ; sometimes when the child is not destroyed, it will itself have convulsions immediately after birth. I have seen several remarkable cases of this kind. With the doctrine that convulsions are oftentimes but the results of irritation upon the spinal cord, either through poisonous blood or some other influence, the explanation of the transmission of the convulsive movement to the foetus is not difficult. The poisonous elements contained in the mother's blood are communicated to the embryo through the act of percolation, of which I have spoken; and these elements Avill produce, caiteris paribus, morbid effects in the latter, precisely similar to those observed in the system of the mother. Change in the Circulation after Birth.—As soon as the child is born, and after its very first inspiration, the Avhole current of the circulation, as it previously existed, becomes suddenly changed. The blood no longer passes to the placenta; on the contrary, it is transmitted in large quantities from the right ventri- cle to the lungs, and these organs are then called upon to perform active and uninterrupted duty, viz. the decarbonization of the venous blood ; in this Avay, it is converted into arterial blood, which, through the pulmonary veins, is conveyed to the left chambers of the heart, and distributed to the entire system, as has already been described. The consequence of this change in the route of the blood is the reduction of the ductus venosus and ductus arteriosus to mere ligamentous matter, Avhile the foramen ovale becomes closed, and ceases to afford an opening for the transmission of blood from the right to the left auricles, as was the case during fcetal existence. But, occasionally, it will occur that, through imperfect develop- ment or other circumstances, the foramen ovale does not become obliterated, and the consequence will be more or less imperfection in the circulatory function, giving rise, among other phenomena, to a disease, knoAvn as puer cmruleus, or blue disease, so called from the circumstance of the defective pas-age of the blood. Such a result, hoAvever, from imperfect closure of the foramen ovale, is not universal, for it has been shoAvn by Dr. J. W. Ogle, and others, that in many adults the foramen still exists, Avithout occasioning any trouble. Does the Fetus Breathe and Cry in Utero ?—It is quite certain that the child cannot introduce air into its lungs if there be no air to be introduced ; nor can it cry Avithout the respiratory move- ment. Under ordinary circumstance-;, the foetus is depiived of tho THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 265 access of the atmosphere during its sojourn in utero, and, conse- quently, breathing and crying are out of the question. But there are some exceptional cases recorded on undoubted authority in which these phenomena have really been observed before birth, and they are explained in this way—the membranes having been torn, and the mouth of the child in communication with air, either in the vagina or at the neck of the womb, respiration and crying have ensued. It was the opinion of Geoffrey St. Hilaire that the foetus absorbs air from the entire surface of its body, but a fundamental prerequisite for this theory is the presence of atmospheric air in utero. LECTURE XIX. Abortion—Its frequency—Loss occasioned by it to the Human Family—Dr. "White- head's Statistics—The Various Divisions of Abortion—Viability of tho Fcetus— The Case of Fortunio Liceti—At what Period of Gestation is a Female most likely to Abort?—The Opinion of Madame La Chapelle—Not sustained by general Facts—Abortion more frequent in the Primipara—Why ?—Reflex Action —Whytt—Reid—Prochaska—Marshall Hall—Concentric and Eccentric Nervous Influence—What does it mean ?—Eccentric Causes of Abortion—Hemorrhoids, Strangury, Tenesmus, Sea-bathing, etc.—How do they Produce Abortion ?—Irrita- tion of the Mammae and Premature Action of the Uterus—Cause and P]ffect— How explained—Lactation, its influence on early Contractions of the Uterus— Centric Causes of Abortion—Anaemia and Abortion—Exsanguification and Con- vulsions—Experiments of Sir Charles Bell and Marshall Hall—Experiments and Deductions of Dr. E. Brown-Sequard—Mental Emotions, Syphilitic Taint, Death of the Fcetus, all Causes of Abortion—Disease of the Placenta and Abortion— Abortion sometimes the Result of Habit—Phenomena of Expulsion in Abortion —The Pain and Hemorrhage of Abortion—How distinguished—Treatment— How divided—Tlie Application of Cold—Its Mode of Action in Arresting Hemorrhage—Tampon and Ergot—When to be Employed—Two-fold Action of Tampon.—Extracting Placenta in Abortion—Exhaustion from Hemorrhage— How Treated—Laudanum, its Efficacy in Exhaustion. Gextlemex—I shall to-day speak of an interesting affection, one Avhich should claim at your hands special attention, for the double reason that it is, in the first place, frequent; and, secondly, it is apt, under certain circumstances, to iin'olve the female in more or less danger—I mean abortion. There is an additional interest surrounding this subject, and it will be found in the extra- ordinary Avaste of life it occasions through the destruction of foetal existence. There can be no doubt that the loss to the human family from premature expulsion of the fecundated ovule is very great, and more particularly, Avhen Ave take into account the numerous instances in Avhich the loss cannot be positively ascer- tained ; such, for example, as in very early pregnancy, when the discharge of blood attending the miscarriage is oftentimes judged to be nothing more than a late return of the menstrual flow. Frequency of Abortion.—Dr. Whitehead,* in his work, gives, as the result of his observation in a certain number of cases, the following statistics: In 2000 married women, in a state of pregnancy, admitted into * Dr. Whitehead on Abortion and Sterility. ♦ THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 267 the Manchester Lying-in Hospital, he found their average age to be a fraction beloAv 30 years. The sum of their pregnancies already terminated, was 8681, or 4.38 for each, of Avhich rather less than one in seven had terminated abortively. But, as abortion occurs somewhat more frequently during the latter than in the first half of the child-bearing period, the real average will, conse- quently, be rather more than one in a dozen. Of these 2000 Avomen, 1253 had not at the time of the inquiry suffered abortion. The average age of these was 28.62 years. The number of their pregnancies 3906, or 3.11 for each person. The remaining 747 had already aborted once, at least; some oftener. Their average age was 32.08 years. The sum of their pregnancies was 4775 or 6.37 ; that of their abortions, 1222, or 1.63 for each person. From these statistics, it Avould appear that more than 37 out of 100 mothers abort before they attain the age bf 30 years; but as 30 years may be considered comparatively young for the child- bearing Avoman, it is estimated that abortion occurs in nearly 90 per cent, of those females, Avho continue in matrimony until the final cessation of the catamenia. This is sufficient, gentlemen, to show you that abortion is by no means of rare occurrence; and the very circumstance of its frequency should impress upon you the importance, as Avell as the necessity, of thoroughly compre- hending its nature and management.* Divisions of Abortion.—You will find in the books various divisions of this subject; for example, one will tell you if the ovum be expelled from the uterus, prior to the third month, it is a mis- carriage; if between the third, and end of the sixth month, it is an abortion; and betAveen the seventh, and before the expiration of the ninth month, it is premature labor. Again : a recent author, Guillemot, divides the subject as folloAvs: 1. Before the 20th day, he calls it ovular abortion ; 2. If before the third month, embryo- nic ; 3. From the third to the sixth month, fcetal abortion. And so I might pursue the subject, arraying before you the multitude of divisions and subdivisions, not forgetting one of the most ancient of all, viz. if the ovule be expelled before the tenth day, it Avas denominated simply an effluxion. But Ave shall leave these refined minutiae for those who like them, and give you what we think to be more in accordance Avith practical observation. We shall, therefore, consider the expulsion of the fecundated ovule from the uterus at any period from conception before the termination of the sixth month—an abortion, and from the seventh month, prior to tho expiration of the ninth month, premature labor. This division is founded upon Avhat I conceive to be a rational basis. * In 41,699 deliveries, there were 530 premature births, or 1 in 78|.(Churchill, 4th London Edition, p. 167.) 268 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. It is noAv generally admitted that the fcetus is incapable of independent existence—in the event of its being throAvn from the uterus—previous to the termination of the sixth month ; so that the laAv of France on this subject, and I maintain that it is a just law—although it will, undoubtedly, oftentimes afford a mantle to conceal guilt—is, that a child born 180 days after Avedlock, shall be considered not only viable, but legitimate, and entitled to all its legal and social rights. At the same time, it must be remarked, that, under peculiar circumstances of constitutional development, it is possible for a child born previous to this period to live, but the chance is so slight, that the laAA'—Avisely, I think—makes no recog- nition of it. I shall not enumerate the instances recorded by authors of extraordinary precocious viability—they do not carry with them that weight of testimony necessary to substantiate them as accepted truths. One of the most remarkable, however, may be briefly alluded to ; it is the case of Fortunio Liceti, men- tioned by Van Swieten. He Avas brought into the Avorld before the sixth month in consequence of a fright his mother experienced at sea ; Avhen born, he Avas the size of a hand, and he Avas put into an oven by his father, for the purpose, no doubt, of making him rise. Fortunio, Ave are told, attained his seventy-ninth year.* The period of Pregnancy at which Abortion is most frequent. —There seems to be no little difference of opinion among Avriters as to the particular period of gestation at Avhich the female is most likely to abort. A good observer, and a clever Avoman, Madame La Chapelle, announced, as the result of her experience in the Maternite of Paris, that abortions Avere more frequent at the sixth month than at any other time. Noav, it must be recollected that Madame La Chapelle exercised a remarkable influence as a Avriter. Her statements were regarded with much favor, and, therefore, it can readily be conceived why it Avas that the opinion advanced by her on this question should have been so generally adopted by her contemporaries, and perpetuated by those who have succeeded her. It is not improbable that Madame La Chapelle Avas quite right, so far as the experience of the Maternite enabled her to decide * October 10, 1842, I requested two of my pupils, Drs. Arendell and Morris, to attend during her labor Mrs. H, who was one of my clinic patients, and whom I had previously attended in three confinements. A few hours after the gentlemen reached her house, she was delivered of a female infant, which weighed two pounds nine ounces; the surface of its body was of a scarlet hue; and there was every indication of its being premature. It breathed, and in a short time after its birth cried freely. I ordered it to be wrapped in soft cotton well lubricated with warm sweot oil. It was nourished with tlie mother's milk, by having a few drops at a time put into its mouth. At first it labored under great difficulty in swallowing; but gradually it succeeded in taking sufficient to nourish it, and it is now a vigorous, ncalthy young woman. Independently of the evidence afforded by the physical appearance of this infant, I am satisfied, from other circumstances, that the mothei could not have completed her sixth month of pregnancy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 269 this point. But that experience is not sufficient to establish the general fact, and for the obvious reason that Avomen, in a state of pregnancy, are not, as a general rule, admitted into the Maternite in the earlier months of their gestation ; so that while it may be true the records of that establishment do show that the period at Avhich Avomen most frequently abort is about the sixth month, yet these statistics, admitting their entire accuracy, are very far from proving the major proposition—that pregnant women are more liable to suffer abortion at the sixth month. Indeed, all correct observation is, in my judgment, directly adverse to the fact; and I think the results of practice will very conclusively exhibit that, ceteris paribus, abortion is most frequent during the earlier months, say from the first to the third; and the reason for this is no doubt founded on the important circum- stance that, at this early period, the attachments of the embryo to the uterine surface are comparatively so friable, that they are more liable to be broken up, thus ending in the premature expulsion of the product of conception. I also think that the primipara is more disposed to abortion than the female Avho has already borne several children. In the former, the uterus, for the first time becoming the seat of those rapid and extraordinary changes consequent upon impregnation, Avill be more likely to aAvaken, through reflex or other influences, irritation calculated to terminate in abortion ; and this is particularly observed in two classes of patients, presenting tAvo opposite conditions of system, viz., 1. In the excessively nervous ; 2. In those characterized by unusual plethora. Causes—Abortion sometimes occasioned by Reflex Movement.— The great fact that irritation of the spinal cord may be induced by the excitor nerves, had undoubtedly been demonstrated by Whytt, Kedi, Prochaska, and others; but it must be conceded that, Avith- out the practical application made by Marshall Hall of this impor- tant physiological truth, its benefit to science would have been extremely restricted. To him, therefore, is due the merit of having faithfully and perseveringly insisted not only upon its value, but its indispensable necessity for the accurate diagnosis and treatment of disease. Previously to the discovery of reflex movement, it Avas supposed that all nervous aberrations producing irritation of the spinal cord, Avere centric, or in other Avords, the result of an influence applied directly to the cord; but now that the action of the incident excitor nerves is understood, we have another division of nervous disturbance, viz. eccentric, in which an irritation is produced on the peripheral or terminal extremity of one or more nerves ; the impression thus made is conveyed by the nervous trunks to the spinal cord and the medulla oblongata by which, and n-ithout the interference of mind, an impulse is reflected back, 270 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. through the motor nerves, to certain muscles, and hence a move- ment is produced. This is physiologically—refl< x movement. I have purposely called your attention, incidentally at tho present time, to this subject, in order that you may have a clear understanding of the true modus operandi, through reflex influence, of certain causes in the production of abortion. For example, it is not difficult to comprehend avIiv it is that hemorrhoids, a. collec- tion of faecal matter in the rectum, irritation of the vagina, etc., will be likely to provoke early action of the uterus. Among the causes of abortion, from excito-motory influence, may also be mentioned excessive sexual intercourse in the newly married. A calculus in the bladder, or strangury produced by the absorption of cantharides from a blister, as also the tenesmus of dysentery, may be enumerated among the causes of abortion; all these influ- ences act upon the same principle, by reflex movement, bringing into play the excito-motory system of nerves. I have knoAvn a lady miscarry from bathing in the ocean. Is it difficult to explain the relation of cause and effect betAveen the cold bath and abortion ? It is but another illustration of reflex influence. It is Avell knoAvn, as Marshall Hall observes, that cattle made suddenly to ford a creek, will, almost as soon as they feel the impression of the chilled water, evacuate both the bladder and rectum. These, gentlemen, are important facts; and I might proceed to illustrate this great principle of reflex action as one of the causes more or less constantly at work in the production of abortion. Why is it that a piece of ice put into the vagina Avill often arrest fearful flooding? Why is it that titillating the mouth of the uterus with the finger will frequently arouse this organ from a state of inertia to one of positive contraction ? In the operation of turning, soon after the hand has passed into the uterus, the accoucheur will experience the most painful sensation, this being the result simply of the firm grasp of the cervix uteri around his wrist. You have had cases before you, in the clinic, of women, soon after parturition, experiencing severe pain in the uterus from the application of the infant to the breast. This is nothing more than another example of reflex influence ; and so true is this connexion between the uterus and mammae, that Scanzoni has recommended suction of the breasts for the purpose of bringing on contraction of the uterus in cases in which, from justifiable motives, it becomes desirable to induce premature delivery. Lactation itself is an active, but, I think, not a sufficiently recog- nised cause of abortion ; and it is important, therefore, for this as Avell as for other reasons, to direct a female, engaged in suckling her infant, who may suspect herself to be pregnant, to wean her child. This advice, if followed, will oftentimes insure her the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 271 completion of her gestation. The well-known sympathy existing betAveen the mammae and uterus will, I think, in part explain why a nursing Avoman is liable to abort; the traction of the child's mouth on the nipple being oftentimes an excitor of uterine action. Dr. Barnes* has written an able paper on this subject, and has shown that in a given number of instances, abortion occurred in 17 per cent, of cases in Avhich the female became fecundated during lacta- tion, and in only 10 per cent, when impregnation occurred at other times. Women will occasionally abort from the extraction of a tooth ; in this case, the particular pair of nerves more immediately connected Avith this result is the fifth, or, as it is called, the trifacial. Diseases of the cervix uteri, such as ulceration, hypertrophy, indura- tion, etc., also deserve to be ranked among the influences occasion- ing premature action of the uterus ; and these, too, produce their effect upon the principle of reflex movement. The important deduction I wish you to make from what has just been said in reference to this particular class of causes of abortion is, in all instances, to exercise a due degree of vigilance by endea- voring to ascertain in a given case the particular influence, Avhich may be in operation at the time, and, by successfully removing it, render to your patient a substantial service, as far as may be. Centric Causes of Abortion.—There is, hoAvever, another dis- tinct class of causes, capable of inducing premature contraction of the uterus; and they differ from those already named in the impor- tant particular that they are centric, that is, their influence is exercised primarily on the medulla spinalis itself, and not secondarily, as is the case in the operation of the eccentric causes, which you knoAV is through a reflected, and not a direct action. To illustrate: suppose a pregnant woman receives a blow on the spine, folloAved by abortion. Here, then, is an example of a centric cause, for the reason, that its primary influence is upon that great nervous centre —the medulla spinalis. A bloodless or anaemic condition of system is not an unusual cause of abortion ; and this should explain to you Avhy it is that women Avho have suffered excessive depletion, either from the lancet, or as the consequence of a long-continued drain, will be exposed to miscarriage. But you may desire to knoAV Avhat connection there is betAveen abortion and anaemia. It has been shoAvn that Avhen an animal is bled to death its dissolution is pre- ceded by convulsions. Sir Charles Bell and Marshall Hall both maintained that, in such cases, the convulsions are the result of loss of blood sustained by the spinal cord. It remained, however, for that eminent physiologist, Dr. E. BroAAm-Sequard,f to demon- strate by numerous experiments that the convulsions, in these cases, * London Lancet for 1852. f Experimental Researches applied to Physiology and Pathology. 1853. p. 117. 2,2 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. are not due to the anamiic condition of the cord, but to the increase of carbonic acid in the blood, which is proportionate to the insufficiency of the respiratory movement—the carbonic acid, under these circumstances, becomes an excitant to the cord, and is the true cause of the convulsions. The same observer has also shoAvn that carbonic acid is an excitor of the muscular system, and, in this way, is to be explained the relation of cause and effect betAveen a bloodless condition of the economy and contractions of the uterus. Albuminuria in pregnant Avomen is often the cause of abortion (Rayer, Martin, Solon, Cahen), of premature parturition (Rayer), or of the death of the child (Cahen). Braun says, in one-fourth of the cases of albuminuria during pregnancy, there is abortion or premature labor. Mental emotions, whether fright, anger, depres- sion, sudden and excessive joy, etc., are all so many circumstances capable of giving rise to abortion; and the influence of these may be said to be through centric action. Other Causes of Abortion.—A prominent and quite common cause of premature action of the gravid uterus, is a hyperaemic or plethoric condition. This organ may be congested, as a conse- quence of the general vascular state of the system; or it may be the result of some special local influence. For example : malposi- tions of the uterus, or any other abnormal condition, inducing an obstruction to the free circulation of the blood; the abuse of emmenagogue medicines; inflammation, either of the external genitalia, or of the organ itself. The syphilitic taint and the abuse of mercury are also to be enumerated among the causes of abortion. Syphilis may be transmitted from the mother to the child in utero; or, it may be derived from the father, through the fecun- dating liquor. In either case, abortion may occur in one of tAvo Avays. In the first place, from the death of the embryo ; or, secondly, it may be occasioned by disease of the placenta, terminating in its early detachment, and consequent expulsion of the ovum. Small- pox may produce abortion, and in one or other of the modes just explained. Death of the foetus, no matter how produced, is to be regarded as one of the most certain of all the causes of abortion ; and Avith a moment's thought you will perceive how fortunate this provision is ; for the continued sojourn of the embryo in utero, after its death, Avould necessarily involve, through its decomposition, the safety of the mother, and hence the necessity for its early ejection. You can readily understand the connection betAveen abortion and disease of the placenta. This latter organ is called upon to perform a most necessary office ; and even its partial separation cannot occur Avithout exposing the embryo to serious hazard. The maladies to which the after-birth is liable are various; sometimes, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 273 it will become indurated; at other times, it will pass to a state of hypertrophy or atrophy; occasionally, it will become the seat of calcareous formations, hydatid developments, unusual fatty dege- neration, etc.; it may also be invaded by inflammation, or over- Avhelmed by an afflux of blood, constituting what has been so well described by Cruveilhier as placental apoplexy. Habitual Abortion.—It is an interesting fact, that some women abort several times successively, and this is called the abortion of habit. A knowledge of this fact inculcates, in the first place, the necessity of the practitioner enjoining on his patient, in her first preg- nancy, the great necessity of avoiding all those causes Avhich are knoAvn to favor a i>remature expulsion of the ovum ; and secondly, in the event of a miscarriage, to exercise more than ordinary vigilance in the subsequent pregnancies; and Avhat I have found an excellent expedient in such cases is—as soon as gestation takes place, to interdict sexual intercourse until after the fifth month, for if the pregnancy pass beyond this period the chances of abor- tion will, I think, be much diminished. These cases of habitual abortion are oftentimes exceedingly difficult to manage, simply for the reason that sufficient care is not exercised in ascertaining the true source of the difficulty. It is a fact, fully indorsed by all sound experience, that abortion is very apt to be followed by chronic affections of the uterine organs, such as displacements, or enlargements, and these are frequently the true cause of the early expulsion of the OA'um. In such instances, the obvious indication is, through appropriate treatment, to remedy the displacement, and subdue the enlargement. If it be apparent, that the source of the trouble is plethora, the remedy will be the diminution of that state by judicious depletion, together with saline cathartics, and restricted diet; and here, if there be an absence of nausea—one of the ordinary and important phenomena of gestation—give tolerant doses of ipecacuanha, say from one- sixth to one-fourth of a grain every two or three hours, for the purpose of exciting action of the stomach. The reason for this latter treatment has been explained in a previous lecture. It is essential that the patients avoid all excitement, either mental or physical; and it is a rule Avith me to enjoin more or less quiet in the recumbent position until the expiration of the fifth month. I need scarcely remark that if the cause of the abortion be traced to excessive nervous irritability, this condition must be allayed by timely recourse to anti-spasmodics and anodynes; at the same time, the general health should be improved by tonics and appropriate diet. Dr. Tanner speaks highly, in these cases, of assafoetida.* * One of the best agents with which I am acquainted in the troublesome cases of repeated miscarriage, occurring in weak and irritable women, in whom there is an absence of vascular congestion and anv specific disease, is assaftetida. The dose 18 274 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Whatever may be the particular cause of the abortion, the phenomena connected Avith the expulsion of the ovum resemble more or less closely those of an ordinary labor. The expulsive force is the same, viz., the contractions of the uterus. As a general rule, unless the membranes should be ruptured by the rude mani- pulations of the accoucheur, previously to the expiration of the third month the ovum is usually expelled entire with its envelopes. Symptoms of Abortion.—They may be embraced in the two terms pain and hemorrhage. When a female is threatened Avith premature expulsion of the embryo, these tAvo phenomena—pain and hemorrhage*—Avill almost ahvays, to a greater or less extent, be present. Diagnosis.—The diagnosis of a threatened abortion needs some little attention. In the first place, a pregnant Avoman may suppose herself menaced with abortion, simply because she has pain. But this is not sufficient —the pain of abortion, like the pain of labor, is peculiar—it is recurrent, paroxysmal, marked by distinct inter- vals, and centring toward the loins eind hypogastric region. It is, in a Avord, nothing more than the contractions of the uterus, either masked or fully developed, and which, you knoAV, are not conti- nuous, but intermittent, when engaged in the expulsion of the ovum, whether at full term or at an earlier period. The pain, Avhich the female may mistake for labor pain, may result from colic, indigestion, or various other circumstances, which have no possible connection with any specific action of the uterus. You see, therefore, it Avill be for you to determine as to the character of the pain, and Avhether it portend danger to the mother and embryo, or Avhether it be transitory, and Avill yield to the adminis- tration of appropriate remedies. So far, then, as either the pain or hemorrhage is concerned, it is incumbent to ascertain, in the first place, Avhether they really proceed from the uterus; and, secondly, if so, does the uterus contain an ovum, or, in other Avords, is the woman pregnant ? The blood, although derived from the uterus, may not positively indicate an abortion, and so likewise with the pain, for both of these phenomena may exist without gestation. For example: they may be the result of a polypoid growth, of carcinoma, &c.; the bleeding and pain may be altogether unassociated with the uterus itself, and may proceed which I usually administer is about five grains of the extract every night at bed- time, and I generally take care that the patient shall have had from three to five drachms before arriving at that period of her pregnancy at which she has formerly aborted. [Signs and Diseases of Pregnancy. By Thomas Hawkes Tanner, M.D., F.L.S., p. 257.] * The bleeding in early gestation may arise from several circumstances—such as rupture of the vessels connecting the ovum to the uterus; or there may be a giving way of the serpentine vessels, which distribute themselves in the uterine walls, and which then pour their contents into the cavity of the organ. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 275 exclusively from some abnormal condition of the vagina. The distinction can be arrived at only by a thorough examination. Again : a pregnant Avoman, especially in the earlier months of her gestation, may have a discharge of blood through the vagina Avithout being at all threatened Avith a miscarriage. This discharge may be nothing more than menstruation, which, you are aAvare, sometimes occurs in pregnancy, several examples of which you have seen in the clinic. As a general principle, you will be enabled to distinguish menstruation from the hemorrhage of miscarriage, as follows: 1. Its occurrence will usually accord with the men- strual periods previous to the pregnancy; 2. It is unconnected with any of the causes of miscarriage; 3. The patient is in good health; 4. The Aoav is not profuse, lasting generally but tAvo or three days ; 5. The pain in menstruation precedes the flow, and usually ceases as soon as the discharge occurs; 6. In miscarriage, whether before or immediately after its completion, the os uteri is more or less dilated and softened; such is not the case in menstruation. Prognosis.—As a general rule, a favorable opinion may be expressed. The danger from losses of blood is much less in the earlier months, for the reason that the blood-vessels are less deve- loped ; it is rare to observe any serious puerperal complications follow an abortion—such as inflammation or fever. Treatment of Abortion.—Let us now consider how a mis- carriage is to be managed—a most important point both for the patient and practitioner. When summoned to a female, who supposes herself menaced Avith an abortion, the first and obvious duty of the accoucheur is to ascertain Avhether she be in fact menaced, or Avhether her fears are Avithout foundation. This, of necessity, will involve a just discrimination of her condition—if she have pain, Avhether it be the offspring of uterine effort; and, if there be discharge of blood, whether it be the result of premature action of the organ. If it be discovered that the patient is really threatened, his duty will be confined to the attainment of one of two objects—either the prevention of the miscarriage; or, if this cannot be accomplished, he must limit himself to those measures, which will the most efficiently enable him to conduct his patient safely through her trouble. With regard to the prevention of a threatened miscarriage, I Avish very emphatically to remark that it can often be accomplished, even Avhen apparently there no longer exists any hope of attaining this desirable object; and you must allow me to impress upon you, not only the necessity, but the high moral obligation imposed on the practitioner, of employing, in the most faithful manner, those means best calculated to arrest the early action of the uterus. It is proper, at this time, to examine in Avhat these means consist. The prevention of a threatened miscarriage is not to be achieved 276 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. by any act of empiricism—it is, on the contrary, to be accomplished, in the first place, by a rigid appreciation of all the circumstances by Avhich each individual case may be surrounded; and, secondly, by a proper adaptation of remedies to the peculiar condition of the system at the time. We will noAV imagine you are at the bedside of a pregnant female, Avho has both pain and a discharge of blood from the vagina, and that you have satisfactorily ascertained, through a care- fully instituted examination, that these tAvo phenomena are posi- tively connected Avith a threatened miscarriage—AA'hat is the first thing to be done? Certainly not, for the mere sake of appearing to do something, to be urged on to precipitate and unprofitable interference ; but the judicious physician will take a survey of the condition of his patient, for the purpose of ascertaining some of the following points: Is she laboring under marked plethora ? Is she of an extremely nervous temperament ? Has she been exposed to any sudden emotion, such as fright, anger, or depression of spirits ? Has she experienced violence from a blow or fall ? Has she been subject to previous abortions ? These are some of the principal inquiries, which a vigilant practitioner would naturally institute in his own mind. You must remember that, in the management of a miscarriage, no matter what may be the cause Avhich has determined it, absolute rest must be enjoined. This is a sine qud non to the success of the remedies to which you will necessarily be obliged to resort. The patient should be placed in a recumbent position Avith her hips slightly elevated. Acidulated drinks, such as lemonade, may be given, or a capital compound under these circumstances Avill be the infusion of roses with dilute sulphuric acid, say f. § viij. of the for- mer to f. 3 ij' of the latter—a tablespoonful every half hour. The room should be cool, and the covering light. The acetate of lead and opium may be resorted to, either in solution or pill, and often- times Avith much benefit, under either of the folloAving formu- laries : Acetat. plumbi, 2>ij. Aquae destillat. f. "f vj. Tinct. opii, f. 3 ij. Ft. sol. A tablespoonful every third hour. Acetat. plumbi, gr. xxx. Pulv. opii, gr. iij. Divide in pil. xij. One pill every two or three hours. A most important adjuvant, under these circumstances, will be the application of cold, by means of cloths wrung out of ice-Avater, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 277 and applied to the sacrum, around the loins, and to the vulva itself. Cold, remember, is the most powerful and efficient agent to pro- duce directly and locally—and indirectly at a distance, by a reflex action—contraction of the blood-vessels. It excites contraction of the blood-vessels of the uterus much more readily than it affects the muscular tissue of that organ ; in this way, it will arrest the hemorrhage, and also cause a diminution of the congestion, which is an excitant to uterine action. Another valuable remedy is bel- ladonna. It is well known that it exercises a marked influence on the blood-vessels of the uterus, as upon those of the iris, intestines, etc., causing them to contract, and consequently relieving them of their congested condition. I have repeatedly had recourse to sup- positories of the extract introduced either into the vagina or rec- tum—the latter is preferable, for the blood will be apt to remove the suppository from the vagina—and I can very confidently com- mend it to your attention, as oftentimes one of the most effectual means of arresting a menaced abortion. Suppose, noAV, that your patient is plethoric, Avith more or less febrile excitement; AA'hat in this case should be done, especially if there be a hope of preventing the expulsion of the ovum ? Why, obviously to reduce the plethora, Avhich you will find not an uncom- mon predisposing cause of abortion. For this purpose, general blood-letting is the great agent. I much prefer it, under these circumstances, to local depletion. The quantity to be taken must depend upon the sound judgment of the practitioner. Two, four, six, or nine ounces may be abstracted, and repeated as events may suggest. It is Avell to bear in mind that, in these cases, the draw- ing of blood is not for the purpose of combating an active inflam- mation seated in an important organ, but the object is simply to diminish the momentum, if I may so term it, of the circulation, and thus protect the uterus from the afflux setting toAvard it. In addition to the abstraction of blood, give ten grains of nitrat. potassae in a tumbler of Avater, Avith vj. gtt. of tinct. digitalis. Let this be repeated every four or six hours, together Avith abste- mious diet. It may, hoAvever, be that your patient is not laboring under plethora, but she is of an extremely nervous temperament. What in this case is indicated ? Certainly not the abstraction of blood, for this would only tend to aggravate the nervous irritability; but on the contrary, the employment of such remedies as will calm and fortify the system, such as the various antispasmodics, ner- vines, etc. In these instances, I haATe experienced much benefit from the injection into the rectum of thirty drops of laudanum to a Avine-glass and a half of water; lubricating the os tincae and vagina with the ungt. belladon. (3j. extract belladon. to f j of ideps), and the introduction of opium suppositories into the 278 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. rectum. Internally, a table-spoonful of the following mixture may be given every half hour, until the object be attained : Syrup, papav. f. 3 iv. Mucil. acac. f. 5 iij. Sol. sulph. morphiae (Majendie) gtt. xx. Ft. mist. In all cases of threatened abortion, the attention of the practi- tioner should invariably be directed to the condition of the rectum; for it will not unfrequently happen that a collection of faecal mat- ter in this intestine is the starting point—the original exciting cause of the difficulty. If this should be so, the first thing to be done is to evacuate the boAvels by means of an enema. It may, on the contrary, be that the patieut is affected with hemorrhoids. If these be external, they should be carefully introduced within the rectum so that they may be relieved from the constriction of the external sphincter. The removal of the hemorrhoidal tumors, under the circumstances, cannot for a moment be thought of, for the operation itself Avould almost certainly provoke the contraction of the uterus. As I have mentioned to you, in a preceding lecture, the preg- nant female is to be sedulously guarded against torpor of the boAvels, and this direction, too, is especially applicable in cases of threatened abortion. Epsom salts in small quantity, a seidlitz powder, manna, the compound rhubarb pill, are all Avell adapted to this end. AHoav me to make one remark in reference to the impregnated uterus in the case of the primipara. You will find, as a general rule, that Avomen of an excessively nervous temperament, Avho may, in fact, be termed very impressionable, are more apt than others to miscarry in their first gestation, and the circumstance is readily explained. In primiparos, the uterus distends with less facility than in subsequent pregnancies; and in Avomen of great nervous susceptibility, the very difficulty encountered in the dis- tension of the organ, frequently tends to premature action of the uterus, and the expulsion of the ovum. In such cases, even before the slightest manifestation of trouble, I have been in the habit of recommending to foment freely, but Avithout using friction, the hypogastric region with Avarm sAveet oil and laudanum. This, I am sure, will often prove an efficient remedy in these instances, and I can speak of it, from no limited success, with much confidence. But let us present to you another vieAv of miscarriage. The treatment AA'hich we have thus very summarily suggested, is intended for the prevention of this trouble, AA'hen it is merely threatened. I shall now call your attention, for a moment, to those remedies indicated in cases in Avhich it becomes impossible to arrest the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 279 expulsion of the ovum, and in which, therefore, the duty of the practitioner will be limited to saving the life of the mother. The true danger to the mother in abortion is the fearful hemor- rhage, and examples are not feAv in which she has sunk from loss of blood. When, then, it becomes an ascertained fact that the mis- carriage cannot be controlled, the obvious duty of the practitioner is to promote, by judicious interposition, the termination of the delivery; and you are also to bear in mind, AvheneA'er the hemor- rhage is such as to endanger the safety of the mother, all regard for the embryo must be suspended ; no matter Avhat may be the possible or probable chances of arresting the miscarriage, every consideration must yield to the higher claim of the parent. It is an extremely nice point always to determine Avhen the hemorrhage is so profuse as to render it essential to induce the expulsion of the ovum, and, also, Avhen it is certain that the abortion cannot be prevented. In some instances, it is true, this question may be decided Avithout trouble; Avhen, for example, a portion of the ovum—which will sometimes happen—has been throAvn off; and, again, if the ovum be distinctly felt protruding through the dilated os, it is unequivocal evidence that its expulsion cannot be controlled. As to the question of the amount of hemorrhage Avhich will not only justify, but absolutely call for the prompt action of the accoucheur to promote the evacuation of the contents of the uterus—this, I repeat, is a question of judgment to be determined by the evidence Avhich may present itself at the time. Permit me, hoAvever, to make a single remark on this point. I have known women to lose immense quantities of blood in a threatened abor- tion, and to be apyparently moribund from exsanguiflcation, and yet they have rallied, and gone on to the full term. These latter examples, hoAvever, are exceptions to the general rule. Well, Avhen there is no longer any hope of restraining the abor- tion, or Avhen the Avoman is flooding so profusely as to endanger her life, the mouth of the uterus -will be in one of tAvo conditions —it will be either sufficiently dilated to enable you to feel the ovum, or it will not be so dilated; and again, the ovum Avill also be in one of tAvo conditions: it will either have partially extruded through the cervix, or it will still be Avithin the cavity of the uterus. Now, let us examine each of these points. 1. Should the uterus be so far dilated as to permit the introduction of the finger, I should recommend you, by all means, gently to increase the dilata- tion—and this is readily accomplished by pressing the finger alter- nately fonvard and backAvard—this very motion of the finger evokes a strong reflex action, Avhich oftentimes results in the prompt expulsion of the ovum. 2. If the os uteri have not undergone dilatation, and the hemorrhage so nrofuse as to occasion alarm for tho mother, then the remedies to be employed are the fohW- 250 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. ing: l.Cold; 2. The tampon; 3. The secale cornutum. Here, you perceive, the object is to bring on, as speedily and effi- ciently as possible, contractions of the uterus, for it is on the effi- cient contractions of this organ that you are to rely for the arrest of the hemorrhage. I have told you that, when a misearriage is merely threatened, and, therefore, it becomes the duty of the medical man to do all in his power to prevent it, the application of cold by means of cloths to the vulva, sacrum, and loins, is of great benefit, because of the contraction it produces in the blood-vessels of the uterus. There is uoaa', however, profuse hemorrhage, plac- ing in more or less peril the safety of the woman ; and here, too, cold, properly resorted to, will prove one of the most positive remedies. If you dash cold water—it Avould be better if it Avere iced—upon the abdomen, you will oftentimes, in these cases, cause a prompt action of the uterus ; or a small piece of ice introduced into the vagina, will occasionally act like magic. In either instance, the uterus is made to contract in consequence of reflex action. The tampon is a valuable agent in this form of* hemorrhage. It should consist of small pieces of fine sponge, or lint, which should be carefully introduced into the vagina, as far as the os uteri, until the passage is completely filled up. The whole is then to be kept in place by a compress and bandage. It may happen that the pressure of the tampon against the urethra, or neck of the bladder, will prevent the floAV of urine ; in this case, the catheter must be used. I Avould advise you not to allow the tampon to remain, at any one time, in the \-agina for a longer period than four hours; it should be AvithdraAvn at the end of this time, and replaced, if found necessary, by another ; this is an important direction, for the long- continued use of the same one will be apt to occasion putrefaction of the fluids Avhich necessarily, to a greater or less extent, saturate it. The tampon acts, if I may so say, in a tAvo-fold capacity. In the first place, it arrests, for the time being, the hemorrhage; and, secondly, the irritation produced by it on the mouth of the uterus provokes contractions of the organ, and thereby facilitates the object in vieAv. Another efficient remedy in these cases is ergot—the secale cornu- tum ; and it is efficient because of its action on both the blood- vessels and muscular tissue of the uterus. It is hoav admitted that this drug affects the vessels and muscular fibres of the organ on precisely the same principle; it acts upon the smooth fibres of the uterus : it acts also on the smooth fibres of the blood- vessels. It, therefore, is true that ergot arrests uterine hemorrhage iu a tAvo-fold manner: 1. By producing contraction of the blood- vessels; 2. Contraction of the muscular structure of the organ. Ergot is not a stimulant of any portion of the nervous system, and may, therefore, be regarded the antagonist of strychnine. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 281 I should not hesitate an instant, in any urgent case where the strength of the mother is giving way from the loss of blood, and the mouth of the uterus still undilated, to introduce Avith my index finger as a guide, a female catheter or bougie—I prefer the former— into the os uteri, and thus hasten the dilatation by promoting efficient contractions. Lot us noAv suppose the ovum is partly protruding through the os uteri: in this case the proper practice is to terminate Avithout delay its expulsion, by introducing the finger, and making gentle tractions upon it. If, on the contrary, the ovum be still Avithm the uterine cavity, and it be desirable, on account of the hemorrhage, to hasten its delivery, then the means already mentioned—cold, tampon, and the ergot—will be indicated ; and what you will find a capital means in addition, for the purpose of promoting strong uterine effort, will be a drastic cathartic—say for example, a couple of aloetic and myrrh pills-—or from one to tAvo ounces of the com- pound tincture of aloes ; or if the case be urgent, requiring prompt contractions of the organ, a drastic enema may be administered. If abortion should occur before the expiration of the first three months of gestation, and the ovum come away piecemeal, the pla- centa Avill sometimes be retained, giving rise to much uneasiness on the part of the patient, and causing no little embarrassment to the young practitioner. These are the cases in which various con- trivances have been projected for the purpose of extracting the retained mass—such as the tenaculum, the small slender forceps, hooks, etc. These instruments are, in my judgment, not only unneces- sary but fraught with danger. The best extractor is the finger. Let it be carefully introduced Avithin the cavity of the uterus, and by skilful manipulation, with the other hand placed upon the abdomen depressing the fundus of the womb, the remaining portion of the ovum can, generally, Avithout difficulty be removed. At a later period the uterus Avill be large enough to admit the introduction of the hand, and in this Avay the after-birth may be extracted. It is a curious and interesting fact that the retained placenta in cases of abortion does not, as at the full period of gestation, undergo decomposition, and, therefore, if it cannot be readily secured, should cause no disquietude. It Avill often pass off spontaneously, even after all efforts to remove it have proved unavailing. The patient, after an abortion, should, as in an ordinary labor at term, be kept quiet, and preserve the recumbent position. Her diet should be light, the bowels soluble, and all excitement avoided. In the event of alarming prostration from loss of blood, there is no remedy more efficient in bringing on reaction than tea-spoonful doses of laudanum and brandy in a Avineglass of strong coffee, every ten, tAventy, or thirty minutes, according to the requirements of the case. Be not afraid of this remedy, it is the sheet-anchor 282 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of hope in cases in which the patient is almost sinking from exhaus- tion consequent upon profuse hemorrhage. But, of all things to be remembered, see that the uterus is avcII contracted, and not in a state of inertia, for it Avould be the essence of folly to attempt to control the exhaustion while the Avaste gate is still open. In abor- tion, as in delivery at full term, flooding is ahvays one of the results of inertia of the uterus. In all cases of abortion, an important direction for you to bear in mind, is to examine carefully any clot or substance which may be thrown off from the uterus; and this rule should be observed from the very commencement of the discharge. The object of the examination is to be assured Avhether the embryo has been expelled; and this necessarily suggests the discussion of the question of moles, or, if you prefer it, molar pregnancy, to which subject the succeed- ing lecture will be devoted. In conclusion, I Avould remind you that you will sometimes meet with cases in Avhich there is more or less oozing of blood after the entire expulsion of the ovum ; and this Avill ordinarily occur in Avomen of a leueo-phlegmatic tempera- ment, Avith a flaccid, muscular fibre ; the hemorrhage in these instances is almost ahvays of a passive type, constituting Avhat may be termed passive or atonic metrorrhagia. When called upon to treat a case of this kind, you will recognise great benefit from the injection, night and morning, into the rectum of a half pint of Avater, cold from the pump, together Avith the internal administra- tion three times a day, as may be indicated, off. 3 j. of the tincture of ergot in half a Avineglass of cold water. LECTURE XX. Moles—Importance of the Subject—Moles variously Classified—Mauriceau's Defini- tion—The Opinion of Fernel—Practical Division of Moles—The True Mole always a Proof of Previous Gestation—Distinction between True and False Mole first made by Cruveilhier—Mettenheimer and Paget on True Mole—Dr. Graily Hewitt —Case in Illustration of a True Mole—Can a Married Woman, if separated from her Husband since the Birth of her Child, or can a Widow, Discharge a True Mole from the Uterus consistently with her Fidelity ?—False Moles, what are they?—Substances expelled from the Womb of the Young Virgin—Fibrinous Clots—The Membrane of Congestive Dysmenorrhoea—The Hen lays an Egg without the Tread of the Cock—Does the Membrana Decidua pass off at each Menstrual Period, or is it simply the Epithelial Covering?—The Testimony of Larnsweerde, Ruysch, and Van Swieten as to the False Mole—The True Hyda- tids—Can they be produced in the Virgin Uterus ?—The Case cited by Rokitan- sky—Importance of the Question—How are the True Hydatids to be distin- guished from the Hydatiform Vesicle ? Gentleaiex—In the course of your practice you will observe, more or less frequently, examples of anomalous substances throAvn from the uterus, and this, too, both in the married and unmarried ; hence you at once perceive how much will necessarily depend upon the sound judgment of the physician in order that character may not be unjustly assailed, or wantonly destroyed. These substances have been differently named and classified ; and there has existed no little discrepancy of opinion as to the particular cause of their origin. In a question so vitally important as is the one noAV before us, it ippears to me there is great Avant of accuracy in the arrangement and description, Avhich the older authors have given of the various matters discharged from the womb; and this Avant of definite arrangement will, I think, account for the marked conflict of opi- nion entertained as to the true source of these expelled masses. One of the great masters of obstetric science is constantly quoted in proof of the alleged fact, that Avhen a female expels from her uterus a substance—knoAvn under the vague name of mole—she could only have done so in consequence of intercourse Avith the other sex. I allude to the learned Mauriceau, Avho, in one of his aphorisms,* says, " Les femmes n'engendrent jamais des moles, si elles n'ont use du coit." In order to prove the fallacy of this apho- * Traite des Maladies des Femmes Grosses. Aphorism, 105. 281 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. rism, and consequently the Avrong of its adoption, I have had the curiosity to examine for myself the actual definition which this dis- tinguished man has given of a mole. I find the following to be his language: " La mole n'est autre chose qu'uue masse charnue sans os, sans articulations, et sans distinctions des membres, engendre contre nature dans la matrice ensuite du coit, des semences cor- rompues de 1'homme et de la femme."* Here, then, according to this definition, a mole is simply a fleshy mass, bearing none of the evidences of the product of a previous conception ; and, therefore, with this restricted signification, we are called upon to pronounce all such substances as unqualified evidence of sexual intercourse—a theory at once cruel and unjust, as we hope to demonstrate before completing this lecture. Another high authority, the celebrated Fernel, physician to Henry II., originated the following maxim, Avhich is also frequently referred to in confirmation of the opinion subsequently advanced by Mauri- ceau : " Xusquam visa est mulier molam sine mare concepisse."f I might, indeed, cite many other authorities in confirmation of the same vieAv, but this is not necessary. I prefer rather, in the face of such testimony, to urge the absolute duty imposed upon you of examining most scrupulously the grounds for this SAveeping decla- ration, and of repudiating its adoption, unless convinced by positive proof of its truth. The opinion bears too directly upon character and the best interests of society to receive a tacit concurrence, and, therefore, become a principle of guidance in cases in Avhich a deci- sion is to be arrived at, involving the important question of chastity or infidelity, either in the married or unmarried. What I object to in the authors just cited is their want of precision in the defini- tion of Avhat a mole really is; for assuredly, in order that we may have a correct judgment as to the true origin of these expelled substances, Ave should first have some standard of comparison, which science recognises, as the only means by Avhich Ave are to dis- tinguish betAveen what is and Avhat is not a mole—the offspring of a previous conception, or, if you please, a blighted ovum. Therefore, for practical purposes, the substances expelled from the uterus may be divided into two distinct orders or classes : 1. Those, Avhich are the product of a diseased or degenerated ovum, and consequently implies a previous fecundation—knoAvn as true moles. 2. Those the origin of Avhich has no sort of connexion with sexual intercourse, but Avhich is due to causes altogether foreign to this influence, known as false moles. The True Moles—Vesicular or IIydatiform Moles.—It has been very satisfactorily demonstrated by Charles Robin, and others, that an alteration in the envelopes of the ovum, with an anomalous * Time i. p. 590 f Fernel, tome i. p. 599. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 285 enlargement of the chorial villosities, is the only origin of a true mole, thus essentially connecting the source of this character of mole Avith a previous conception. The hydatiform* or vesicular mole has recently occupied much attention. Cruveilhier, it is now gene- rally admitted, was the first clearly to point out the absolute differ- ence between the vesicular or hydatiform mole, and what is under- stood, in pathological language, as the true hydatids, Avhich are occasionally found in the heart, liver, spleen, and other organs. Whether, under any circumstances, these true hydatids, the origin of which is of course unconnected with pregnancy, can exist in the uterus, we shall examine in the course of this lecture. Various theories have been advanced to explain the special changes the chorial villi undergo preliminary to their transforma- tion into the hydatiform bodies. It is supposed by Mettenheimer and Paget that the change consists essentially in the conversion of certain of the cells in the villi of the chorion into so many cysts; on the outer surface of these new-formed cysts, a neAV vegetation of villi sprouts out, being identical in structure with the proper A'illi of the chorion ; and in these last villi there commences a new deve- lopment of cysts, and so on ad infinitum. The opinion of Paget and Mettenheimer is opposed in a recent paper by Dr. Graily Hewitt,f who maintains that, in the hydatiform mole, there is not a new formation, but simply art alteration and degeneration of previ- ously existing structures. This Avriter also dissents from the opi- nion, now generally admitted, that the starting-point or cause of the transformation is disease of the chorion, Avhile the effect is the destruction of the embryo. Dr. HeAvitt, on the contrary, endea- vors to show that the degeneration is the result of the death of the fcetus. His paper embodies much interest, and Avill amply repay perusal. Dr. BarnesJ has presented an elaborate resume of the Avhole question with his accustomed ability, and the reader will find much of profit in his valuable contribution. You were told, Avhen speaking of reproduction and pregnancy, that certain phenomena are absolutely essential to the formation and ultimate development of the embryo; these phenomena have already been pointed out in detail. The moment the act of fecun- dation has been consummated, then the work of groAvth and deve- * The hydatiform mole is usually thrown off before the completion of the ordinary term of pregnancy. If not ruptured during its expulsion, the mole will be found to exhil it a cavity full of a serous liquid, in which are never observed the small gra- nular bociies (echinococci) first described, I believe, by Rudolphy, and which always exist in true hydatids or acephalo-cysts. Should the mole be expelled soon after tho death of the young embryo, portions of the latter may be detected in its cavity; but if it pass oft* long after its destruction, then the mole assumes more or less the aspect of the placenta, and there remains but little of the cavity. f Obstetrical Transactions. London, vol. i., 1860, p. 249. \ Brit, and For. Medico-Chirurgical Review, 1854-5. 286 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. lopment commences—these tAvo latter phenomena being the results of a healthy nutrition. It will, however, sometimes happen that, after the vitalized germ is deposited within the uterine cavity, some morbid influence may arise in the germ itself, which Avill compro- mise the progress of a normal gestation, and lead to the destruc- tion and degeneration of the ovum; so that, in lieu of fcetal deve- lopment, the product of conception exhibits a more or less anoma- lous mass, in Avhich, Avith a due degree of care, there will be recog- nised the alterations of the chorial villosities, if not Avith the naked eye, at least under the poAver of the microscope—and this, remem- ber, is the conclusive affirmative proof of the true mole. In other instances, and they are not rare, the foetus may be expelled normal and fully developed, Avhile the placenta Avill exhibit a partial hyda- tiform degeneration in its villosities. It is an interesting fact to bear in memory, that, as a general rule, soon after the death or metamorphosis of the ovum, the uterus be- comes intolerant of its presence, and expels it. This result, however, is not universal; the exceptions are not feAv, and the degenerated ovum Avill occasionally remain for a long time in the uterine cavity. The latter circumstance may involve character in one of tAvo Avays —for instance, a lady may bring forth a healthy living child at full term; in three, six, or twelve months subsequently she may have expelled from the womb a true mole.* This may occur in a case in which the husband has been absent during the whole period from the birth of the child until the expulsion of the mole. Again : the same circumstances may be observed in a Avidow, some considerable time after the decease of her husband. In instances like these, what is to protect the fair fame of the parties but the testimony of the medical man that such occurrences may be entirely consistent with individual purity ? In order to illustrate this point, let us suppose, in the former instance, that the female is pregnant with tAvins : in an early part of the gestation one of the germs dies, and the other reaches its full term of deve- lopment. The germ which survived for so short a period is trans- formed into a degenerate mass, and continues in the uterus for some months after the birth of the living child. In the second case, the female becomes impregnated before the demise of her hus- band, but the germ, instead of progressing through its various phases of development, from some cause or other becomes changed into a molar body, and may continue its sojourn Avithin the uterus for months after the widoAvhood of the female. When, therefore, I tell you that such contingencies have occurred, is it not import- ant that we should be someAvhat reserved in the expression of a prejudicial opinion in either of these citations, without some broader foundation than the isolated circumstance—that a mole has been expelled ? THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 287 Without yielding the slightest endorsement to the fanciful pic- tures draAvn by some authors of the striking resemblance betAveen uterine moles and certain animals, such as lizards, screech-oAvls, monkeys, frogs, etc., yet it is well to remember that the mole is not of a uniform aspect, but will assume a variety of shapes and figures, and still exhibit all the evidences of a true mole. The folloAving interesting case, in Avhich I performed, almost in extremis, an important operation, may not be Avithout instruction, as having a bearing on the question now under consideration : On Wednesday, April 7, 1849, Mr. D. requested me to pay a professional visit to his wife. She had been attended for several weeks by two medical gentlemen who, on the day before I saAV her, had voluntarily withdraAvn their attendance under the conviction that her case was without remedy, and with the opinion fully expressed to Mrs. D. and her friends that, in all probability, she Avould survive but a few hours. Her husband, in his intervieAV Avith me remarked, that he was Avithout the slightest hope, he and his friends having watched Avith the suffering patient the tAvo previous nights, expecting her death at any moment. With such a repre- sentation of the case, I frankly told him I thought a visit from me useless, but if it would afford him any gratification I would cheer- fully accompany him. He repeated his desire that I should see his wife. On being introduced into her chamber, I found her lying on her back, her face pale and emaciated, with every indication of extreme prostration; the expression of her countenance also gave evidence of great suffering. Her pulse Avas thready, and beat one hundred and tAventy to the minute. Such Avas her exhaustion that when I addressed a question to her it became necessary for me to place my ear to her lips to distinguish her answer, and even then the articulation avus almost inaudible ; in one Avord, the appearance of the patient Avas that of a dying Avoman. Her respiration was labored, and the abdomen as much distended as is usual at the ninth month of gestation. On percussing the abdomen, I distinctly recognised fluctuation ; in attempting to introduce my finger into the vagina, Avith a view, if possible, of ascertaining the character of the enlargement, I felt, at the opening of the vulva, a soft, elastic tumor, projecting through the mouth of the Avomb, Avhich was dilated to the size of a dollar piece. The parietes of the os uteri thus*dilated Avere extremely attenuated, and did not appear to be thicker than common writing- paper. I found no difficulty in introducing my finger betAveen the tumor and internal surface of the cervix, the adhesion being so delicate as to yield to the slightest effort. I satisfied myself that there Avas no action in the Avomb; the patient had not experienced anything like labor pains, and the dilatation of the cervix was the result merely of mechanical pressure produced by the tumor within 288 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the uterus. While pressing gently with my finger on the tumor, as it presented at the mouth of the Avomb, and grasping Avith the other hand, the abdominal enlargement, I could a second time distinctly feel fluctuation. Again: in placing my finger on the outer portion of the posterior lip of the uterus, and seizing Avith the other hand the upper surface of the tumor through the abdominal Avails, alternately elevating and depressing the tAvo hands, it Avas evident that I embraced the womb itself, AA'hich Avas immensely distended by the groAvth of the tumor. In making an examination, per rectum, the enlarged uterus Avas detected Avithout difficulty. These circumstances, together Avith the important fact, that the abdominal enlargement Avas uniform on its surface, possessing nothing of the features usually attending extra-uterine groAvths, such as ovarian and fibrous tumors, caused me to arrive at the con- clusion that, in the present case, the tumor Avas exclusively intra- uterine. It Avill be perceived that, on this decision, depended the remote hope of giving to the suffering and almost dying patient even temporary relief from her agony. Having, therefore, formed my judgment as to the seat of the tumor, and partially as to its nature, I stated to the husband that, desperate as the case was, and immi- nently perilous as Avould of necessity be any attempt to remove the tumor in the exhausted and nearly hopeless situation of his Avife, yet, it Avas my opinion that it could be removed, although the serious hazard icas, that the patient would sink under the opera- tion. This opinion was given emphatically, Avithout reserve, and unac- companied by a Avord of comment, calculated to urge consent to an operation, which presented but little prospect of permanent relief, and could only be justified by the reasonable expectation that, if the patient should survhre the removal of the tumor, her sufferings Avould be mitigated, and her progress to the grave rendered com- paratively comfortable. The opinion was communicated to the patient by her husband, and she expressed an unqualified desire that the operation should be performed Avithout delay, remarking that she was prepared to encounter everything, even death itself, Avith the remote hope of temporary relief from the agony occasioned by the pressure of the tumor. The husband and friends acquiescing in this appeal of the unhappy patient, I left the house for the necessary instruments, promising to return in half an hour and per- form the operation. On my return, I was accompanied by Dr. Detmold and two of my pupils, Messrs. Woodcock and Burgess. These gentlemen heard Avith me the folloAving particulars of the case, as related by the husband and sister of the patient: Mrs. D. was forty-seven years of age, and married in 1832. Soon after her marriage she Avas attacked Avith cholera; during her con- valescence from this disease, she miscarried. Her health had been THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 289 more or less infirm for the last ten years. Her menstrual periods had ahvays been regular, with the exception of the last year, during whicli time they occurred once in tAvo or three months, and then not freely. This she imputed to change of life, and the circum- stance did not attract any special attention. Her abdomen had begun to enlarge in July, 1849, and continued to do so to the present time. In January last, she suffered greatly from distension of the bladder, and could not void her urine except in small quantities, accompanied by excessive pain. For this she consulted a medical man, who found it necessary to introduce the catheter, from time to time, to relieve the bladder. She commenced as early as January to be constipated, and defecation Avas attended Avith excruciating suffering. These difficulties about the bladder and boAvels continued to increase, and for weeks before I saAv her, she repeatedly passed over ten days Avithout an evacuation—medicines having no effect, and injections, per rectum, immediately returning Avithout bringing aAvay any fiecal matter. Her urine was voided in very small quantities, not more than tAvo tablespoonfuls at a time, and it Avas nearly the color of blood. It was impossible for her to evacuate the bladder, except Avhen resting on her elboAvs and knees; this position, hoAvever, occasioned so much fatigue, that, in her present exhausted condition, she could not avail herself of it. In a Avord, the agony of this unhappy sufferer Avas induced almost entirely by the pain consequent upon the attempt to evacuate either the bladder or rectum. With these facts before me, together wdth a knowledge of the position and bearings of the tumor, it Avas not difficult to arrive at the important conclusion that the pain and distress in the bladder and rectum were due to mechanical pressure of the intra-uterine growth. At my request, Dr. Detmold examined the patient, and, in view of all the circumstances of the case, concurred with me in opinion that, without an operation she could survive but a few hours; while if she did not sink under the attempt to remove the tumor, her distress xoould be sensibly palliated, and her life possibly prolonged. AVith the understanding, therefore, of the uncertainty and im- mediate danger of the operation—an understanding fully appreciated by the patient and her friends, I proceeded to remove the tumor in the folloAving manner: A mattress Avas arranged on a table, and Mrs. D. placed on her back, her hips being brought to the edge of the mattress, the thighs flexed on the pelvis, and an assistant on either side to sup- port the feet and limbs. I then introduced the index finger of the right hand into the Avomb, steadying the tumor with the other hand applied to the abdomen, and succeeded in directing my finger its full length betAveen the tumor and cervix of the uterus; this 19 290 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Avas done with great caution, for the parietes of the cervix Avere so extremely thin, that indiscreet manipulations Avould almost cer- tainly have produced rupture of the organ. With a vieAv, there- fore, of obviating such a result, I thought it more desirable to break up the adhesions of the tumor simply Avith the finger than incur the hazard of introducing instruments into the uterine cavity. In proportion as the adhesions yielded, I grasped the tumor, and AA'ithout much effort was enabled to remove it Avith my hand in fragments. Having brought aAvay in this manner all the solid por- tions, and carrying my hand Avell into the cavity of the womb, I distinctly felt a sac pressing, as it were, against my finger. I im- mediately ruptured this, and there escaped, by measurement, three quarts of fluid Avhich resembled in all its physical qualities, Avith the exception of the smell, pure pus. This fluid Avas collected in a vase as it passed from the womb, and half an hour aftenvard on examin- ing it, Ave found it no longer liquid, but presenting a solid mass, pearly, like hardened lard. It Avas evident, therefore, that the temperature of the body kept this substance in a fluid state. As soon as the fluid had escaped, I introduced my hand still higher, and felt something in touch resembling human hair. It was, in fact, a mass of human hair matted together, with no other vestige of an embryo—there Avas no trace of scalp or anything else save the hair. I grasped this body, and removed it from the womb entire, it being so compact as not to separate in fragments. The uterus, thus freed of its contents, contracted, and there Avas no loss of blood. After the solid parts of the tumor had been extracted, there escaped from the bladder an incredible quantity of high-colored urine, which gave such relief to the patient that it caused her to exclaim, in simple, yet emphatic language, " Doctor, I am in Heaven !" It may here be asked Avhy the catheter had not been introduced before commencing the operation. In answer to this very proper question, I would merely remark that every legiti- mate attempt had been made to effect this desirable object, but it was found physically impossible—Avithout inflicting serious injury on the patient—from the pressure of the tumor on the neck of this organ. Mrs. D. bore the operation Avith a heroism aa hich greatly surprised us; and although it became necessary to suspend all manipulations, to rally her from fainting, which occurred three different times, yet, considering her extreme prostration, it may well be deemed a matter of amazement that she did not sink. The operation being completed, the patient Avas placed comfortably in her bed. In the course of half an hour, her breathing became easy, the pulse fell ten beats in the minute, and there was an expression of composure about her countenance, AA'hich gave sincere joy to all of us, feeling, as Ave did, an intense and unaffected anxiety as to the immediate THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 291 issue of the case. Without the aid of an anodyne, she fell into a sleep Avhich lasted six hours, the first repose she had enjoyed for many long nights of agony. When she aAvoke, she appeared greatly refreshed, and, although extremely prostrate, seemed to take pleasure in gazing on her friends, to each of Avhom she gave a look of recognition. In the morning after the operation, her bowels AA'ere spontaneously and freely moved, a large quantity of hard faecal matter passing away. Subsequently, injections, simply of warm Avater, sufficed to afford her a daily evacuation, and the urine Avas discharged freely and without obstruction. Mrs. D. continued to improve in appetite, digestion, and strength; and, although her friends Avere admonished not to be too sanguine as to her recovery, yet they regarded the fear of any other issue as utterly groundless. On the 22d of April, fifteen days after the operation, she began to fail, and in defiance of everything winch could be brought to bear in her case, she con- tinued to sink, and expired on the 25th of April, having survived the operation eighteen days. I have no doubt the anomalous mass found in the Avomb of this patient Avas the product of a blighted ovum, and it may be reason- ably asked Avhether her chances of recoA'ery Avould not have been greatly enhanced if the tumor had been removed at an earlier period, before the poAvers of the system had become exhausted by long-continued and uninterrupted suffering. The adhesions, it will lie remembered, of the shapeless mass to the internal surface of the womb were slight. The stearine, Avhich escaped after the sac Avas ruptured, I regard as nothing more than the fcetal brain, and other fatty portions of the system, in solution. These circumstances, together AA'ith the quantity of human hair removed from the uterus, and the fact that the tumor Avas comparatively of rapid groAvth, are, in my judgment, conclusive proof of previous conception. False Moles—Moles Spuria?.—These will embrace all the sub- stances formed in the uterus, in no way connected Avith impregna- tion—such as polypoid and fibrous growths, blood clots, the mem- brane of congestive dysmenorrhoea, and, perhaps, the true uterine hydatids denominated acephalocysts. It may be mentioned here that the mucous polypus has often been confounded with the mole due to a previous fecundation. Young girls Avill sometimes, after extreme local suffering, expel substances more or less solid from the uterus; in cases like these, the medical man cannot be too much on his guard—a shade of doubt expressed by him Avill immediately be interpreted adversely to character; and rumor, Avith her thousand Avings, Avill soon con- sign to infamy the purest and most spotless. Remember, gentle- men, that the young girl Avho has become the object of suspicion is 292 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. worse than the Avithered floAver—nay, she is the upas of society—■ her very presence is avoided, for the reason that social contact Avith her begets, as it Avere, an atmosphere of pestilence, destructive alike to all Avho breathe it! A man may be suspected of forgery, and yet, by a chain of irresistible evidence, he may prove his inno- cence, and become restored to society. So may one of you be charged Avith the high crime of murder, and yet it may be in your power to demonstrate Avith mathematical certainty that you are unstained with the alleged victim's blood. But Iioav different with woman, Avhose chastity is once questioned; no eloquence can appease the credulous in her behalf—no proof can emancipate her from the damning influence of suspicion—there she is, repulsed and scorned, although as immaculate as purity itself! Look to it, then, and see that you do not sacrifice character by hasty and unjust decisions. Even in the days of Hippocrates it Avas admitted that substances will sometimes be expelled from the uterus of strong, plethoric young girls, and this, too, in perfect keeping Avith their chastity. That clever observer, Galen, to Avhom Ave are indebted for so much that is sound and practical, contended that, as hens Avill occasion- ally lay eggs Avithout the tread of the cock, in the same Avay will it be possible for females to generate moles independently of sexual intercourse.* I imagine there can be very little doubt that the substances alluded to by Hippocrates, as being thrown from the uterus in robust and plethoric young girls, are identical with what will be observed oftentimes in congestive dysmenorrhoea. I have, you will recollect, when speaking of menstruation, reminded you that the catamenial fluid consists of t\Aro distinct elements, viz. blood and epithelial mucus. Some avliters, among others, Dr. Tyler Smith, f maintain that the mucous membrane itself passes off at each menstrual turn; but this I think is not so. As a general rule, it is simply the epithelium, the surface covering, as it Avere, of the mucous lining, which is expelled from the organ with the menstrual fluid, and the epithelium is again reproduced, only to pass off at the folloAving monthly evacuation. On the other hand, however, it must be conceded that the mucous membrane itself has occasionally been recognised in the expelled mass. Plater long since published a case of this nature in a paper entitled, Molm incipient is frequens dejectio ; and Morgagni has described, with * The feet of hen3 and birds occasionally throwing off eggs without the tread of the cock, is physiologically extremely interesting. These eggs are not the result of fecundation, but merely the offspring of excitement. They are deciduous, and can- not be incubated, for the reason that they have not been vitalized by the male. There is a strict analogy between these eggs and the ovules, which pass with the catamenial fluid from the human female at each menstrual turn. f Lectures on Obstetrics, Gardner's edition, p. 95. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 293 great minuteness, a membrane throAvn from the uterus, Avhich pos- sessed all the characteiistics of the mucous covering of that organ.* In the congestive type of dysmenorrhoea, it not unfrequently hap- pens that, in consequence of the extraordinary afflux of blood to the mucous lining of the uterus, there is poured out a quantity of coagulable lymph, analogous to Avhat occurs on the internal surface of the larynx in the membranous form of croup. This exudation of coagulable matter becomes, so to speak, a foreign substance Avithin the uterine cavity; its presence stimulates the uterus to contraction ; and, hence, there will be recurrent pains, simulating, in their general character, but in a much less exaggerated degree, the throes of labor. Finally, this substance is expelled from the uterus, and the pain subsides. Now, gentlemen, this is not at all unlikely to occur in a young girl whose purity is beyond suspicion. Yet the phenomena to AA'hich I have just alluded may blast that girl's character if you are not prepared to shoAv that they are in perfect accordance Avith chastity, and are the result simply of a pathological condition of the menstrual function. This coagulable lymph will sometimes be dis- charged in shreds or patches, and again it Avill assume the form of a sac or membrane, exhibiting a complete cast of the uterine cavity. In the Gazette Medicale, of Paris, f there is recorded by Dubois, of Neufchatel, an interesting case of a young Avoman Avho, at each menstrual period, expelled a hollow, membranous body, correspond- ing precisely with the shape of the uterus. Besides this membrane, there will sometimes be throAvn from the virgin and unimpregnated female, other substances; such, for example, as small, fibrinous masses, Avhich appear, at first sight', to be organized, but oftentimes are simply coagula of blood; and again, there will be observed scales of epithelium, Avhich, by possi- bility, might compromise the character of the woman. Therefore, in all such cases, where suspicion is on the alert, it is your duty, by a careful examination of these substances, to decide as to their true nature, so that, by the strength of your professional opinion, you may at once do justice to the girl, who has not only selected you as the guardian of her health, but at the same time the pro- tector of her honor. In the case of the discharge of epithelial fragments, either from the uterus or vagina, the microscope will readily enable you to recognise the scales or squamae, Avhich consti- * Follin, Lebert, and others have recognised in the dysmenorrhoeal membrane th€ following peculiarities, known to exist in the mucous tissue of the uterus: 1. Con siderable thickness, greater than that of any of the mucous surfaces of the body 2. Tubulous glandules, readily detected with a lens, and visible even to the naked eye 3. These glandules are united to each other by a fibro-plastic tissue and blood-ves- sels, which together constitute the dermis of mucous membranes. f See Gazetie Medicale. p. 7^9. 1847. 29-4 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tute their characteristics ; and so, too, with regard to the fibrinous concretions ; these are usually small, almond-shaped bodies, with an undefined central cavity, and a smooth exterior. In none of these substances, of course, Avill there be the slightest vestige of any of the fatal annexse, such, for example, as the villi of the chorion, fragments of the placenta, or umbilical cord ; and for the best possible reason, that their production is entirely independent of sexual intercourse, and consequently of pregnancy. I could very readily multiply authorities on this question, but shall content myself Avith the folloAving: Lamsweerde * divides moles into tAvo kinds—one he calls the mole of generation, the other the mole of nutrition; in reference to the latter, he affirms that a fleshy tumor may spring in the virgin womb from the matter of nutrition—" Mola nutritionist This author insists that, for the production of the mole of generation, coition is absolutely necessary. Ruysch, f speaking of false moles, says, "Such moles have been forced out by virgins, or, at least, by such as Avere not suspected of being otherwise." The folloAving is the language of Yan Swieten :| " It is certain that all those masses called moles, Avhich contain a human embryo, and those Avhich are formed by the corruption of the little placenta left in the Avomb, cannot be produced Avithout coition. But it is equally certain that the sarcomas of the womb, and the masses that spring from clotted blood, may be generated Avithout any coition. But as these are comprised under the general name of moles, it is evident that the name of moles should be used with great caution, lest untainted virgins and chaste AvidoAvs should be branded with the infamy of incontinence!" Can True Hydatids form in, and be expelled from the Ute- rus?—It has already been remarked, that Avhat are known as true hydatids haA-e no connexion Avhatever Avith a previous conception ; they are entirely independent in their origin of any such influence. Therefore, it is a question of unqualified interest to inquire Avhether it be possible for them to be generated within the uterus. It is true, science has but slender evidence recorded of the true hydatids being discharged from the uterus; and the general belief is, that they cannot originate in that organ. Rokitansky,§ certainly a good authority, says, " Cysts are very rarely formed in the uterus ; Ave haAre not met with a single example in Yienna, and I myself have only inspected one case of uterine acephalocysts." Here, then, is an admission that, in one instance, at least, the true hydatids have originated in the uterus. The admission, therefore, of this one case, while it proves the extreme rarity of the occurrence, conclusively * Histor. Molar. Uteri, cap. 1. p. 13. f Observat. Anatomic. Chirur., p. 54. J Commentaries on Apho. of Boerhaave, vol. xiv., p. 180. § Pathological Anatomy, vol. ii., p. 291. London, 1849. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 295 establishes the fact of the possibility of these formations. Indeed, I do not understand what there is in the anatomical structure of the Avomb at all incompatible Avith the groAvth of these acephalocysts ; it is universally agreed that they are found in other portions and structures of the economy—why not, also, under certain circum- stances, may they not originate in the uterus? But a most material question is this: Have we any reliable means of distinguishing the true hydatids from the products originating from the degenerated villi of the chorion ? This ques- tion may be answered affirmatively—under the microscope, and sometimes with the naked eye, Avhen true hydatids exist, it will be observed that the cysts are inclosed one Avithin the other; on the contrary, in the hydatiform vesicles, these latter, Avhich may be rounded or oval shaped, are attached to each other by slight pedicles, and have not been inaptly compared to a string of beads'. These distinctions are now recognised as ample to prevent any possibility of confounding the one with the other. The conclusion, therefore, is manifest, that, in all cases, in Avhich these bodies, of either class, are discharged from the uterus of an unmarried female or widow, no deduction adverse to the party should be draAvn except upon the evidence just mentioned; for science fully justifies the evidence. LECTURE XXI. Labor—Multiplied and Unprofitable Divisions of; Classification of the Author into Natural and Preternatural; Labor consists of a series of acts—Important Practi- cal Deduction connected with this Succession of Phenomena; Duration of Preg- nancy—When does it Terminate ?—The Original Mode of Calculating Time; Calen- dar and Lunar Months—Has Pregnancy a Fixed Duration?—The Gardner Peerage Case—Conflicting Opinions; Testimony of Desormeaux—The Code Na- poleon in reference to Tardy and Premature Births; P'xperiments of Tessier; Tropical Heat and Vegetation—How is the Period of Pregnancy to be ascer- tained ?—The various Modes of Calculation—Dr. Reid's Experiments in reference to a Single Coitus ; Naegele's Opinion ; Dr. Clay, of Manchester—Influence of the Age of the Parent on the Duration of Pregnancy—Can a Female be Fecundated during her Menstrual Period ?—Case in Illustration. Gentlemen—We have now, in the order of succession of subjects, reached an important and interesting topic—one Avhich will necessa- rily demand much attention, for it is most intimately connected Avith your duties in the lying-in chamber—I mean labor. I am not a little surprised at the singular and multiplied divisions, Avhich dif- ferent authors have given of parturition. In my honest judgment, these divisions tend more to complicate than simplify the subject. Without, therefore, embarrassing you with Avhat I am disposed to term unnecessarily minute classifications, I shall present you Avith a very simple division of labor, Avhich, I think, you will recognise to be in entire accordance Avith the revelations of nature. Divisions of Labor.—Labor, for all practical purposes, is either natural or preternatural. Natural labor, Ave denominate that form of parturition in Avhich delivery is effected by the unaided efforts of nature ; or, in other words, without the assistance of art. But, in order that nature may be thus adequate to the discharge of this duty, certain conditions are demanded both as regards the mother and child, and these conditions Ave shall enumerate in detail hereaf- ter. Preternatural labor, on the other hand, as its name implies, is contrary to the natural process, and therefore, needs the inter- position of science. It may be divided into manual and instru- mental ; in the former, the introduction of the hand is necessary to overcome the obstacle ; in the latter, the hand being insufficient, the employment of instruments is indicated. Instead, therefore, of calling labor tedious, complicated, laborious, or difficult, after the example of most writers on this subject, Ave propose to discuss the various topics and duties connected Avith human parturition, under THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 297 the two divisions of natural and preternatural labor—divisions Avhich Avill not only be recognised as just in the lying-in chamber, but Avhich will embrace every possible contingency that may arise during the parturient effort. Natural labor, Avhen accomplished, may be said to be the separa- tion of the mother and foetus; it is the transmission of the latter through the maternal organs, in order that it may enjoy an inde- pendent existence, for which its previous uterine development has prepared it. Its organization is iioav so complete, that, Avhen thrown into the world, it can breathe, and elaborate its own blood; it is no longer dependent upon the functions of the placenta; in a Avord, its birth constitutes it physiologically an independent being. This expulsion, hoAvever, of the foetus and its annexae from the parent Avomb is not a sudden and abrupt act—on the contrary, it is a deliberate effort on the part of nature—made up of a series of successive processes Avhich, when in completion, constitute parturi- tion. It is this very succession in the order of phenomena, Avhich guarantees safety to the child, and immunity to the mother; so that, under ordinary circumstances, natural labor may be regarded as one of the functions of the female economy, in no Avay necessarily compromising human life; and I am quite certain that it is to " meddlesome midAvifery " that much of the fatality of the parturi- ent chamber is to be imputed. The usual processes to Avhich I allude as connected with the accomplishment of labor are, in the order of sequence, as follows: 1st. The uterus contracts, the result of which will be to dilate the mouth of the organ ; 2d. The membranous sac or "bag of Avaters" is formed, and becomes ruptured, affording escape to the liquor amnii; 3d. After the escape of the amniotic fluid, the uterus grasps more firmly the body of the foetus, resulting in an increased expul- sive force, Avhich accomplishes its delivery ; 4th. The placenta and its annexae—the cord and membranes—are then expelled; 5th. There is for some days a discharge from the vagina, known as the lochia. These, therefore, make up the chain of acts, or processes, which, in the aggregate, constitute child-birth, AA'hen accomplished by nature herself. Does not this very order of phenomena inculcate upon the obstetric student the order of his duties? It should emphatically impress upon him the necessity of studying nature in her own inimitable ways, so that Avhen she is embarrassed by cir- cumstances, Avhich she cannot control, he may be there to act as her substitute, and render the needed assistance. Duration of Pregnancy.—As preliminary to the consideration of your duties in the lying-in room, it is proper that Ave should examine three interesting questions—the period, the causes, and the signs of labor. The period at Avhich labor commences, neces- sarily involves the discussion of the duration of pregnancy; for it 298 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. is evident that the termination of pregnancy is but the advent of labor. The duration of pregnancy, you must at once perceive, is a question of no trifling import ; for the honor as Avell as the rights of individuals will oftentimes depend upon a just decision of this point. The popular opinion, endorsed by the general voice of the Profession, is, that the human female carries her infant nine months. Now, then, the question arises—can a female be spontaneously delivered before the expiration of this period—or can she retain the foetus beyond the nine months consistently with fidelity to her hus- band, and the civil and social rights of her child? The term nine months is too indefinite—it is Avanting in precision, and for the very obvious reason, that betAveen calendar and lunar months there is a fixed difference; so that nine lunar months or nine calendar months represent an important difference in time. Each lunar month embraces a period of 28 days—so that ten lunar months are equal to 280 days or 40 weeks. Nine calendar months, on the contrary, including February, represent 273 days, or 39 Aveeks. It is, therefore, perhaps, better, as many authors have done, to fix the period of human gestation, not at nine months, but at 40 weeks, or 280 days. There can be no doubt that, as a gene- ral rule, 40 Aveeks constitute, Avith the exception of tAvo or three days, the true period of fcetal existence. But is this rule so gene- ral—in a Avord, is it so universal, that it admits of no exceptions ? This is the plain putting of the question—and Ave shall noAV proceed briefly to examine it, for on its just decision must depend the high- est social and legal interests. On this subject—as on many others— there is a difference of opinion. It has been much discussed, and the advocates on either side—earnest in pursuit of truth, except when animated more by love of victory than of justice—are arrayed against each other in the emphatic spirit of uncompromising con- troversy. Tiiose Avho contend that gestation has a universally fixed dura- tion, and consequently reject the possibility of protracted or prema- ture births, found their opinion on the folloAving arguments: 1st. The uniform and immutable law of nature in the reproduction of all lh'ing beings—a laAV which defines, with unerring precision, the period of gestation for each species of animal. 2d. Against the pos- sibility of protracted gestation, they invoke the aid of physical influence, for they maintain that the sojourn of the foetus in utero, beyond the allotted time, would result in such an increase of vol- ume as to render its safe delivery impossible. These, I think, are the chief arguments of writers, Avho oppose the idea of a depar ture from what they conceive to be the invariable standard of nature. In order that you may understand that this difference of opinion, on the interesting question uoav under consideration, was not con THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 299 fined to the men of the past ages, I shall cite the folloAving impor- tant case, Avhich Avas tried in the House of Lords in 1825, knoAvn as the celebrated Gardner Peerage Case: Allen Legge Gardner, the son of Lord Gardner, by his second Avil'e, petitioned to have his name inscribed as a Peer on the Parlia- ment Roll. The Peerage, hoAvever, was claimed by another person —Henry Fenton Iadis—Avho alleged that he Avas the son of Lord Gardner by his first, and subsequently divorced Avife. It Avas con- tended that the latter Avas illegitimate; and in order to establish this point, the evidence adduced Avas partly medical, and partly moral. Lady Gardner, the mother of the alleged illegitimate child, parted from her husband on board of his ship on the 30th of Janu- ary, 1802. Lord Gardner went to the West Indies, and did not again see his Avife until 11th of July folloAving. The child, Avhose legitimacy Avas disputed, Avas born on the 8th of December of that year. Therefore, the plain medical question, taking the extreme vieAA', Avas, whether a child born 311 days [forty-four weeks and three days), after intercourse (from January to December), or 150 days (twenty-one weeks and three elays), from July to December, could be considered to be the child of Lord Gardner. If these questions Avere answered in the affirmative, then it folloAved that this must have been a very premature or a very protracted birth. There Avas no pretence that this Avas a premature case, the child having been mature AA'hen born. The question, then, Avas reduced to this: Was this alleged protracted gestation consistent Avith medical experience ? Many medical Avitnesses, comprising the principal obstetric practitioners of Great Britain, Avere examined on this point. Their evidence Avas very conflicting—five positively main- taining that the period of gestation Avas fixed; and therefore, denying the possibility of such a protraction. The other eleven sustained the affirmative side of the question, and concurred in opinion that natural gestation might be protracted to a period which Avould cover the birth of the alleged illegitimate child. On the moral side of the question, it Avas clearly proved, that Lady Gardner, after the departure of her husband, was living in open adulterous intercourse Avith a Mr. Iadis ; and, on this ground, Lord Gardner obtained a divorce from her after his return. It Avas con- tended that the other claimant Avas really the son of Lady Gardner by Mr. Iadis. The decision of the House was, that this claimant Avas illegitimate, and that the title should descend to the son of the second Lady Gardner.* There are two interesting points in this case: 1st. The extraor- dinary difference of opinion among the medical Avitnesses; 2nd. The undoubted proofs of adultery on the part of Mrs. Gardner, on Taylor's Medical Jurisprudence, 5th edition, p. 586. 300 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. which ground alone the case AA'as decided against her illegitimate offspring. On this memorable occasion, the folloAving Avas the opinion delivered by Sir Charles Clarke, certainly a man of no doubtful reputation: " I have never,'1'' he said, " seen a single instance in which the laws of nature have been changed, believing the late oj nature to be, that parturition should take p>lace forty weeks ctfter conception." There is an exclusiveness, might I not say, Avithout meaning any disrespect, an arbitrary positivencss in this opinion, Avhich is more in keeping Avith the dictum of an ancient Romau Emperor, than Avith the requirements of science. But Sir Charles Clarke was not alone in his views; he Avas sustained, in his general assumption, by Prof. Davis, Dr. Gooch, and others of equal emi- nence, Avho maintained that Avomen never exceeded the ordinary period of gestation. Strange to say, however, as unanimous as these gentlemen Avere as to the cardinal point—the immutability of nature Avith regard to the period of human gestation—yet there was an extraordinary Avant of concurrence among them as to Avhat measure of time that period really is! Whether upon the Avitness's stand, or in the professorial chair, the opinion of a medical man is worth nothing except Avhen in accordance Avith facts. Hypothesis is one thing ; clear and avcII- established facts another. It seems to me that if human testimony is to be regarded, under any circumstances, as a guide for opinion, the possibility of protracted as Avell as premature gestation is placed beyond a peradventure. There are so many well-authenticated cases, thoroughly and essentially truthful, in confirmation of this statement, that I cannot understand how a contrary sentiment can, at least at the present day, prevail. I think a most satisfactory and irresistible evidence of the possibility of a gestation protracted beyond 40 AA'eeks, or 280 days, is to be derived from the interesting case recorded by the learned Desormeaux, and it affords me much pleasure to advert to it, for the reason that, independently of his high character for learning and moral Avorth, I feel that I owe much to his personal kindness, for it Avas through his partiality that I was admitted, for a period of nearly two years, into the Maternite of Paris, during which time I had abundant opportunity of witnessing his tact and skill. After remarking, that " Observations, Avell attested, conclusively shoAv, that the term may be prolonged beyond the usual period,'' he introduces the following case as having occurred Avithin his OAvn experience: " A lady, the mother of three children, became deranged after a se\'ere fever. Her physician Avas of opinion that pregnancy might have a beneficial effect on the mental disease, and permitted her husband to visit her; but Avith the restriction that there should be an interval of three months between each visit, in order that, if THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 301 conception took place, the risk of abortion, from further intercourse, might be avoided. The physician and attendants made an exact note of the time of the husband's visits. As soon as evidences of pregnancy began to exhibit themselves, the A'isits Avere discontinued. The lady Avas closely watched during the Avhole period by her female: attendants. She was delivered at the end of nine calendar months and a fortnight, and Desormeaux attended her. If the nine calendar months Avere those of the smallest number of days, they would have equalled 273, in addition to Avhich must be taken into account the days of the fortnight, Avhich will make 287 days; but if the calendar months Avere not of the shortest period, there Avould be 276, to Avhich are to be added 14, giving an aggregate of 290 days." I cite this case to show that nature does sometimes exceed the ordinary period of 280 days, or 40 weeks; and it does seem to me, if it be demonstrated that, under certain circumstances, nature dis- closes a departure from the usual period of gestation, it is a con- cession amply sufficient for science, Avithout involving the necessity of showing on Avhat this departure is founded, or the conditions Avhich regulate it. There are numerous other cases recorded by authors of equal probity, exhibiting not only the occasional pro- traction of gestation, but proving, beyond a shade of doubt, that Avomen will sometimes bring into the world living children before the expiration of the 40 Aveeks. , Let me here remind you that one of the most enlightened coun- tries of Europe, after a scrupulous investigation of all the facts for and against the question, has enacted, by legislative decree, in the Code Napoleon, that a child born 300 days after the departure or death of the husband, or 180 days after marriage, shall be considered legitimate, and, therefore, entitled to all its social and legal rights. It may, indeed, appear at first sight, that this enactment is one of too much latitude, and Avill oftentimes afford a mantle for the guilty. Be it so—but is that a justifiable reason for destroying the character of the pure and innocent? Indeed, there are cases re- ported upon authority Avhich Ave have no right to question, in which human gestation has been retarded many days beyond the period sanctioned by the Code Napoleon. Dr. Simpson records, as having occurred in his own practice, cases in AA'hich the period reached 336, 3«2, 324, and 319 days. Dr. Merriman, 298 days; and Prof. Mur- phy, 297 days. Dr. Atlee reports two cases Avhich nearly equalled 356 days each; and Prof. Meigs publishes a case, which he deems entirely trustworthy, of 420 days. It is not for me to say that there Avas probably a miscalculation in some of these extreme cases; but admitting the error, Avhich I do not think at all unlikely, yet with such acute observers, and with no motive to subserve but that of truth, it must be conceded that, 302 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. with a liberal margin for error in computation, these examples should be accepted as undoubted evidences of the fact that preg- nancy will, occasionally, extend beyond 300 days. If the main proposition be accepted, that the ordinary term of 280 days is not the universal term of gestation, and of this there can be no doubt, it appears to me an extremely difficult problem to fix the particular period of time, in Avhich nature may be found to depart from her usual standard. After all, it must be admitted, the only important point in the discussion is this: Is nature as regards the period of human gestation governed by any fixed and immutable laic, or is the rule ichichshe observes only a general one, subject to occasional exceptions ? That the latter is true is most perfectly demonstrated. If we turn, for a moment, from the evidence deduced from the observations connected Avith human gestation, and examine the record of reproduction as it occurs in the loAArer animals, Ave shall find not only substantial, but very convincing testimony that nature is not governed by any uniform laAv as regards the particular period of pregnancy. The experiments of Tessier, made Avith great care, and with every effort to guard against the possibility of error, continued, too, for a period of years, have revealed some extremely interesting facts. His experiments embraced various animals— cows, mares, sheep, rabbits, &c.; and it should be remembered that the results gathered from these experiments are the more satisfactory, for the reason that they were not liable to the fallacy, or exposed to the possible error contingent upon this species of observation in the human subject. In 577 coavs—and it is impor- tant as well as interesting to recollect the usual period of gestation in this animal is the same as in woman—20 calved beyond the 298th day, some reaching the 321st day—amounting to a departure from the ordinary term of Avithin a fraction of six Aveeks. In 447 mares —the period of gestation is 335 days—it Avas noticed that 42 foaled between the 359th and 419th days, so that in them the greatest excess Avas 84 days. In the sheep and rabbits the same dis- crepancy Avas recognised ; while in the hen, it was remarked that the period of incubation Avas often protracted for three days. These results have been amply confirmed by other observers. The following are the observations of Prof. Krahmer, of Halle, made on the coav, and it will be seen that they accord, in their general results, with those of Tessier : 12 cows calved in the 38th week. 72 n " 39th " 335 u " " 40th u 429 II " " 41st " 135 ii " " 42d II 33 II K " 43d, " 9 " u i 45th " 3 " ii " 46th " 5 " it i :' 47th " 4 " u < 48th " 1 " u i 51st " THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 303 But, gentlemen, it is altogether unnecessary to accumulate proof in support of the affirmative of the question. There can be no doubt that, in the great reproductive scheme, the general type is found to prevail throughout animated nature ; and it must also be conceded that this type is subject to occasional variations, Avhich, because they cannot be adequately explained, should not, therefore, be rejected. In the vegetable kingdom, the influence of climate and seasons is invariably admitted. Under the genial rays of a southern sun, the earth sends forth its fruits* with a precocity unknoAvn to the more northern latitudes. May it not be that there is some kindred, yet occult influence exercised upon the human system which, in one case, leads to a premature development of the germ, while in the other, it retards the reproductive processes of nature ? This hypothesis, it appears to me, is about all that the present state of science can furnish in explanation of premature and protracted births. I might have mentioned that Dr. Charles Clay, of Manchester,* Avhose name is so honorably intenvoven Avith the operation of ovariotomy, in which he has had most remarkable success, has pro- mulged the suggestion that the duration of pregnancy may be influenced by the age of the parents, and from the observation of cases, Avhich have occurred in his own practice, he believes that the younger the mother, the shorter is the period of gestation. This theory corresponds Avith the very general belief that the older the animal the more protracted will be the duration of preg- nancy. From all that Ave have said on this subject, we may, I think, safely arrive at this conclusion—that the precise duration of preg- nancy is not positive, but simply relative. Period of Pregnancy.—How is the period of pregnancy to be ascertained—or, in other Avords, is there any rule by Avhich the term of an ordinary gestation can be estimated ? This inquiry is one of more than usual interest, and will have a bearing on your duties as practitioners of midAvifery; for you will often be ques- tioned by your patients in regard to the particular period of their gestation Avith a view of kuowing when they may expect their approaching confinement. There are various modes of calculation, and I think they may be classified as folloAA'S : 1st. The peculiar sensations experienced by the female at the moment of conception; 2d. The period of quickening; 3d. From a single coitus; 4th. From the last menstrual period. Let us now examine briefly, and in order, each of these tests. I. Peculiar Sensations.—The notion that a woman is made con- scious of the instant of her fecundation by a sensation, characteristic * Otservatfons on the Term of Utero-Gestation. By Charles Clay, M.D., p. 9. 30-1 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and peculiar, is not one of modern origin. This opinion has pre- vailed for a long time ; indeed, it can be traced back to Hippocrates himself who, in speaking of conception, observed: "Liquido autem constat harum rerum peritis quod mulier, uti concepit, statim inhorrescit, et incalescit, ac dentibus stridet, ct articulum reliquum- que corpus convulsio prehendit et uterum torpor, idque iis, quae purae sunt, accidit,"* which may be rendered into our OAvn tongue thus: It is AA'ell understood by those skilled in these matters that the instant a Avoman conceives, she experiences a general shivering and heat; her teeth chatter, and the articulations Avith other por- tions of the body are throAvn into convulsive movement, Avhile the uterus itself is attacked with numbness, and this occurs even to women quite pure. Van SAA'ieten says, " From many observations, Ave are assured that Avomen, in the act of copulation, when they are impregnated, enjoy a more than ordinary degree of pleasure; this change in the female organs appropriated to generation is also, Avith good reason, thought to be greater at the time of conception, than AA'hen coition is performed, Avithout impregnation immediately fol- lowing." f There is one insuperable objection to this theory of sensations as a guide for computation, and it is, that Avhatever may occur in individual cases, the fact is abundantly established that occa- sionally Avomen will conceive avIio do not experience the slightest feeling of sexual pleasure—they are as inanimate as the bed on AA'hich they repose; and, under such circumstances, I have knoAA'n ladies continue incredulous as to their true condition until the very approach of their labor, so fully Avere they imbued Avith the popular conviction that sexual enjoyment and impregnation bear to each other the necessary relation of cause and effect. I am aware that some modern authors concede to this theory of sensations a very marked value; and, while I am Avilling to admit that, in certain cases, from some peculiar feeling, more readily experienced than explained, a woman may become satisfied that she has been fecun- dated, yet, as a general principle, the evidence is deceptive, and presents, therefore, no claims as a reliable test. II. The Period of Quickening.—It is recommended by some writers to take the time of quickening as a rule for calculation, and they assume that, as the Avoman quickens at the fourth and a half month, it is quite easy to ascertain the termination of her pregnancy by the addition of four and a half months to the time at which she first felt life. The fallacy of this rule must be obvious, if it be recollected that the time of quickening is by no means a fixed one. Some women feel life at four months, others a little earlier, others- not until the fifth month ; again, in some instances, the entire terra * De Carnibus, cap. 8, torn. v. p. 309. \ Commentaries upon Aphorisms of Boerhaave, vol. 13, p. 369. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 305 of pregnancy will pass without the slightest consciousness on the part of the female that she carries Avithin her a living being.* III. From a Single Coitus.—Efforts have been made to deter- mine the duration of pregnancy by calculating from a single coitus; but it is very evident, that this mode of computation is liable to much deception, for the reason that the majority of such cases Avould most probably occur in the unmarried, who, of course, to diminish the measure of their shame, would very naturally refer their impregnation to a solitary intercourse. Some interesting statements, however, founded upon researches conducted Avith every care to elicit truth, and guard against the possibility of error, have been made by Dr. James Reid, in regard to the question of a single coitus. The following table, embracing forty-three cases, collected by him of conception, supposed to have resulted from a single intercourse, exhibits features not unworthy of attention: f 260 days after single coitus, delivery occurred in 1 263 " u " " " 1 264 " " " " " 2 265 " " ii « "1 266 " " " " " 2 270 " " " " " 1 271 " " " " " 2 272 " " " " " 3 273 " " " " " 1 274 " « e to much alarm, and it Avill be your duty to explain to the patient, not only the cause of these neuralgic pains, and of the menaced paraplegia, but also to assure her that both one and the other v\ ill be evanescent in their character, and are simply the results of the pressure of the prolapsed uterus and its contents against the sacral and other nerves of the pelvic canal. In some females, you will remark the exhibition of great anxiety —accompanied by remarkable depression—a short time before the 328 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. setting in of labor. They will become extremely nervous and irri- table, and it will require, on your part, sound judgment in your appeals to their good sense not to cherish feelings of despondency. I have generally observed that this depression usually manifests itself in Avomen of a naturally morbid irritability, and it is impor- tant to control it, as far as may be, because, beyond certain limits, it may exercise a prejudicial influence on the confinement. Such, gentlemen, are some of the more notable of the indica- tions Avhich precede the commencement of labor, and AA'hich, there- fore, have Avith much propriety been denominated preliminary or precursory. You must not, I repeat, confound the vesical irrita- tion, or the tenesmus, or the increased discharge of mucus from the vagina, Avhich are but the effects of mechanical pressure, Avith morbid conditions of these organs. Suppose, for example, a mar- ried lady should send for you a few days before her confinement, and say to you, "Doctor, I am very much alarmed about myself; I am afraid I have some serious disease of the bladder.'' " Why do you think so, madam ? " " Because, sir, for the last Icav days I have had so much irritation in that part; I have a more or less constant desire to pass Avater.'' Noav, gentlemen, it Avould be a very foolish thing, to use a mild expression, to mistake this irrita- ^ tion of the bladder—simply a premonitory symptom of approach- ing labor—for disease of the organ, and hence subject your patient not only to useless, but, very probably, mischievous medication. Nor, if another lady complain of distressing tenesmus, must you hastily conclude that she is afflicted with dysentery, and therefore place her on the sick list, and conA'ert her innocent and unoffending stomach into a veritable drug shop, for a malady which exists only in your own imagination. You must pardon me for calling your attention to these matters, but I am most anxious that you should, Avhen you enter on the mission of duty, be able to trace effects to causes, and thus distinguish betAveen the shadow and the substance. In these cases, the irritation of the bladder and rectum, like the neuralgic pains and threatened paraplegia—all results of a common antecedent—will disappear as soon as that antecedent, through the termination of delivery, has been removed; and so you must tell your patient. She will find you a true prophet, and consequently her faith in your skill and judgment will be greatly enhanced. Essenticd Signs.—The essential or characteristic signs of labor are four in number: 1. Pain; 2. Dilatation of the mouth of* the Avomb; 3. A muco-sanguineous discharge ; 4. Formation and rup- ture of the membranous sac, or " bag of Avaters." These four phenomena constitute the elements of labor ; and do, in fact, make up its diagnosis. When they are present, parturition is undoubt- edly in progress, and hence they are properly named its charac- teristic indications. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 329 1. Pain.—Under ordinary circumstances, pain is the inevitable penalty of childbirth. " In sorrow shalt thou bring forth," is the decree of Heaven, and it has always seemed to me that the suffer- ing entailed upon the parturient woman but tends to strengthen and consolidate the undying love she cherishes for her offspring. The progress of science, through the application of anaesthetics, has, it is true, to a great extent, emancipated the lying-in chamber from the anguish incident to it, but it may be a question whether this interference Avith the role of nature has not, oftentimes, been productive of serious consequences. That the employment of anaesthetic agents, notwithstanding their undoubted value under judicious administration, has been sadly abused, will, I think, be conceded by every unprejudiced mind. But this is a subject upon Avhich we shall have something to say in a succeeding lecture. Are the Pains of Labor, and the Contractions of the Uterus Identical ?—Those of you who have ever attended a case of labor, and witnessed the intense agony of the Avoman, will, perhaps, express more than ordinary surprise that certain authors should have endeavored to shoAv that the process of childbirth is not one of suffering. It is neA'ertheless true that such demonstrations have been attempted, but to my mind they have failed most signally in their proof. Again : even among those, Avho admit one of the characteristic attributes of the parturient effort to be pain, there is much discrepancy of opinion as to the peculiar manner in which the pain is produced. Some writers, and, indeed, they constitute the great majority, maintain that the contractions of the Avomb, and the pains of labor are identical—but this, I think, is an error and has, no doubt, led to some of the confusion which exists on this subject. So far from the contractions of the uterus and the pains of labor being one and the same thing, I shall endeavor to prove to you—and I hope I may succeed in the development of the opinion—that labor pains are the direct consequences of the contractions, and that they hold to each other the relation of effect and cause. One of the essential conditions in support of this hypothesis is, that the contractions must precede the pain; and do they not ? Let us, for a moment, examine this question. Suppose you are attending a case of labor, which has fairly com- menced—what do you observe ? Your patient, who may have had several severe pains, will, perhaps, be in pleasant conversation with you, when suddenly she will exclaim, " Oh, there, doctor, I am going to have another pain." Properly translated, what is the true import of this language ? Why, it means simply that the patient becomes cognizant of a movement in the uterus, which is nothing but the incipient contraction, and experience has admo- nished her that this moA-ement or contraction of the organ will immediately be followed by the pains of labor. Again : place 330 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. your hand on the abdomen of the patient in whom parturition has commenced, and you Avill, by a few seconds, anticipate the coining on of a pain, because you feel the uterus harden under your hand ; or, with the finger introduced into the vagina, you will know that a pain is about commencing the moment you feel the neck of the Avomb stiffening, if I may so term it, in response to the contractile effort. There is no speculation here; it is a matter of fact, Avhich you can ascertain for yourselves in the very first case of labor which may present itself to your observation—show- ing conclusively that the contraction precedes the pain—the former being the cause, the latter the effect, But, I can readily imagine you to say—Avell, for argument's sake, sir, Ave accept the hypothesis that uterine contraction and labor pain are- not identical, and arc truly cause and effect. This admission, hoAvever, you properly urge, does not explain to us Iioav the contraction produces the pain. Well, gentlemen, I shall noAV endeavor to satisfy you on this point. In the first place, you must bear in mind that the object of the contraction of the gravid uterus is to afford an exit to the foetus and its appendages ; and, in order to accomplish this end, there must of necessity be an opening made by these contractions in some portion of the organ, through Avhich the escape of the foetus may be effected. It is the dilated os uteri Avhich constitutes this opening, and the dilatation is mainly accom- plished by the contraction of the longitudinal muscular fibres, which pass from above doAvmvard parallel to the long axis of the organ, and Avhich, therefore, concentrate their Avhole force upon a given point,* viz. the mouth of the womb. When these longitudinal fibres contract, as a necessary consequence of that contraction, their previous physical condition undergoes tAvo important changes: 1. They shorten in their long axis ; 2. They increase in volume in their respective diameters. This increase in the diameters is, of course, the necessary result of the diminution in the length of the fibre. What, therefore, I desire especially to direct your attention to is this: When the respective muscular fibres of the gravid womb undergo this augmented volume, they must, as a consequence, exercise, for the time being, an unusual pressure on the nerves dis- tributed throughout this very muscular tissue ; and it is this pres- sure which, I believe, in part, satisfactorily explains the phenomena of labor pain. When the contraction ceases, the pain ceases, for the reason that, in the absence of the contraction, the nerves enjoy * The fundus of the gravid womb undergoes a more marked development than any other portion of the organ; and if, in addition to this fact, it be recollected that the longitudinal muscular fibres exist in greater abundance there, it is ea.sy to imagine the feeble resistance offered by the cervix, which is not only less developed, but more sparingly provided with muscular tissue. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 331 an immunity from pressure. While, therefore, I am disposed to think that this, to a certain extent, is the true exposition of labor pain, yet I am inclined to adopt, in connexion with the theory of pressure, the vieAvs propounded by Dr. BroAvn-Sequard on this question. He maintains that the pain is partly due to the galvanic discharge caused by the muscular fibres under con- traction, and when they meet with resistance. It is the irritation of the sensitive nerves of the uterus, under the influence of that discharge, Avhich he regards as a principal cause of the pain.* However, as labor advances, the increase of suffering can be traced to other sources. Such, for example, as the pressure of the foetal head against the os uteri during the process of dilatation; and, when the head has passed the mouth of the organ, its pressure on the Avails of the vagina and outlet are additional causes of dis- tress ; add to this the irritation Avhich the various pehic nerves undergo from compression during the egress of the child, and you will at once see that the necessary consequence will be enhanced suffering, the susceptibility to which will depend much on the peculiar temperament of the individual. Division of Labor Pains.—Authors have divided labor pains into true and false ; and this distinction it is important for you, as practitioners, clearly to appreciate. True pain is the offspring of uterine contraction; in other words, it is synonymous with the existence of labor. False pain, on the contrary, has no connexion whatever with any movement of the uterus, and is the product of some cause entirely foreign to uterine contraction. It may be occa- sioned ^ by flatus in the intestines, indigestion, diarrhoea, constipa- tion, disease of the kidneys, distension of the bladder, rheumatism of the uterus or adjacent muscles. There are few things, gentlemen, more essential for the accou- cheur than a just and prompt discrimination between the true and spurious pains of labor. Without an accurate diagnosis on this point, he will be like the ship without its rudder; his process will not only be uncertain, but will be unsafe, and sometimes, indeed disastrous. How, for example, without the ability to dis- tinguish betAveen these two grades of pain, can you know, when summoned to the sick-room, whether or not your patient be in labor > Failure in this particular will lead to much embarrassment, and oftentimes prove perilous, if not destructive, to your reputation True Labor iW-These pains, remember, are always con- nected with the contraction of the uterus, and are slight and almost imperceptible at the beginning of labor. They are first felt in the back, and usually pass on to the thighs; they are distinctly recur- rent-that is, they are not continuous-but come on at intervals. * London Lancet. 1857. 332 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. They may be divided into two kinds—grinding or cutting pains at first; after the os uteri has advanced in its dilatation, they assume a bearing doAvn or forcing character. When the true pain is present, the entire area of the uterus becomes hard; and this change in it* condition can readily be recognised by placing your hand on the abdomen. As soon as the pain subsides, the hardening of the uterus is folioAved by relaxation; again: if during the pain the finger be introduced into the vagina, and the os uteri dilated, the membranes will be felt slightly protruding, in response to the pain, and they will present to the finger a sense of resistance ; but Avith the discontinuance of the pain they cease to protrude, and become flaccid. Besides these characteristic evidences of true labor pain, the patient, during its presence, will manifest her sufferings by sup- pressed groans, or in some more marked Avay. As soon, hoAvever, as the pain has passed, she Avill not only be free from distress, but will join in agreeable con\rersation with you. Spurious, or False Pains.—These, as I have already remarked, are not connected Avith any action of the uterus; for during their existence the organ Avill be in a state of entire tranquillity. They are more or less continuous, depending on the special cause Avhich may produce them, and are, therefore, not recurrent. It can scarcely be necessary for me to observe that these pains can only effectually be removed by tracing them to their proper source. For example, if from constipation or indigestion, aperients AA'ill be indicated. Should they be due to spasmodic action, or, as some- times will be the case, to excessive fatigue, a gentle anodyne, in some form not inconsistent Avith the idiosyncrasy or peculiarity of your patient, will prove the remedy. These pains will not unfre- quently be the result of superabundance of acid in the primae viae; what better, under the circumstances, than the employment of antacids ? It may also happen that inflammatory action or febrile excitement has evoked this character of pain. General or local bleeding, Avith a judicious resort to purgatives, diaphoretics, etc., will constitute in these cases the elements of relief. II. Dilatation of the Os Uteri.—The doctrine has prevailed, and indeed it has among its supporters some clever names, that the mouth of the womb is opened by the foetus itself—that this latter, as it were, under the influence of a peculiar instinct, desires to be liberated from its accommodations, and therefore spontaneously, and upon its OAvn responsibility, makes a passage for its escape. It cannot be necessary to demonstrate the fallacy of this proposition —its absurdity must be apparent to all of you. We, consequently, are to seek for some other explanation of the true cause of the dilatation, which is so essential to the completion of labor. You must remember that the cervix of the uterus is well supplied Avith circular muscular fibres, and, as a general rule, they exercise a THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 333 species of guardianship over this particular portion of the organ. Were it not for them, constituting as they do, a veritable sphincter, the closure of the os would be imperfectly maintained. But as the object of labor is the expulsion of the fcetus, there is a necessity for an opening of the mouth of the uterus, and consequently a temporary surrender of the rigidity of these circular fibres. When the uterine contractions commence, the longitudinal muscular fibres are thrown into action, the result of which is a concentration of force, directed from above downward, falling on a common point or centre—the os uteri. The only resistance to this force will be the circular fibres. Through successive efforts, hoAvever, these yield to the more poAverful impulse of the longitudinal fibres, and the result is dilata- tion. Muscular contraction, therefore, may be regarded as the primary or efficient cause of the dilatation of the os uteri; but there are also tAvo secondary or auxiliary causes, which exercise their influence. The first of these is the "bag of waters;" the second the foetal head. For example, when the dilatation has fairly commenced, the membranes with the liquor amnii will be forced through the opening, and, thus protruding, wall exercise a uniform and gentle pressure against the orifice. When the " bag of Avaters," through successive contractions, is ruptured, and the amniotic fluid escapes, then the head itself, by its pressure, forms a kind of A\redge, Avhich, acted upon by the contractions of the longitudinal fibres, contributes its part to the required dilatation. If proof be required that this is the process through which the opening of the mouth of the gravid womb is accomplished, you will find very substantial evidence of the fact in cases in Avhich there is a marked want of parallelism betAveen the long axis of the uterus and the axis of the superior strait of the pelvis. For in- stance : if there should be ante-version, retro-version, or a right lateral or left lateral obliquity of the organ, the consequence would be that the os, instead of corresponding more or less with the centre of the pelvic excavation, Avould present its anterior surface backAvard, forward, or laterally. In such case, the force of the contractile effort of the longitudinal fibres would lose its concen- tration, and consequently the dilatation Avould be greatly retarded, if, indeed, it Avere not altogether prevented. We shall, hoAvever have occasion to allude to these malpositions of the uterus, as con- nected Avith childbirth, in a future lecture. There is one important and material point, in a practical view, which you should not lose sight of, as regards the dilatation of the os uteri, and it is this: in the primipara it is much more tardy than in women who have already borne children ; and again, as a general principle, a longer time is required to effect an opening the size of a four-shilling piece than for the completion of the entire process. 33l THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Here, alloAv me to remind you that, during the progress of dila- tation, the female is not unfrequently attacked Avith rigors or shi- vering fits, as they are sometimes called. These rigors should create no alarm Avhen they are simply the product of uterine contraction ; on the contrary, I am disposed rather to regard them as favorable indications. You may, under the circumstances, administer Avarin tea or gruel, and assure your patient that she need feel no anxiety. But, gentlemen, there is another species of rigor in the lying-in room, Avhich is not so innocent, and Avhich may be the prelude of trouble. I mean those distressing chills, Avhich sometimes occur in Aery pro- tracted labors, and Avhich are accompanied with furred tongue, excessive thirst, oppressed breathing, and a hard and accelerated pulse. These are usually rigors of danger, and will require all the vigilance of the accoucheur. They point to serious inflammatory action. The same obseiwation applies to the vomiting AArhich occurs during labor. It is not unusual for Avomen to be affected Avith "sick stomach " during the stage of dilatation. This is regarded as a most favorable circumstance; it portends no evil, but, on the con- trary, it renders a material service through the relaxation it pro- duces, thus facilitating, among other things, the opening of the mouth of the Avomb. There is, hoAvever, another kind of vomiting, Avhich will occasionally manifest itself after a long and tedious labor; and unfortunately it is but too often the precursor of death. Such is the vomiting, Avhich occurs after or before full dilatation of the os uteri, with a suspension or entire cessation of contractions —a feeble and rapid pulse, great pain on the hand pressing the abdomen, a sunken countenance, Avith extreme pallor, and cold perspiration. This is the vomiting indicative of rupture of the uterus, one of the most alarming, because one of the most fatal of the contingencies of the lying-in chamber. III. A Muco- Sanguineous Discharge.—Another of the ordinarily characteristic signs of labor Avill be this discharge from the vagina ; but it will sometimes happen that there will be an absence of the discharge during the parturition, and this is knoAvn as a " dry labor." The mucous secretion is derived from the numerous little follicles in the cervix and vagina. It is poured out usually in great abundance at the close of gestation, and at the commencement of parturition. It is intended to ansAver a most important object—the relaxing and lubricating the parts, thus facilitating the approaching distension. Commonly, there is commingled Avith this secretion of mucus a slight tinge of blood, and it is knoAvn as the show. Some women will have this show several days before labor commences. The blood probably comes from rupture of the more minute vessels of the uterine orifice. IV. The Formation and Rupture of the Membranous Sac, or THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 335 Bag of T^ers.—When describing the appendages of the foetus, and their relation to the uterus, you will remember I told you that the most internal of the membranes is the amnion, and that this incloses a fluid—the liquor amnii—in Avhich the foetus, as it were, floats. One of the first effects of the contraction of the uterus Avill fall upon the amniotic fluid; but as, from its very nature, this fluid is incompressible, and consequently its volume cannot be diminished, the impulse it receives from the contracting Avomb forces it to some point of the organ Avhich presents the least resist- ance to its escape, and this point is the os uteri. As soon, there- fore, as the latter begins to dilate, there Avould be no obstacle to its exit, were it not that it is inclosed in the membranes. These membranes constitute a sac for the amniotic liquor; and, in pro- portion as the os uteri dilates, the loAver portion of this sac, dis- tended by the liquor amnii, protrudes. Under contraction it becomes hard and resisting; in the interval, on the contrary, it softens, and slightly recedes. This sac, as has already been stated, by its gentle and uniform pressure, assists materially in dilating the mouth of the Avomb; and you AviU observe in practice, that Avhen the os uteri is sufficiently open to alloAV the head of the foetus to pass, the sac becomes spontaneously ruptured. It will sometimes, however, occur that, OAving to inordinate resistance of the mem- branes, it does not rupture. In such cases, when the os uteri is fully dilated, longer to respect its integrity Avould only be a useless protraction of the labor; and therefore it Avill be your duty to pro- ceed at once to effect its rupture, Avhich may be done by pressing the point of the index finger against the centre of the sac during a contraction. This, hoAvever, will not ahvays answer, and I have occasionally been obliged to open the bag by grasping a fold of it during the interval of contractions, between the thumb and fore- finger. I have, indeed, met Avith cases in Avhich it became neces- sary to pierce the sac Avith the point of a bistoury. But this needs caution for fear of injuring the fcetus or adjacent soft parts. The practical fact Avhich I have just mentioned, that there is, generally speaking, a spontaneous giving way of the " bag of Ava- ters" as soon as the mouth of the uterus is sufficiently dilated to alloAV the head of the child to pass—is one full of interest, and should admonish you against an officious intrusion on the laws of nature. Hoav often, for example, is a labor made protracted, and, as a consequence, the mother's strength exhausted, and the life of the foetus endangered, through the officiousness of the accoucheur in prematurely rupturing the sac. In doing so, an escape is afforded to the Avaters before the necessary dilatation is accomplished, thus entailing upon the feinale much unnecessary suffering, and involv- ing both her and the child in more or less peril. It should be recol- lected, as a sound maxim in midAvifcry, that to rupture the mem- 336 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. branes, except in certain cases which tcill be mentioned hereafter, before the os uteri is fully dilated, is bad jyractice. Let us examine this point for a moment, When the sac is ruptured, of course the amniotic fluid in more or less quantity escapes—therefore, in this premature rupture, and consequent loss of the fluid, nature is deprived, in the first place, of an important auxiliary in accomplish- ing the dilatation of the os; and secondly, as there is little or no fluid left in the womb to interpose betAveen the uterine Avails and foetus, the latter will be exposed more or less to undue and pro- tracted pressure; in this Avay the umbilical cord is in danger of compression, thus interrupting the foeto-placental circulation, and consequently leading to the destruction of the child. In certain cases, you Avill meet Avith an exceedingly unyielding os —it Avill give but slightly, and the membranes will protrude in a conoidal form, stretching doAvn in this peculiar shape to the \rulva itself. Be careful not to be deceived under these circumstances— do not mistake this abnormal form of the sac for one of the extre- mities of the child, an error which has been committed, and which can only be avoided by a proper degree of caution. Finally, the child will occasionally come into the Avorld with a portion of the membranes over its head—this is known as the caul or hood, and is regarded by the ignorant as a circumstance most auspicious to the future of the child, for it is supposed that the caul is a certain pre- cursor of the high destiny of the little stranger. It cannot be necessary to say that such an opinion is but the offspring of super- stition, and, like many other things, has no foundation but in igno- rance and morbid imagination. LECTURE XXIY. Natural Labor: Conditions for—"What is required on the part of the Mother; what on the part of the Foetus—Hippocrates and Head Presentations in Natural Labor; Fallacy of his Opinion—Face Presentations in Natural Labor; Mechanism of— Diagnosis of Face Presentations; may be Confounded with Presentations of the Breech—Face Presentations in Dublin Lying-in Hospital—Error of "Writers with regard to Version and Forceps Delivery in Face Presentations—Presentation of tlie Pelvic Extremities; the Breech, Feet, and Knees—Opinion of Hippocrates; his Direction for bringing down the Head in these Presentations—The Practice of A. Petit, Bounder, and others—Presentation of the Pelvic Extremities and Natu- ral Labor—Dr. Churchill's Statistics—Statistics of Dr. Collins; Deduction—Dr. Hunter on Management of Breech Presentations—Diagnosis of these Presenta- tions ; may be Confounded with those of the Shoulder; Prognosis—Are Breech Presentations necessarily Destructive to the Child?—Do they in any way Com- promise the Safety of the Mother?—Mechanism of Breech Presentations—Pre- sentation of the Feet; Diagnosis and Mechanism of—Presentation of the Knees- Diagnosis and Mechanism of. Gentlemen—Labor, to be natural, necessarily presupposes the existence of certain conditions ; and it is, therefore, proper, that Ave should noAV examine in what these conditions consist. Some of them refer to the mother ; others to the foetus. I. On the part of the Mother.—-The pelvis must be well con- formed, exhibiting a capacity sufficient for the exit of the child; the mother possess strength adequate to the wants of the delivery; the gravid uterus parallel, or nearly so, to the axis of the superior strait; the os uteri, A'agina, and vulva sufficiently yielding to the forces of expulsion; and these latter should possess the requisite degree of efficiency. It must be quite evident to you that these conditions are essentially material to the accomplishment of deli- very by the unaided efforts of nature. For example, if the pelvis be so diminished in size as to render it physically impossible for the child to pass, the interposition of art will be called for, and there- fore, in such case, the labor ceases to be natural; so it is with the other prerequisites. How, for instance, could the expulsion of the foetus be effected by the resources of nature, if the uterus, instead of being in its long axis parallel, or nearly so, to the axis of the brim, should be in a state of ante-version, retro-version, or exhibit a decided right or left obliquity ? In either of these malpositions of the organ, the cervix, in lieu of regarding the pelvic cavity, would be turned toward the sacrum, symphysis pubis, or to one or 22 33S THE PRINCIPLES AND PRACTICE OF OBSTETRICS. other of the lateral Avails of the pelvis, so that the AA'hole force of the uterine effort would be negative in its influence, because of tho resistance of the bony structure of the pelvic canal.* II. On the part of the Fetus.—The foetus, in its parent's Avomb, is doubled upon itself in such Avay as to preserve an ovoid form; this ovoid is divided, for practical purposes, into the superior and pelvic extremities—the superior embracing the head—Avhile the pelvic extremities include the breech, knees, and feet. It is, there- fore, necessary, in natural labor, that one of the extremities of the ovoid should be present, viz., either the head, breech, knees or feet. In either of these presentations, all things being equal, or, in other words, in the absence of any complication, the resources of nature will be adequate to accomplish the delivery. I am aware that the presentation of the pelvic extremities is usually regarded as preter- natural, calling for the interference of the accoucheur; and this lat- ter opinion, I am sure, has often led to hasty and unnecessary action, resulting frequently in disaster to the child, and more or less injury to the mother. The idea that, in natural labor, the head must present, is a very ancient one ; it originated with Hippocrates himself. The Father of Medicine very aptly illustrated the relation of the fcetus to the Avomb by comparing it to an olive in a long-necked bottle. He 6aid, that in order to afford escape to the olive one of its extremities must present. This is perfectly true, and applies with equal force to the exit of the foetus. But, strange to say, Avith all the truthful- ness of the comparison, he taught that for the child to be expelled by the unaided resources of nature, consistently with the safety of both mother and foetus, an essential prerequisite is—that its head should present at the superior strait.* The authority of the illustri- ous Father of Medicine on this question has not been without its effect; it has introduced bad practice into the lying-in chamber; it has caused the accoucheur to be officious, Avhen he should trust to nature—it has, in a Avord, inducted him to a " meddlesome mid- wifery " in all cases of pelvic presentations; for, under the convic- tion that this presentation is contrary to nature, he has, as soon as he ascertained its existence, proceeded by ill-advised efforts to terminate the delivery. * These obliquities of the organ may often be corrected by change of position on the part of the female, or through the skilful manipulation of the accoucheur; and whenever they exist so completely as to embarrass delivery, prompt assistance should be rendered in order to remove them. \ Ut enim si quis in lecythum angustre oris olivce nucleum immittat, hunc trans- versar iumeducere non facile est; sic sane mulieri est gravis affectio, ubi foetus trans- versarius fuerit; etenim ipsum exire per arduum: grave vero etiam est, si in pedes prodierit et plerumque aut matres aut puellae aut ambo, pereunt. Est autem et hsec magna causa cur non facile exeat, si mortuus aut sideratus aut duplicatus fue- rit. [De Mulier. Morb. lib. 1, torn, vi] TnE PRINCIPLES AND PRACTICE OF OBSTETRICS. 339 This, I maintain, is all wrong; nature, under ordinary circum- stances, being quite as adequate to accomplish the labor when the pelvic extremities present, as when the head comes first. At the same time, it must be conceded that, as a general principle, delivery in head presentations is more advantageous for both mother and child. What I Avish to impress upon you is this—do not, simply because the breech, knees, or feet are found at the upper strait, therefore conclude that interference is called for. Besides the conditions for natural labor already mentioned, it is essential that there be no disproportion between the dimensions of the foetus and the pelvis through which it has to pass. Again : the adhesions of the placenta to the uterus should not be such as to resist the efforts of the latter to detach it; nor should the umbilical cord be relatively or positively too short. Presentations of Fcetus in Natural Labor.—So far as regards the presentations of the foetus in natural labor, they maybe enume- rated as follows: 1. The vertex; 2. The face; 3. The breech; 4. The feet; 5. The knees. In either of these presentations, therefore, I wish you to recollect, if there arise nothing to compli- cate the delivery, nature can, by her own resources, accomplish the expulsion of the child; and it must be borne in mind that any other region of the head, except the vertex and face, is preter- natural ; to this fact, however, your attention will be more par- ticularly drawn when treating of preternatural labor. We have already described the mechanism by which the head is made to pass through the pelvic canal in a vertex presentation,* and shall now speak of the interesting subject of face presentations. S'at isties of Face Presentations.—Instances in which the face is found at the superior strait are comparatively rare; occurring, according to statistics derived by Dr. Churchill, from British', French, and German sources, 1167 times in 260,817 cases, or about one in 223|.f The majority- of writers class this presentation among preternatural labors; but I cannot understand why—for it is a matter of clear observation that nature is perfectly competent to effect the delivery if left alone. Indeed, it is a very significant fact, well worthy of reflection, and amply proved by statistics, that, in face presentations, death, among both mothers and children, is most frequent when science attempts to interpose. This is an important circumstance, and should inspire you with renewed con- fidence in the ability of nature in this species of labor. In the Dublin Lying-in Hospital, under the mastership of Dr. Collins, in 16,654 births, there Avere thirty-three presentations of the face; these cases were all submitted to the natural process, and all the children born alive, except four, one of which Avas acephalous. \ In * See Lecture IV. f Churchill, fourth London edition, p. 410. X A Practical Treatise on Midwifery, by Robert Colling, M.D., p. 32. 340 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the same Avell-conducted charity, under the mastership of Dr. Shekleton, as reported by Drs. Johnston and Sinclair, in 13,748 deliveries, the face presented thirty-one times, all the children born alive, except six, and recovery of all the mothers but one, she having died of peritonitis. Of the six children born dead, one Avas an acephalous monster, one sunk from pressure of a loop of the cord, and the death of another Avas ascribed to a beating to Avhich its mother had been subjected.* These statistics I regard most interesting in their practical bear- ings, and, to my mind, are irresistibly conclusive—if proof be needed—as to the propriety of classing face presentations among those of natural labor, f And again, they demonstrate how Avell nature is prepared to discharge her duty AA'hen not encroached upon by umvarrantable officiousness. It is the opinion of some writers that, in all cases in Avhich the face presents, an attempt should be made to bring doAvn the vertex; others recommend in these instances version, Avhile some are more Avedded to the forceps as the only means of terminating the delivery. These Ararious directions, gentlemen, do Avell enough, perhaps, in the books, but they are utterly out of place at the bedside of the parturient woman. Diagnosis.—It will be difficult, under ordinary circumstances, positively to decide that the face presents, previously to the rupture of the membranous sac ; but after this has taken place, an attentive examination per vaginam will soon disclose the true nature of the presentation. The first circumstance Avhich will become obvious, is the marked irregularity of the surface of the part with Avhich the finger comes in contact; then the different features Avill be felt and recognised, such as the eyes, nose, and mouth. Occasionally, how- ever, Avhen severe pressure has been exerted by the uterus, the general character of the face will be so altered by the tumefaction it has undergone, as to render it difficult to decide at once the question of presentation. It is in these cases of compression of the parts, that the eye may be mistaken for the external organs of generation in the female fcetus, or the nose for the penis in the male. The face is more likely to be confounded with the breech than with any other portion of the fcetus; Avhen, for example, the finger reaches the malar bone, this latter may, Avithout due caution, be mistaken for one or other of the tuberosities of the ischium ; all doubt, however, will be at an end if the finger should distinctly feel the mouth and gums of the child. Let me here advise you of the importance, as far as may be, of the early recognition of a face * Practical Midwifery. By Drs. Johnson and Sinclair, p. 75. f In the deliveries under my direction in the Royal Maternity and other charities, the face presentations alone have been 110; of these, 102 were born living, under the natural efforts. Of the eight still-born children, in the above number of face present- ations, one was in a putrid state, and had been dead long before labor set in. [Illus- trations of Difficult Parturition. By John Hall Davis, M.D. London, 1858. Page1?.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 341 presentation; repeated vaginal examinations in these cases will necessarily expose the child to more or less danger. For instance: the eye would incur the risk of injury, if indeed it were not destroyed, by the too frequent introduction of the finger. You might, perhaps, suppose that a positive evidence of a breech presentation would be the discharge of meconium ; this, however, is not so. I have met Avith instances in which the meconium has passed into the vagina in head presentations, and this may occur in cases in which any extraordinary pressure is exercised on the body of the child by the contracting uterus. Prognosis.—It is, I think, quite consistent with the results of practice to say, that the child is ordinarily born alive in presenta- tions of the face ; and the convalescence of the mother as favorable as in an ordinary vertex delivery. It is not unusual, however, for the child to come into the Avorld with its features extremely dis- torted, owing to the general swelling of the face ; but this in a few days will disappear, and in no way compromises the life or health of the infant. Looking at the facts as they exhibit themselves in the lying-in chamber, the face will be found, as a general rule, to present at the superior strait in one of tAvo positions, al- though, occasionally, there will be variations. The me- chanism, however, by which the head makes its transit through the pelvic canal is essentially the same. Presentation of the Face in, the First Position.—In this position, the finger being introduced into the vagina, and carried up to the mouth of the uterus, will feel the nose; in passing the finger from the right to the left side of the pelvis, along the dorsum or back of the nose, the coro- nal suture AviU be recognised; this proves evidently that the fore- head of the foetus is toward the left iliac bone ; and, consequently, the chin will regard the right ilium (Fig. 48); so that the fronto- mental diameter of the face is in apposition or correspondence Avith the transverse or bis-iliac diameter of the superior strait; while, on the contrary, the transverse diameter of the face is parallel to the Bacro-pubic diameter of the pelvis, in the first position; and hence Fio. 48. 342 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. it is called the right mento-iliac. According to Naegele, in this position the right side of the face is slightly loAver than the led. In response to the contractile efforts of the womb, the head is made to descend into the pelvic cavity ; it there undergoes a rotary movement, Avhich so changes its relation that the fronto-mental diameter of the face accords Avith the right oblique diameter of the pelvis, and the chin is opposite to the right foramen ovale; the chin is next brought behind the symphysis pubis, and the forehead turned into the cavity of the sacrum (Fig. 49). From what has just been said, it is obvious that the forehead is obliged to traverse the anterior surface of the sacrum, while the chin descends only the length of the symphysis pubis, in order to reach the inferior strait. The progress of the face having been thus far accomplished, the chin, under the expulsive influence of the uterus, is made to pass under the symphysis pubis, while the occiput is pushed dowmvard, and the flexion or disengagement of the head is completed. Here let me caution you to guard Avith great care the perinaeum during the progress of the delivery, for the distension which it is called upon to undergo in the descent of the face is much greater tl an in a vertex presenta- tion ; and, without a due de- gree of vigilance, rupture may take place, always an unpleasant complication of childbirth, and sometimes re- sulting seriously to the mo- ther. When the head has passed the vulva, the face is turned upward. As the deli- very proceeds, the head un- dergoes the movement of external rotation in the same way that this movement oc- curs in the presentation of the vertex, and Avhich has been described in a previous lec- ture. Presentation of tlie Face in the Second Position.—In is precisely the reverse of the first, the fore- Fig. 50. this position, Avhich THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 343 head is towards the right iliac bone, while the chin regards the opposite point of the pelvis (Fig. 50). On a vaginal examination, the finger, if directed along the dorsal surface of the nose to the left, will distinctly feel the nostrils, Avhile the coronal suture will be found to the right; thus shoAving a reverse position, and consti- tuting the left mento-iliac position of the face. The mechanism of passage in the second position of the face is, in all respects, the same as in the first, excepting that, in consequence of the change in the direction of the face at the superior strait, the movement of rotation is from left to right, instead of from right to left. It is Avell to remember that, in face presentations, the duration of labor will usually be more or less protracted, for the reason that the bones of the face not undergoing compression, as is the case Avith those of the cranium, do not mould themselves to the form of the pelvis, and consequently a more lengthened duration and greater effort are necessary for the transmission of the parts through the pelvic canal. It is an error, however, to suppose that the safety of the child is necessarily dependent upon the shortness of the labor. You Avill sometimes have occasion to note the falsity of such an opinion. The error frequently leads to officiousaess on the part of the accoucheur, and consequent injury to mother and child. In- deed, I am disposed to say that, all things being equal, slow births are generally safe births. Permit me to enforce this upon you as a maxim in the lying-in chamber; it is, as you must perceive, strictly conservative, and at the same time strictly true. Presentation of the Pelvic Extremities.—I have told you that, when either of the pelvic extremities is found to present at the superior strait, nature Avill be competent to achieve the delivery, unless something, other than the mere presentation, should inter- fere, calling for the assistance of the accoucheur. You will read in the books some very contradictory opinions upon the subject of these presentations; and you AviU be not a little surprised at the conflicting rules inculcated for their management. For example, as has already been stated, Hippocrates regarded this character of presentation as contrary to nature ; his direction Avas, Avhenever the breech, feet, or knees Avere discovered at the upper strait, to introduce the hand, and, through the operation of version, to bring down the head! Again : the doctrine has prevailed, and been sus- tained by Antoine Petit, Bounder, and others, that the most natural presentation is Avhen the feet come first; and, in keeping Avith this opinion, it Avas suggested that, in cases of head presenta- tion, the accoucheur should turn and bring down the feet. But, gentlemen, it is not necessary to refer more at length to the various opinions of authors on this question. The substantial point for you to remember, and which will serve you Avhen at the bedside of your patient is, that the presentation of the pelvic extremities h 344 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. undoubtedly entitled, for the reasons already mentioned, to be classi- fied as perfectly consistent Avith natural labor. I. Pixscntation of the Breech.—The nates or breech present much more frequently at the superior strait than either the feet or knees. Dr. Churchill, with his usual industry, has furnished some interesting statistics, touching the frequency of breech presenta- tions, taken from the records of British, French, and German practice. In an aggregate of 197,318 cases, the breech presented 3325 times, or about 1 in 59J; and in 1148 cases, all he has been able to collect, 337 children Avere lost, or about 1 in 3£. At first sight, this Avould appear to be a great mortality; but it must be recollected that these tables are derived from very mixed sources— that is, in many instances, no doubt, the presentation of the breech being regarded as preternatural, artificial aid Avas had recourse to, and in this way, it is not at all improbable that the safety of the child Avas compromised. In order to sIioav the actual as Avell as the relative fatality to the child, in this form of presentation, it does seem to me that an essential prerequisite for such data A\ ould be, to derive our facts from those cases which had been entirely confided to nature, and Avhere, consequently, there had been no in- terruption to the natural process by premature or unjustifiable interference. We should then be better able to approximate a just comparison, all things being equal, betAveen the proportion of children lost in breech and vertex presentations.*' The presentation of the breech Avas formerly regarded as one of great danger, because it was supposed that the child thus, as it were, doubled on itself, could not have sufficient space to enable it to be transmitted through the pelvis. This opinion, hoAvever, is AA'ithout foundation, for the parts composing the breech are quite compressible, and will yield to the forces of the uterus. Based upon the apprehension that the breech could not pass, it Avas a faArorite practice among some of the English accoucheurs always to interpose, endeavor to push it upward, and then search for the feet, * Dr. Collins, who recommends that, in the absence of any complication, there should be no interference in breech presentations, reports this presentation to have occurred 242 times in 16,654 deliveries. Of these 242 children, 73 were still-born, of which 42 were putrid. Forty of the 242 were premature births, 28 of which were still-born. Fourteen of the 28 were born at the eighth month ; twelve at the seventh ; one at the sixth; and one at the fifth. Twenty-six of the 28 were putrid. Twelve of the 40 premature children were born alive, viz., two at the sixth month ; seven at the seventh; and three at th.j eighth month. These statistics are extremely interesting and, as far as they go, are decidedly in favor of the position I have as- sumed. It is but fair, I think, to deduct from tlie 73 still-born cases, the 23 prema- ture births, which were also still-born, for as 26 of the 28 were putrid, it is strong proof that their death was altogether unconnected with the particular form of presen- tation. Therefore, Dr. Collins' statistics will give us 45 still-born children in 242 breech presentations, or about 1 in 5 1-2. which it will be perceived differ widelj from the results furnished by Dr. Churchill. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 345 and deliver the child in this manner. Such practice Avas not only bad practice, for it had no justification Avhatever, but it Avas most destruc- tive to the child, and, at the same time, full of peril to the mother. I can afford you no better admonition upon this subject, than by recording the experience of Dr. Hunter, Avho, in the commencement of his professional career, became so imbued Avith the prevailing opinion at that time, that he adopted it, but soon found cause for its repudiation. " When," says he, " I first began practice, I fol- lowed the old doctrines in breech presentation, although I did not like them ; but yet dared not broach new ones, till I got myself a little on in life ; at this time I lost the chill in almost all the breech cases ; but since I have left these cases to nature I always suc- ceed."* There is much good sense in this observation of Hunter, and it demonstrates the folly of blind obedience to mere opinion. Diagnosis.—It will, in general, be extremely difficult to recog- nise a breech presentation before the rupture of the " bag of waters ;" but after the escape of the amniotic liquor, a careful ex- amination will enable you to detect the nates at the upper strait; the finger will feel a rounded tumor, softer than the head, and im- parting someAvhat of an elastic sensation; the cleft between the nates and the organs of generation will also be important guides; there is usually, likeAvise, in this presentation, a discharge of meconium. In consequence of the great tumefaction of the face, and the necessary alteration of its features, errors have sometimes been committed by confounding it with the breech of the infant. Indeed, under certain circumstances, it will need more than ordinary circumspection to avoid the blunder, HoAvever, as has already been remarked, the recognition of the mouth and gums, together with the nose, will readily dissipate all embarrassment. In women, Avhose abdominal Avails are not loaded Avith adipose or fatty matter, and Avhich, in consequence of previous births, are in a state of more or less relaxation, it will sometimes be possible to feel quite distinctly, through these Avails, the head of the fcetus turned upward. This is a very positive indication, in case of a single pregnancy, that one of the pelvic extremities presents, and which it is, must be determined by a vaginal examination. Ao-ain : a strong evidence of this kind of presentation is disclosed by the fact of your being able to detect the pulsations of the foetal heart on a level Avith, or above the umbilicus. It is an interesting circumstance that, Avhen the foetus is dead, the anus is open, so that the apex of the finger maybe introduced; but Avhen alh-e, it is closed. As the nose is an important guide in face presentations, so the coccyx is Avhen the nates present, not only indicating the character of the presentation, but also the true position of the part. It is possible to confound the breech with * Hunter's Lectures, MS., 1768. 346 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the shoulder, and it is essential that the distinction should be made early, for, as we shall tell you, when speaking of the management of a shoulder presentation, it is very important that a correct diagnosis be arrived at before the labor is far advanced. The acromion pre - cess, without a due degree of care, may be mistaken for the tuberosity of the ischium ; but the absence of the ribs, Avhich can be easily felt in a shoulder presentation, Avill remove all doubt upon the subject. Prognosis.—Although it is unquestionably true that, when the pelvic extremities present, nature is competent to accomplish the delivery, yet it must not be forgotten that the mortality to the children is much greater than in vertex presentations; and, I am inclined to refer, Avith most authors, this increased mortality to the undue pressure exerted on the umbilical cord, thus interrupting the circulation betAveen the foetus and placenta. The death of the child may also be the result of delay in the delivery of the head, after the other portions have passed into the Avorld. Notwith- standing this comparative mortality of the child in pelvic presenta- tions, yet it cannot be denied that the danger is much enhanced, and the fatality, therefore, augmented by the officiousness of the accoucheur, in not submitting these cases to nature. As regards the mother, there is no more danger in a pelvic than in a vertex presentation ; and, contrary to the generally received opinion, Avhen the breech presents, the labor is usually more favor- able and shorter than when the feet are found at the superior strait. It is not difficult to explain this circumstance. As soon as the nates begin to descend into the pelvic excavation, they produce upon the surrounding parts a pressure, Avhich immediately calls into action the tributary influence of the spinal cord, thus adding vigor and efficiency to the contractions of the uterus. This, as is evident, is not the case Avhen the feet pre- sent first, for the reason that the diminished volume of the pre- senting parts is incapable of making the degree of pressure necessary to evoke the reflex action of the cord. The breech, feet, and knees may assume four different posi- tions at the superior strait, and we shall iioav proceed briefly to describe the mechanism of trans- mission in each of these positions. First Position of the Breech. —The sacrum of the fcetus regards the left acetabulum (Fig. 51), constituting the left anterior sacral position. Here, the nates, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 347 back, and occiput, correspond to the left anterior portion of the uterus and pelvis, while the abdomen, chest, and face regard the right posterior portion. It will thus be seen that the nates present at first diagonally at the superior strait; but as, in , response to the contractile efforts of the uterus, they are made to descend, the right is turned toward the sacrum, the con- cavity of Avhich it pursues (Fig. 52), Avhile the left is placed under the pubes, forming, as it Avere, for the other a point of Fig. 52. Fig. 63. support. During the progress of the delivery, the right hip appears first at the vulva (Fig. 53), and then the trunk is expelled, being slightly curved in the direction of the pubes. As soon as the breech makes pressure on the perineum, great care should be exercised in giving proper support to the latter, in order to prevent rupture; and, as the hips pass out of the vulva, a loop should be made of the cord, by drawing down a small portion of it. If the pulsations be found to grow weak, the delivery should be hastened by tractions on the body of the child, as will be described Avhen speaking of preternatural labor. The arms, because of the resistance offered them by the brim of the pelvis, will occasionally ascend tOAvard the face so as to become extended on the lateral portions of the head ; the shoulders descend diagonally at the superior strait, the right, which is posterior, appearing before the left, Avhich is in front; in the pelvic cavity they undergo the movement of rotation, which, of course, places them in the direct position at the inferior strait, whence their expulsion is soon folloAved by that of the arms. The head passes from the superior strait into the pelvic excavation in a flexed con- dition, the chin being approximated to the sternum, the occiput turned toward the pubes, and the face tOAvard the sacrum; thus, with the neck under the arcade of the pubes, and the face resting against the coccyx and perineum, the chin escapes from the vulva, and the delivery is completed. Second Position of the Breech.—The sacrum regards the right acetabulum—the right anterior sacral position. Here, the nates, back, and occiput, are in front, and to the right; the abdomen, 348 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. chest, and face behind, and to the left. The mechanism in thin position, is fundamentally the same as in the first. Third Position of the Breech.—The sacrum corresponds Avith the right sacro-iliac symphysis—the right posterior sacral position —the breech, back, and occiput being behind, and to the right, while the abdomen, chest, and face are in front, and to the left. This position is the reverse of the first, and the same mechanism causes the delivery of the child. The head, hoAvever, will experi- ence somewhat more difficulty in its egress, from the fact that the face is obliged to glide along the symphysis pubis, while the occi- put is passing the hollow of the sacrum, the coccyx, and perineum.* The head, in its exit from the vulva, becomes extended, so that the chin first,f and successively the mouth, nose, and forehead emerge from under the pubes.J Fourth Position of the Breech.—The sacrum corresponds Avith the left sacro-iliac symphysis, and is the reverse of the second—the left posterior sacral position—the breech, back, and occiput are behind, and to the left; the abdomen, chest, and visage in front, and to the right. Here again, the mechanism is precisely the same as in the preceding position. It is Avorthy of remark that, in the various breech presentations, the inferior extremities almost ahvays remain flexed lengtlnvise upon the trunk, and usually pass out of the vulva simultaneously with the head. Presentation of the Feet.§—When the feet present, it is possible * In addition, in these posterior sacral positions, the head of the child will be very apt to be obstructed by the chin catching, as it were, upon the ramus of the pubes, giving rise necessarily to a protracted delay, and involving, in more or less peril, the safety of the infant. In order to prevent this difficulty, as soon as tlie hips are being delivered—if nature have not spontaneously changed the position, which she sometimes, though rarely, does—the hips should be gently grasped by the two hands, and the body of the child rotated upon its long axis, for the purpose of converting the posterior sacral into one or other of the anterior sacral positions; the third being changed into the second, and the fourth into the first. | Dr. Ramsbotham says, " I believe that in no instance, if the case were left entirely to nature, provided the child and pelvis were of common size and form, would the face be expelled under the arch of the pubes." This is adverse to my observation on the subject, and is certainly not consistent with the evidence fur- nished by the lying-in room. [Ramsbotham's System of Obstetrios. Keating's edition, p. 327 ] X It will sometimes happen, as an exceptional circumstance, that the face, under the influence of a strong contraction of the uterus, will be turned from the symphy- sis pubis into the hollow of the sacrum, and the body of the child will also partici- pate iti this semicircular movement. It was Naegele who first directed attention to this fact, and observed it to occur only when the foetus was small, and not at full time. Scanzoni, however, records two instances of this conversion, in which it took place when the foetuses were large, and had completed their intra-uterine life. § In 192,174 cases, there were observed 1831 foot or knee presentations, or about 1 in 105. The mortality to the children 1 in 2J.—[Churchill's Midwifery, 4th Lon- don Edition, p 427] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 349 to confound them Avith the hand of the fcetus; and this, you may readily imagine, Avould result in a serious complication of the labor. For example, suppose the accoucheur, always in the habit of inter- fering in these cases, because he believes them preternatural, should seize the hand at the superior strait, and, mistaking it for the foot, make traction, and bring it down into the vagina. It would then be too late to repair his error, for he would find it not so easy a thing to replace the hand. Diagnosis.—The diagnosis of a foot presentation is not difficult; it only needs thought and judgment to make the proper distinction. In tlie first place, the foot is thicker and larger than the hand ; the toes are shorter than the fingers, the great toe being near its fel- Ioavs, Avhile the thumb is separated from the fingers; the foot is narroAv, the hand is broad and flat; the foot is at a right angle with the leg; the hand, on the contrary, is, as it Avere, but an extension of the forearm. First Position of the Feet.—The heels regard the left acetabu- lum, and the toes the right sacro-iliac symphysis—the left anterior- calcaneo position. The breech, back, and occiput are tOAvard the left anterior portion of the uterus and peh'is; the abdomen, chest, and face tOAvard the right posterior portion. As in the case of breech presentation, the feet cannot be readily recognised until after the rupture of the membranous sac. Second Position of the Feet.—The heels regard the right aceta- bulum, the toes the left sacro-iliac symphysis—the right anterior- cedcaneo position. The breech, back, and occiput in front, and to the right; the abdomen, chest, and face behind, and to the left. Third Position of the Feet.—The heels regard the right sacro- iliac symphysis ; and the toes the left acetabulum, being the reverse of the first position—the right posterior-calcaneo position. The breech, back, and occiput behind, and to the right; the abdomen, chest, and face, in front, and to the left. Fourth Position of the Feet.—In this position, the reArerse of the second, the heels are turned toward the left sacro-iliac symphy- sis, and the toes toward the right acetabulum; the left posterior- calcaneo position. The breech, back, and occiput, behind, and to the left; the abdomen, chest, and face in front, and to the right. In the various positions of the feet, the mechanism, after the escape of these latter, is precisely the same as in the breech pre- sentations; and, therefore, it is unnecessary to repeat Avhat we have said on the subject. First Position of the Knees.—The tibiae correspond with the left acetabulum, and the thighs AA'ith the right sacro-iliac symphysis— left anterior-tibialposition. Second Position of the Knees.—The tibiae at the right acetabu- 350 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. lum, the thighs at the left sacro-iliac symphysis—right anterior- tibial position. Third Position of the Knees.—The tibiae to the right sacro-iliac symphysis; the thighs to the left acetabulum; this is the reverse of the first position—the right posterior-tibial. Fourth Position of the Knees.—The tibiae to the left sacro-iliac symphysis ; the thighs to the right acetabulum, the reverse of the second position—the left posterior-tibial. As soon as the knees are expelled, the various positions are reduced to the corresponding positions of the feet. Without care, it may be possible to confound the knee, especially Avhen only one can be felt at the superior strait, Avith the elbow or shoulder. In the case of the elbow, the olecranon process and condyles will serve as guides, while the ribs and axilla will determine the fact of a shoulder presentation. It Avill be seen that I have not spoken of the management of pelvic presentations in cases in which the labor becomes complicated, and in which consequently it will be necessary for the accoucheur to interpose. This subject will be discussed in a future lecture, Avhen treating of preternatural labor. LECTURE XXV. The young Accoucheur's Debut in the Lying-in Chamber—"What he is to do, and what he is not to do; his Chat with the Nurse—The Examination per Vaginam; how it is conducted, and what it should reveal—Is the Patient Pregnant ?—Is she actually in Labor?—Are the Pelvis and Soft Parts Normal or otherwise? A Woman may imagine herself in Labor, and yet not be Pregnant; Illustration— What is the Presentation of the Foetus?—Is it Natural or Preternatural ?—What will be the Duration of the Labor ?—How this question is to be answered— When Labor has commenced, the Bowels and Bladder to be attended to—Quietude of the Lying-in Woman important; Loquacity of the Nurse—The Stages of Labor; what are they?—Conduct of the Accoucheur during each of these Stages —After the Escape of the Head, Rule to be followed—When the entire Expul- sion of the Foetus is completed, important rule to be observed—How many Liga- tures are to be applied to the Cord ?—The Author recommends but one—Reasons for—Trismus Nascentium, and Inflammation of the Umbilical Vessels; Scholer's Opinion—When the Child is separated from the Mother, what is to be done ?— Respiration of the Infant; Causes which Impede it—Asphyxia; Causes of— Treatment of Asphyxia—Marshall Hall's Method—Ability to resist Asphyxia greater in the New-Born Infant than in the Adult—The Opinion of Bracliet, of Lyons, Josat, and others, as to the Restoration of Life some time after the Pulsa- tions of the Heart have ceased—Death of the Mother not necessarily Fatal to Foetus in Utero; Why ?—Brown-Sequard's Experiments. Gentlemen—We will noAV suppose that your services are demanded in a case of labor; and shall, therefore, proceed to speak of the duties devolving upon you at the bedside of your patient. The first entrance of the young accoucheur into the lying-in chamber is a matter of no little importance. In the first place, he has popular prejudice to contend Avith; he is not "an old gentleman, and con- sequently knows nothing of his business." The only means of putting an end to this prejudice, and of demonstrating that, although not a patriarch in years, yet he is nevertheless fully com- petent to the discharge of his duties, is his conduct after he crosses the threshold of the parturient room. One mistake in his debut in obstetric practice may exert a singularly unhappy influence over his future prospects; should he, on the contrary, make a favorable impression in his first case, the best consequences may ensue to him. Something more is required of the accoucheur, if he wish to suc- ceed, than a profound knoAA'ledge of his subject: conjoined to an intimate acquaintance with the varied details of the sick-room, he must understand human nature; he must discriminate between a harmless concession to popular whim or caprice, and a concession 352 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Avhich may compromise his OAvn character and the dignity of his art. In a Avord, he is constantly to bear in mind the full measure of his responsibility. Punctuality and promptness, in responding to professional calls, are especially important in the practice of obstetric medicine. A messenger has arrived, requesting the immediate attendance of the accoucheur. The latter proceeds Avithout delay to the residence of the patient; he rings the bell; he is admitted ; and if this should be his first professional visit to the family, all eyes will naturally be turned toward him, surveying him Avith marked care; if he falter under the scrutinizing gaze, it will very likely be attributed to Avant of professional skill! His general bearing, as soon as he enters the house of his patient, should be that of a well-bred gentleman ; he should manifest no excitement, but his conduct be such as to impress the conviction that he is accustomed to these calls, and understands hoAV to comport himself. Soon after being introduced into the parlor, the nurse will probably leave the patient for the purpose of having a little preliminary chat with the doctor. In this intervieAV Avith the nurse, if adroitly conducted, much can be learned as to the general condition of the patient—whether it is her first child—Avhether the labor has regularly commenced, Avhether she has suffered unusually from her pains, Avhether she is nervous and irritable, whether she is agitated at the doctor's arrival. These preliminaries over, the nurse then leaves Avith the promise that, in a feAV minutes she will return, and conduct you to the sick room. When you enter the room, your patient will be reclining on the bed or sofa, or sitting in a chair. In either case, you approach her gently and courteously, and, instead of saying, "Well, madam, you are about to have a baby—does it hurt much ?" or some such kindred expression, bearing the impress of a vulgar mind—I say, in lieu of such rudeness, you enter into conversation with her, talking of any and everything except of the subject directly connected Avith the object of your visit. Talk of France, or Egypt, or Kamschatka, or the marine telegraph ; in this way, a little professional diplomacy will enable you very successfully to accustom your patient to your presence. The first intervieAV has passed; she finds that, after all, it is not such an embarrassing thing to hold converse Avith a doctor, and you will have impressed her quite favorably merely by your manner. She will rather like you, and will be apt, as soon as occa- sion presents itself, to say to the nurse—" What a clever man that is; he is so very agreeable." "Yes, madam," replies the nurse, " he knows what he is about." These mutual compliments betAveen patient and nurse give you a substratum in that family; your authority will be hearkened to, and you will have achieved an early and important victory. Well, thus much for the first scene—Avhat next ? THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 353 Tlie object in sending for you Avas of course to have the benefit of your counsel and skill; as soon, therefore, as you have fairly introduced yourself to your patient, it Avill then be essential to become satisfied as to her true condition ; to do this it Avill be necessary to institute a vaginal examination. For this purpose, you speak to the nurse, and tell her that you are anxious to ascertain how things are progressing. This is communicated by the nurse to the patient, and her assent is readily obtained; for, as a general rule, she will be found most solicitous to knoAV if " all is right.'' AUoav me here to call attention to some few details in reference to this first examination. The patient should be in the recumbent position, either on her side or back; and whichever position may be assumed, it is important that she be near the edge of the bed, so that you may have every facility for conducting the examination. While the nurse is arranging the patient, you will generally be requested for the time being, to Avalk into an adjoining room ; but if not, be careful that you occupy yourself with something else than gazing at the movements of the parties; take a seat, and turn your back ; become thoughtful, as if lost in the solution of some great professional problem ; or, if a book be at hand, open it, and improve your mind. When everything has been arranged, you then proceed to make the examination, the mode of doing which has already been pointed out in Lecture XIII., to Avhich I refer you. When you are summoned to at- tend a lady Avho supposes herself to be in labor, the examination AA'hich you institute will have the folioAving objects : 1. Is she pregnant ? 2. Is she actually in labor, and has the os uteri begun to di- late ? (Fig. 54.) 3. Arc the pelvis and soft parts in a normal condition, or are they deformed ? 4. Is the presentation of the foetus in accordance Avith the requirements of natural labor, or is it otherwise? These are the points to be ascertained in this exploration. I. Does Pregnancy Exist ?—You may think it strange, almost bordering on the ridiculous, that your services should be required by a lady who imagines her labor at hand, when in fact she is not 23 Fig. 54. 354 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. in gestation. Put, alloAV me to tell you that such occurrences arc now a part of history ; and it would be a severe blow to your virgin aspirations to be found ministering, for several days, to the wants of a patient supposed to be in parturition, Avho in truth Avas not even pregnant. Women Avho have never borne children, and Avhose desire it has been to have offspring, are sometimes quite apt to imagine themselves in a state of gestation ; as I have remarked in a preceding lecture, the accoucheur should never rely upon any statements made by his patient in cases of this kind. It is his duty to judge for himself, irrespective of all adventitious or other influ- ences. His mind must be free from bias, and his decision of the case based upon the evidence Avhich maybe presented to his senses. Such is the rule of conduct I would most earnestly enjoin on all, who may wish to discharge their trust fearlessly, and at the same time justly. A most amusing case occurred in this city some years since, and will, perhaps, serve more effectually to illustrate an important truth in midwifery than any argument I can advance. It is Avhat may be denominated a tangible fact, and is entitled to full appreciation : A lady, aged 47, married since her thirtieth year, had cherished an ardent desire to become a mother, but had not succeeded in her Avishes. She was about abandoning all hope, Avhen, of a sudden, she noticed that her abdomen began to enlarge, and really imagined herself pregnant. In addition to other symptoms, she thought she distinctly felt the movements of the child. Her heart Avas full of joy; she received the congratulations of her numerous female friends, Avho complimented her on her proAvess, and the final accom- plishment of her hopes after years of fruitless effort; she commenced making the necessary preparations for her approaching accouchement. Her physician was advised of the happy circumstance, and informed that his services in due time Avould be needed. In the course of a few months the labor commenced ; a messenger hastened to apprise the doctor that the lady's time had come, with an urgent request that he would be prompt in reaching the bedside of his delighted but suffering patient. The doctor arrived—all in the house was confusion, and in high expectation; the nurse Avas enchanted ; the husband, in a spirit of humility, could scarcely realize the advent of this long expected era in his life; the patient was in actual labor; the pains frequent and distressing. The physician was entreated by the good nurse to lose no time in assisting madam ; he made an examination ; the silence of death noAV pervaded the lying-in cham- ber to receive from the lips of the oracle the exact facts of the case ; the friends Avere soon made joyful, by hearing from the doctor that all was right—that the labor Avas quite advanced, and in a very short time would be completed. The sufferings of the patient increased; she Avas urged to make the most of her pains : " To bear THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 355 doAvn and assist nature "—when lo ! in the midst of one of those powerful efforts to " assist nature,'' there Avas heard an explosion, which struck terror into all present, the doctor included. The patient, as soon as she recovered from the prodigious effort which had occasioned the explosion, exclaimed: " Oh! dear Doctor, it's all over; do tell me if it's a boy !" The explosion Avas nothing more than an escape of air from the bowels; the patient having mistaken flatulence for pregnancy, and the rumbling of the gas in the intestines for the motions of the foetus! Let this case, there- fore, keep before you the recollection of the fact, that one of the first duties devolving on you in the examination is to be certain that your patient is pregnant. II. Has Labor Actually Commenced?—You have only to refer to Avhat we have said in Lecture XXIIL, regarding the signs of labor, and the mode of distinguishing betAveen true and spurious pains, to be enabled at once to determine whether the parturient effort has really begun. If you find labor is in progress, your next care AviU be to acquaint yourselves with the character of the pains; are they merely commencing, and, therefore, slight, or have they already assumed a degree of intensity ? What is the condition of the os uteri ? Has it begun to dilate, and to Avhat extent ? Does the membranous sac protrude, and Avhat is its volume ? These are important questions, for they Avill aid you in the prognosis as to the probable duration of the labor. Has your patient already borne a child, or is she a primipara ? In the latter, the labor is usually more protracted. III. A re the Pelvis and Soft Parts in a Normal Condition ?— While conducting the vaginal examination, you should not fail to assure yourselves of the state of the pelvis and soft parts. Is the for- mer natural in its dimensions ? Is it deformed ? If so, Avhether by an increased or diminished capacity ? Is its diminished capacity such as to involve the safety of the mother or child, or will it only tend to make the labor tedious and more lengthened ? Hoav is the uterus—does it preserve its parallelism with the axis of the superior strait—or is it malposed, so as to exhibit either of the obliquities to M'hich Ave alluded in the previous lecture ? Hoav are the vagina and vulva ? Are they contracted and rigid, or relaxed and dilata- ble ? Is the bladder distended, or the rectum more or less filled with fiecal matter ? These are so many points to be ascertained by the accoucheur in his first exploration ; they will involve no diffi- culty on his part, if he understand himself—nor will they, in any Avay, expose the patient to annoyance or suffering; the index finger carefully introduced will be all that is necessary to arrive at just conclusions upon these various heads. IV. Is the Presentation of the Fcetus in Accordance with the Requirements of Nature ?—Does one of the extremities of the 356 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ovoid present at the superior strait ? If so, Avhich is it ? Is it the head, breech, feet, or knees ? If the head, is it the vertex, or face, and Avhat position does it assume ? If the presenting part have begun to descend into the pelvic cavity, is its descent consistent with the mechanism of labor, or otherwise ? Instead of one of the extremities, is some portion of the trunk of the foetus at the upper Btrait, constituting a cross birth ? In addition, the careful accou- cheur will inform himself as to other points ; such as the tempera- ment, disposition, age, moral and physical condition, etc., of his patient. Is she plethoric, or feeble, and nervous? Is she in good health, or is her labor complicated Avith some serious dis- ease, either of an acute or chronic form ? Is she young, or has she already approached the meridian of life, and yet a primi- para ? It can scarcely be necessary to impress upon you the importance of becoming thoroughly and promptly cognizant of these various conditions; in doing so, you place yourselves in a strong and safe position ; you knoAV, at once, Avhether the labor is natural, or whether the interposition of science Avill be called for. In truth, Avith this knowledge, you will be not unlike the skilled general on the battle field, who, having fully informed himself of the various points of the field itself, and of the strength and arrangement of the adverse forces, knows, not only hoAV, but Avhen to make his attack. Under these circumstances, his charge upon the enemy will usually be one of victory, for the reason that it has been Avell con- sidered, and based upon a knoAviedge of circumstances more or less essential to success. So, gentlemen, will it be in the lying-in chamber in cases of trouble, if you Avill early inform yourselves of the true nature and extent of the difficulty to be overcome. Duration of the Labor.—Well, the examination has been made, and you are in possession of all the circumstances of the case, having ascertained that everything is auspicious to a natural deli- very. A pressing question, which will be urged not unfrequently by the patient and friends, as soon as you have completed the exa- mination, Avill be as to the probable duration of the labor. Much anxiety will be evinced for a prompt reply to this interrogatory, and the friends will be more or less importunate for your opinion. Xo measure of experience Avill enable you to give an unqualified an- swer to this inquiry, for there is a vast deal of caprice about nature, and although we may approximate, yet Ave cannot definitely fix the period which she will require for the completion of her Avork. In order, therefore, to relieve the very natural anxiety on this point, and, at the same time, avoid a positive committal, you should say— all is right, and everything will depend upon the character and efficiency of the pains. This is certainly an equivocal ansAver, but it Avill be accepted as quite satisfactory, and will serve to liberate THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 357 you from the consequences of naming any particular time in Avhich the delivery may be accomplished. Duties of the Accoucheur after Labor has Commenced.—As soon as you have ascertained that your patient is in labor, your next care should be to conduct her safely through it, and Avith this vieAA', Ave shall noAV speak of certain duties, which will necessarily devolve upon you. In the first place, if the boAvels have not been evacuated for one or tAvo days, and more especially if the rectum be distended Avith faecal matter, it is quite essential that an enema should be administered, or, if preferred, some castor oil; and also if there be an accumulation of urine in the bladder, the patient should be di- rected to attempt to relieA'e herself; if, however, she should be unable to do so, the catheter must be employed. You will not have forgotten Avhat Ave said regarding the introduction of this instru- ment in the latter stages of pregnancy, or during labor; the posi- tion of the urethra at this time is nearly vertical, being more or less parallel to the internal surface of the symphysis pubis ; there- fore, the direction of the catheter, in order to reach the bladder, must be from below upward, describing nearly a perpendicular line. Quietude in the Chamber.—I Avould earnestly suggest that the room of the parturient Avoman be kept quiet, and that she be saved the perils of excitement from the presence of persons, Avho can ren- der no assistance, but who tend to contaminate the air, and often- times, by their frivolous conversation, disturb the patient. The nurse and one other assistant will suffice, under ordinary circum- stances, for all the purposes needed. You should early study the character and disposition of your patient—if she be nervous and timid, and full of despondency, open before her vistas of hope and cheerfulness; encouragement from her physician, in the hour of tribulation, is ahvays a grateful boon to a confiding Avoman, and it should not be denied her at the time at which, of all others, she most needs support and comfort. The nurse, if loquacious, and fond of recording her doleful experience of "horrible cases," must be promptly checked. There seems to be a growing and morbid disposition on the part of certain unthinking females, to indulge in narrations of the frightful scenes they have witnessed in childbirth, and they usually avail themselves of the most inopportune occasion for their recital. Nothing of this should be allowed, for it often- times has a most pernicious effect. It will be proper, as the labor is progressing, to ask the nurse if she have in readiness a piece of tape and a pair of scissors, which will be required as soon as the child is born for the purpose of tying and cutting the cord. I have knoAvn great confusion to ensue from the neglect of this apparently trivial direction. Stages of Labor.—In order to simplify as much as possible the 358 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. question of natural labor, Ave shall divide it into three stages, and shall speak of what may be necessary for you to do in each one of them: First stage consists in the full dilatation of the os uteri, and rupture of the membranous sac; second stage, the descent and expulsion of the foetus; third stage, the delivery of the placenta. Authors differ much in their division of the various stages, but the one just given you will, I think, for practical purposes, be found sufficiently comprehensive. First Stage.—This I have just told you is occupied in the dilata- tion of the os uteri, and rupture of the membranous sac. During the commencement of this stage of labor, the pains are at first slight passing from the back to the thighs, and are denominated grinding ; it is not until the os uteri becomes so dilated and the membranous sac and presenting portions of the foetus begin to make a decided pres- sure upon it, that the pains assume a strongly marked bearing-down character. It is Avell to note the change in the female as soon as these latter pains are in full development; at this time, during a contraction, she grasps anything Avithin her reach, and endeavoring to fix her feet firmly against some resisting object, she holds her breath, and concentrates all her efforts on the uterus—the dia- phragm and abdominal muscles contributing their respective aid in this effort. This, I repeat, is what you will ordinarily observe as a characteristic difference in the contractions of the uterus, during the commencement and completion of the first stage. You cannot but perceive that this very difference inculcates an important practical precept, viz., not to urge your patient to make any effort, or, in the ordinary phrase, " bear down " Avhile the pains are simply grinding ; for, at this period, no effort of hers can avail; on the contrary, you should caution her to economize her strength until, when the os uteri has progressed in its dilatation, the contractions themselves become forcing, and, consequently, may be materially aided by the efforts of the female herself. The more, therefore, she endeavors to assist nature at this period, the greater, under ordinary circum- stances, Avill be the facility of the birth. Rupture of the Membranous Sac.—As a general principle, Avhen the os uteri has become sufficiently dilated to enable the head of the foetus to pass (Fig. 54), there is a spontaneous rupture of the sac, folloAved by the escape of more or less of the amniotic fluid. You have, in a previous lecture, been admonished not to rupture the sac prematurely ; for, in doing so, you deprive nature of an important adjunct in the dilatation of the os—the uniform and steady pressure of the sac itself. When the liquor amnii es- capes before the proper dilatation of the mouth of the uterus, instead of this gentle and effective pressure of the sac, there is simply the hard and unequal pressure of the head to accomplish the object, resulting ordinarily in a protracted delivery, and sometimes THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 359 in injury to both mother and child. There are, howeA-er, circum- stances in which it may become essen- tially necessary for you to rupture the " bag of waters'' early in the labor, and before the pro- per degree of dilata- tion has been accom- plished. Suppose, for example, the labor from the very com- mencement should be extremely rapid, and that you appre- hended a too sudden expulsion of the foe- tus and its annexae; in a case of this kind, it Avill be your duty early to afford, by fi.-,. 55. runture of the sac *^8 ute" fully dilated—membranous sac unruptured. escape to the amniotic fluid. Should you fail to do so, the rapid and brusque evacuation of the uterine contents might endanger the life of the mother. The uterus, under these circumstances, would be apt to be throAvn into a state of inertia, giving rise to hemorrhage, Avliich, to say the least, Avould involve the safety of the parent in a greater or less degree of peril. If you Avill allow me to say so—you should, as a general rule, regard quick births as dangerous births. Position of the Parturient Woman.—Previous to the rupture of the sac of Avaters, the patient may be permitted to assume Avhat- ever position may be most agreeable to her. It is a great mistake to confine her to the bed from the very commencement of her labor. In the first place, it is uncalled for; and secondly, Avhile it enervates her strength, it is calculated also to break the Aving of her spirit, and occasion more or less depression. AHoav her, therefore, the largest liberty ; she may sit in a chair, recline on the sofa, walk about the chamber, or get on her knees. In one word, let her do just as she pleases.* Put after the rupture of the sac, it Avill be prudent for her to remain in bed.f * If, in your examination per vaginam, you ascertain that the pelvis is unusually capacious, then it will become important to depart from this rule, and enjoin upon your patient to continue in the recumbent position during the entire progress of the labor; otherwise, from the excessive size of the pelvis, there would be danger of a sud- den delivery while walking about the room. Such a contingency might result sadly. \ I am in the habit of ordering a cot to be placed by the side of the bed, for the 360 THE PRINCIPLES AND PRACTICE OF OBSTETUICS. The position assumed by the female at the time of delivery varies in different countries. In England, the usual position is on the left side; in France, on the back—and, indeed, throughout (Germany, with the exception of Vienna and Heidelberg, Avhere the English custom seems to prevail, the Avoman is ordinarily delivered on her back. In some portions of Ireland, it is said, the custom obtains of having the birth completed with the woman either in the stand- ing position or on her knees.* When there is no special objection on the part of the patient, I am in the habit of recommending the position on the back, because I think she can give herself much more efficient support than Avhen on the side ; and, in all cases of operative midwifery, Avhether manual or instrumental, the back is infinitely preferable. Let me here remark that, in some instances in Avhich the contractions of the uterus become defective, I have observed great advantage from alloAving the female to place herself, for a short time, on her knees ; this change of position will often- times stimulate the organ to rcneAved effort. Impropriety of Frequent Vaginal Examinations.—Let me cau- tion you against frequent vaginal examinations during this stage of labor. The practice of constantly introducing the finger into the Aagina, is a vicious one; nothing, under ordinary circumstances, can justify it; it is both annoying and injurious to the patient. After you have satisfied yourselves, as far as may be, of the true state of things in the examination you instituted at the commencement of labor, Avhat necessity can there be for more than one or two repetitions until after the escape of the Avaters, when it becomes necessary again to explore, and inform yourselves as to the progress of delivery, and the precise position of the presenting part ? Diet of the Parturient Woman.—The patient should occasionally be permitted to take bland nourishment, such as tea, barley Avater, gruel, light broth, etc.; but do not fall into the pernicious habit of recommending Avines, spirits, or other stimulants, unless specially indicated. They excite the system, and almost ahvays do harm. Ice Avater will be both grateful and efficient as a drink, particularly if there be a degree of lethargy in the contractions of the uterus. Rigidity of the Os Uteri.—In some cases, dilatation of the os uteri will be extremely sIoav and irksome, and this may be owing to tAvo different conditions; 1. To extreme dryness of the parts, an absence of the mucous secretion, which Ave have already stated produces a lubricating influence, relaxing and preparing them for purpose of delivering the patient; there is much advantage in this, for, after the delivery, she can be transferred to her own comfortable bed, which has been neither disturbed nor soiled by the labor. * Dr. Rigby says, " in some remote parts of Ireland and all of Germany, the patient sits upon the knees of another person, and this office of substitute lor a labor chair is usually performed by her husband."—Rigby s SysUm of Mtdwijvry, p. iii. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 361 the distension necessary for the transit of the child. In such an event, you will find much benefit in directing your patient to sit over a vase of Avarm water. This I have frequently resorted to, and Avith signal success. Advantage will also be derived from throwing into the vagina, at intervals, mucilaginous injections, or lubricating the os uteri, vagina, and vulva freely Avith fresh lard or butter. Here, too, the application of the Pelladonna ointment Avill be of signal service. The abominable practice, commended by some of the older Avriters, of introducing the hand into the vagina for the purpose of stretching and distending it, is not for an instant to be tolerated. These rude manipulations can never receive the sanction of the scientific accoucheur. 2. The delay in the dilatation of the os uteri may be due to excessive plethora of the system, conjoined with unusual muscular rigidity. Under these circum- stances, you have in the judicious employment of the lancet an efficient remedy. Abstract from the arm, early, just so much blood as your judgment tells you is indicated—six, eight, twelve ounces. The effect of general blood-letting in producing a softening of the os uteri is often marvellous. I have said resort to the lancet early, and for this reason—if the female be permitted, in this state of plethora and muscular resistance, to continue in labor for some hours Avithout relief, she groAvs wearied by fruitless effort. The child incurs the hazard of undue pressure, and the mother, in this hyperaemic condition of system, is exposed to dangerous congestion of some of the more important organs. Touching the subject of blood-letting, alloAV me to suggest to you an important lesson: Whenever you are summoned to attend a lady in labor, if she should be surcharged Avith blood, as will be indicated by her bounding pulse, flushed countenance, and general physical condition; and, if under these circumstances she complain of more or less intense cephalalgia, with throbbing of the temporal arteries, and an approach to suffusion of the eyes, do not hesitate to tie up the arm, and abstract blood until a decided impression has been made upon the system. A neglect of this precaution has more than once left its melancholy trace in the lying-in chamber— either in the production of puerperal convulsions, apoplexy, paralysis, or haemoptysis. When at the bedside of his patient, the sagacious practitioner must have his eyes about him, and be prepared for Avhatever emergency may arise. How many noble ships have been Avreckcd because no precaution had been exercised until the storm had broken forth in all its resistless intensity. While I recommend a resort to the lancet during labor, when the abstraction of blood is plainly indicated, yet I would most emphatically inculcate upon your recollection this essential obstetric truth—women in parturition are always more or less liable to be attacked with flooding, and, therefore, great caution is to be observed 362 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. in the artificial drawing of blood. Again: excessive losses of blood, whether from flooding or the lancet, are not unfrequently folloAved by serious puerperal complications. Fortunately, Ave have at our command several therapeutic agents, most efficient in theii action, in cases of rigid os uteri; and among them may be men tioned tartarized antimony and ipecacuanha. It is not, in my opinion, at all necessary, as some authors maintain, to insure vomit- ing in order to derive the full benefit of these remedies; I much prefer their exhibition in tolerant doses—the nausea thus occasioned will tend directly to relaxation of the general muscular system, with which the mouth of the womb will speedily sympathize. For this purpose dissolve i gr. of tartarized antimony in 3 i of Avater; give a dessert-spoonful every five or ten minutes, closely Avatching the effects; or, a quarter or half grain of ipecacuanha may be administered. Put, gentlemen, there is a remedy of all others, when not contra-indicated by plethora or other circumstances, which you will find most prompt and decisive in overcoming rigidity of the os uteri or vagina—I mean sulphuric ether, not given to full anaesthesia, but simply with a view of producing a gently lulling influence. I regard it in these cases as the remedy par excellence, and, if judiciously used, will fulfil, as it has done for me, your highest hopes. It will occasionally happen that the os uteri does not respond to the efforts of the uterus; the contractions recur at intervals, but they have not sufficient force; the patient becomes wearied with the abortive efforts of nature; her strength gives way, and the nervous system is much disturbed. Here, then, is a condition of things Avhich must not be misapprehended—do not mistake it for rigidity of the os. The palpable indication is to protect the patient against these mischievous and inefficient contractions—administer an anodyne, which will cause her to lapse into a sweet and refresh- ing sleep; you will thus have economized her forces, and when she awakes, she will be revived not only in physical energy, but in moral strength. Second Stage.—When the membranous sac has ruptured, and the liquor amnii escaped, the contractions of the uterus increase in violence, and become decidedly expulsive. It is noAv proper that you should make an examination, in order to ascertain more speci- fically the state of things Avith regard to the fcetus—its true position, and progress. The nurse should attach a sheet to the foot of the bed, so that the suffering patient may grasp it Avith her hands ; with her feet steadily braced, she should, during the expul- sive effort, be urged to bear down and assUt nature. Generally, a short time after the escape of the Avaters, a segment of the uterus will be felt between the head of the foetus and symphysis pubis; and it will sometimes, depending upon the amount of pressure it THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 363 has undergone, be more or less sAvollen. You can be of very material assistance, by pushing this segment of the cervix gently upward during a pain; or if, as is sometimes the case, it should be more toward the rectum than in front, the same thing may be done also in this case. I speak from no little experience, Avhen I tell you that, by this simple manoeuvre, if dexterously performed, the labor will oftentimes be most favorably advanced. Again : if there be a sluggishness in the contractions, much benefit will arise from care- fully insinuating your finger within the dilated os uteri, and titil- lating it. This, you at once perceive, evokes the reflex faculty of the spinal cord, and imparts vigor and efficiency to the contractions ; indeed, the introduction of the finger under these circumstances Avill act also on a mechanical principle, for the dilatation of the os uteri is both vital and mechanical. It is during the second stage of labor that the patient Avill com- plain of distressing pain in her back, causing her frequently to exclaim, " Oh ! my back Avill break; Oh ! dear doctor! my poor back; Avhat shall I do ?" Great relief will be afforded in these cases, by tAvisting a napkin, and placing it under the back, the two ends being held by assistant*, one on either side; during the pain, they should be instructed to gently elevate the patient, by raising the ends of the napkin, so that firm pressure may be made on the back. This is an old suggestion ; I do not recollect to Avhom it is due, but it is a good one. I often avail myself of it. As the head of the foetus approaches the vulva, the patient AA'ill feel an urgent desire to evacuate the boAvels, and she AviU insist upon being permitted to leave her bed. This you cannot consent to, for it AA-ould, at this advanced period of labor, involve both herself and child in danger. The desire is caused by the pressure of the head against the rectum. Should there be fiecal matter in this portion of the intestinal canal, it will, hoAvever, be pressed out; but this is matter of no moment, for the nurse, if experienced, will have pre- viously provided a napkin for its reception. Supporting the Perineum.—The head having approached the os externum, the perineum now becomes the seat of extraordinary distension, and the anus itself is more or less open. Support must be given to the perineum in the folloAving manner : the accoucheur will place a piece of folded linen in the hollow of his hand, in order to constitute it a plane surface, and make, during the contraction, a firm and equable pressure, being careful not to have the radial portion of his hand above the inferior commissure ; for, in this case, in lieu of supporting the perineum, he would press more or less directly against the head of the foetus, thus antagonizing the expul- sive efforts of the uterus, and, therefore, incurring the liability of rupturing the organ (Figs. 55, 56). The sufferings of the patient at this period of her parturition are 364 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. generally most intense; her shrieks are terrific, and to an unprac- tised ear will be any thing but SAveet music. Do not alloAV her cries to alarm or perturb you; and while I Avould not advise you to dry up the fountains of your sympathy in this her hour of dis- Fig. 56. tress, yet you must be firm, and at the same time consolatory— giving her every possible encouragement, and assuring her in terms of emphatic kindness, that in a very few moments there will be an end to her tribulation. The accoucheur has much in his poAver; if Fig. 67. he be clever, and comprehend human nature, he can prove the very balm of Gilead to his patient; he can make her faith in him so strong, that it will tend very materially to break the intensity of physical suffering, and remove from her mind the apprehensions of gloom and despondency. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 365 The vulva, during these last throes of the uterus, becomes greatly distended ; the head protrudes, and the labia externa are appa- rently so tightly drawn over it, that you Avould imagine it almost impossible for the birth to be accomplished Avithout serious lacera- tion. Put nature is so conservative that, under ordinary circum- stances, the exit of the head is effected without injury to the parts. During the interval of pain, there is usually a slight retrocession of the head. It is not, you must remember, by one sudden and abrupt expulsive effort, that the delivery is consummated ; on the contrary, it is through a series of consecutive forces, the necessary tendency of Avhich is gradually to prepare the parts for the distension to Avhich they are subjected, and which, for this reason, they can sus- tain Avith impunity. In these last struggles, just as the head is about making its final passage into the Avorld, the patient will sometimes be attacked with nervous tremblings. They are entirely involuntary, and she has no power for the moment of controlling them. They are of no sort of importance, and need give rise to no disquietude. When the head has thus escaped, there is experienced great relief, and you will be asked in terms of kindness, " Oh! dear doctor, is it all over ?'' " In one moment, my good patient," you will reply ; " the head is delivered, and the rest will occasion you very little trou- ble." She is soothed by this assurance, and is fortified Avith hope for the remainder of the birth. It is proper here to remark that, in some instances, as the head is passing through the os externum, and the same thing may occur as it escapes through the os uteri, the patient will lose her consciousness—she will Avander, and if it be not recollected that this loss of reason is but for the moment, unnecessary alarm may be excited.* Does the Cord encircle the Neck of the Child?—There is at this period of the labor an important duty for you to perform ; and you must be careful not to omit it. As soon as the head has effected its transit through the vulva, you should immediately introduce your index finger, for the purpose of ascertaining Avhether or not the umbilical cord, as sometimes will be the case, is around the neck of the child; if so, does it encircle the neck tightly ? If it be * Dr. Montgomery called attention to this temporary loss of mind during labor some years since: " It comes on suddenly during perfectly natural labor, and most frequently at that particular stage of the process—dilatation of the os uteri. It is not accompanied nor followed by any other unpleasant or suspicious symptom; it occurs, perhaps, immediately after the patient has been talking cheerfully, and, hav- ing lasted a few moments, disappears, leaving her perfectly clear and collected, and returns no more, even though the subsequent part of the labor should be slower and more painful. In every instance which came under my observation, the patients were conscious that they had been wandering, and occasionally apologized for any- thing wrong they might have said, although they were not aware of what the exact nature of their observations might have been." [Dublin Journal, vol. v. p. 51.] 366 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. loose and exercise no compression, let it alone. Should it, however, be found constricting the neck, you should endeavor to relax it, so that it may be gently draAvn over the head. If this cannot be accomplished, and the pressure so great as to cause you to appre- hend the death of the child from the impossibility of atmospheric air passing into the larynx and trachea, then, at once, Avith your fin- ger as a guide, introduce a pair of scissors, and make a section of the cord; or, in the absence of scissors, a penknife Avill ansAver every purpose. Generally, as soon as the head is in the Avorld, the child Avill gasp, and give evidence that it is alive. Unless something should indi- cate the necessity for interference, I Avould advise you to submit the termination of the delivery to nature, except see that the bed- clothes do not obstruct the mouth so as to interfere with the func- tion of respiration ; see, too, that the mouth and nose are not obstructed by the membranes. In a feAv moments after the expulsion of the head, the uterus again contracts, Avhen the shoulders and entire foetus are expelled. During the passage of the shoulders, the perineum must be care- fully supported. Some practitioners are in the habit, as soon as the head has made its exit, of making traction upon it for the pur- pose of expediting the delivery. This is, as a general rule, bad practice, for the sudden evacuation of the uterus will be apt to induce inertia and hemorrhage. It is very essential, the moment the head has passed the vulva, to allow a free access of air to the face of the child, and this can be done Avithout in any way unnecessarily exposing the person of the mother. Infants are, I am sure, oftentimes sacrificed by indif- ference to this simple but fundamental rule. The physiologist has sliOAvn that respiration is dependent upon the excito-motory system; or, in other words, upon the spinal cord. It is an excited act, and the first effort of the new-born infant to breathe is, perhaps, as Mar- shall Hall has declared, induced by the stimulus of the atmosphere acting upon the cutaneous or terminal branches of the trifacial nerve. It is not necessary for me to repeat here what I have already mentioned, when speaking of the mechanism of labor, respecting the different movements of the head, shoulders, etc., during their passage into the world. For these details I refer you to Lecture IV. As soon as the Child is born what is to be done?—Put, gentle- men, I am now about to enjoin upon you a lesson, Avhich I hope you will not fail to observe. I regard it as one of the most import- ant connected with your duties in the lying-in chamber. It is this ; the moment the child is in the world, place your hand gently upon the hypogastric region of your patient, for the purpose of being assured that the uterus responds to the birth; the evidence of this THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 367 response will be, that you will feel the organ gathered, as it were, upon itself, occupying the loAver portion of the abdominal cavity, and presenting the feel of a hard, contracted object. In the recog- nition of this circumstance, your mind is at ease Avith regard to the fear of hemorrhage. Suppose, on the contrary, instead of this con- tracted condition of the uterus, you should find the organ uncon- victed, and in a state of inertia, occupying more or less of the abdomen: this state of things Avould at once admonish you of the certainty of flooding ; and being thus admonished, you Avould lose no time in staying the current, which, if not promptly checked, will destroy the life of your patient. The subject of flooding, with its causes and treatment, will be discussed in a future lecture. Demands of the Infant.—Let us now turn our attention to the infant. As soon as the child has escaped from the uterus, care should be taken to place it transversely as near the vulva as possi- ble, Avithits back toward the mother; the object being, in the first place, to prevent laceration of the cord ; and, secondly, the passage of any discharge from the vagina into the mouth of the child. Should the cord be tAvisted round the body or extremities of the infant, you must not fail carefully to liberate it. Usually, if the labor have been auspicious, simultaneously Avith, or a feAV seconds after the exit of the child from the maternal organs, it is heard to cry, a proof that the respiratory movement has taken place, and that the infant is noAV independent of its mother. Under these circumstances, you should place a ligature around the cord, about two inches from the umbilicus, not, how- ever, Avithout previously having assured yourselves that there is no fold of the intestine protruding from the umbilicus, thus constitut- ing a species of congenital hernia. Should there be this fold, it must be carefully pressed back into the abdomen before applying the ligature. I recommend you to use for this purpose a piece of flat tape, Avhich exercises an equable but firm pressure.* After the ligature * Dr. Scholer, in speaking of that very fatal affection among new-born infants— Trismus nascentium—says that in eighteen children who died of it he discovered inflammation of the umbilical arteries in. fifteen, the arteries having been found swollen at the point at which they approach the urinary bladder. The same observer has failed, in all examinations of infants who have died from other com- plaints, to detect inflammation of the umbilical vessels. I am quite disposed to believe that there is much truth in the opinion of Dr. Scholer, that trismus is caused by this inflammation of the vessels; and, moreover, that the inflammation is owing to the rude manner in which, frequently, the cord is tied; sudden an 4 undue pres- sure on these vessels by a round string being apt, I think, to excite inflammatory action, which is soon propagated to the vessels in their progress toward the bladder. To avoid this unnecessary constriction, therefore, I recommend you to substitute foi the round string a piece of flat tape. 368 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. has been properly applied, you should cut the cord a few lines in front of the ligature Avith a pair of scissors; but, in doing so, be guarded that you do not, in your confusion, amputate a finger or the penis of the unoffending little infant, both of Avhich blunders are matters of record. You see, gentlemen, I propose but one ligature, while the gene- ral practice is to employ tAvo, and separate the cord betAveen them.* For this practice, I can perceive no solid reason ; and the argu- ment usually advanced in its favor is full of error, because it is founded upon a false hypothesis. It is alleged that if one ligature be applied, the mother will be exposed to all the hazards of flooding through the untied extremity of the cord. The absurdity of this apprehension I have already pointed out, Avhen describing the ana- tomical arrangement of the placenta, and the foetal circulation.! I never, in single births, apply but one ligature, and for the fol- loAving reasons: 1. Tavo are unnecessary, because the small quantity of blood, which floAvs from the untied extremity of the cord, consists merely of the disgorgement of the vessels on the fcetal surface of the after- birth, and does not come directly from the system of the mother; 2. This very disgorgement, in my opinion, assists in the more prompt expulsion of the placenta.J Transferring the Infant to the Blanket.—When the infant has been separated from its mother, the nurse should be instructed to have in readiness on the side of the bed a Avarm flannel, or blanket, which is to receive the little stranger. Put, remember you are to place it in the blanket yourselves, and not alloAV the nurse to do so. You may suppose it quite unnecessary for me to state any direc- tions as to the manner in Avhich you are to remove the child; but sometimes very ludicrous scenes have occurred for the Avant of a little forethought on this subject. If, in your attempt to take hold of the child for the purpose of giving it to the nurse you should, as may be the case, alloAV it, from awkAvardness on your part, to slip out of your hands, you Avould very justly be exposed to the censure of those around you; or if, to prevent such an accident, you should suddenly press it tOAvard your person, the blunder would, to say the least, Avring a hearty laugh from the Avitnesses to your gaucheries, in seeing your clothes besmeared Avith the albumi- * It has been urged by some writers that there is no necessity for any ligature, and this opinion is predicated upon the fact that in the case of young animals there is no ligature, and no hemorrhage. It was Dr. Hunter, I think, who first pointed out the error of this reasoning by showing that the parent, in dividing the navel-string in the young animal, necessarily subjects the vessels to a degree of torsion, which pre- vents the bleeding. f See Lectures XVII. and XVIII. X Should there be twins, it would be safe to employ two ligatures because, in this case, there might be an inosculation of blood-vessels between the two placentae. THE PRINCIPLES AND PRACTICE OF OBSTETRICS 369 nous material with which the surface of the neAV-born infant's body is more or less covered. Then, to prevent any blunder on the sub- ject, you will place the posterior surface of the child's neck in the space bounded by the thumb and index finger of one hand, gently seize the thighs with the other, and in this way you remove it from the mother, and give it to the nurse. It is received in the blanket, and the nurse must be directed to put it, for the present, in some secure place, either in the bed or crib, where it will be out of harm's Avay. Sometimes, through carelessness, it is placed in an arm-chair. This is a dangerous practice, for it is very apt to be crushed by the Aveight of some good dame who, in coming into the room, seats herself in the comfortable chair, not knowing that it is already occupied, and that, by so doing, she is intruding upon the little stranger's rights of hospitality; at the same time giving it a pressing welcome Avhich may be anything but salutary to its deli- cate physical structure. The Infant does not Breathe.—It will sometimes happen that the infant, when expelled from the maternal organs, does not breathe ; and, under these circumstances, it Avill require prompt and efficient attention. Its Avant of respiratory movement may be due to various causes—for example, after a protracted labor, in which the head may have been exposed to long-continued and severe pressure, the brain may be so congested as to occasion an apoplectic condition. In such a contingency the cord should be instantly cut, but no liga- ture applied, for the reason that the safety of the child Avill depend upon the immediate escape of a small quantity of blood from the untied extremity of the cord; it will be proper, however, to exer- cise a discreet vigilance that too much blood may not be lost. The moment you perceive the evidences of the congestion to have passed, which will be made manifest by the change in the color of the face of the child, and a return of vitality, then without delay apply the ligature, and arrest the bleeding. I am quite confident that many an infant, coming into the Avorld in this apoplectic state, has been sacrificed from the neglect of this simple but efficacious practice. The child will occasionally be born in a state of asphyxia—this term I think a bad one, for it does not convey an accurate idea of its meaning. It is derived from tAvo Greek words, sphuxis, the pulse, and a privative, Avhich literally signify Avithout pulse. You see, therefore, that this definition of the Avord gives but a very inadequate idea of its true import. Asphyxia, in truth, is that con- dition of system consequent upon impeded respiration, and the respiratory process may suffer derangement from several different causes, and in various degrees. Carbonic acid gas, carburetted hydrogen gas, submersion and strangulation, or hanging, are all so many causes of asphyxia. Again : Ave may have asphyxia in a case 24 370 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. in which the respiratory process has never been established, and this is occasionally exemplified in the new-born infant. We shall noAV briefly allude to its management in these latter circumstances. 1. Examine speedily the condition of the mouth, and ascertain whether the larynx be obstructed either by a collection of mucus, or any other substance; if so, remove it Avithout a moment's delay. The best mode of doing this is to introduce into the mouth of the infant the small finger, and by a gentle scoop you will be enabled to clear away whatever may have obstructed the access of atmo- spheric air to the lungs. 2. If there be no mechanical obstruction, cold water should be dashed on the face with a vieAV of acting on the medulla oblongata, through stimulation of the terminal branches of the fifth pair or trifacial nerves, thus producing a motor influence from the medulla to the respiratory muscles. Should cold thus applied to the face not suffice to accomplish the purpose, then dip the entire body of the child alternately into cold and Avarm Avater. This alternation of Avarmth and cold exercises a very remarkable influence on the cutaneous nerves, by imparting to them a decided stimulus. It is necessary, however, that the temperature of the water be very Ioav and very high—35 and 100 degrees. The trunk and limbs of the infant should be kept in the Avarm water about one minute, and in the cold Avater from fifteen to tAventy seconds; friction and flagel- lation should also be employed. If these efforts prove abortive, then recourse may be had to artificial respiration, which consists simply in blowing air from your OAvn lungs into the mouth of the child, using, at the same time, the precaution of closing the nostrils of the child. After each inflation the chest should be gently com- pressed Avith the hand, in order that the air may be expelled from the lungs, thus simulating the action of the expiratory muscles.* The extremities are to be kept Avarm by means of friction, toge- ther Avith hot flannels or mustard cataplasms, rolled in folds of old linen ; and Avhile these points are being attended to, it AA'ill be useful * Dr. Marshall Hall a few years since introduced to tlie attention of the profession certain rules for the resuscitation of the asphyxiated. These rules are now known as the "Ready Method" and have resulted in very marked success. Besides the alternation of the hot and cold bath, etc.—in the use of the bath, the immersion should be momentary, and the alternation quick—he insists, as one of the prerequi- sites of success, upon placing the child in the prone position, and alternately but rapidly changing it from this position to the side, and vice versa. While in the prone position, slight pressure is to be made along the back and ribs. Dr. Hall deduces the following truths: Experiments innumerable have demonstrated that if the subject be laid prone, and pressure be briskly made on the back, there is good expiration; and that, if the pressure be removed, and the body turned on its side, and a little more, there is good inspiration; that if this pronation and pressure, and this removal of the pressure and rotation be instituted alternately, there is good respira- tion. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 371 to throw Avarm water into the rectum, mixing with the water assa- fcetida or brandy. The stimulating effect of the enema is some- times followed by prompt and marked benefit. These are the directions, which, under ordinary circumstances, you are to pursue in cases of asphyxia occurring in the new-born infant. The faculty of resisting asphyxia, that is, of living without breathing, is very much greater in the neAV-born infant than in the adult; so that if a child should not breathe for an hour, or even much longer after birth, it should not be abandoned as dead, and, therefore, considered beyond remedy. Cases are recorded in which resuscitation has been accomplished by some of the means alluded to, even after the asphyxia had continued for a long time.* Another important fact is this: a newly-born infant affected with asphyxia, should not be regarded as dead, because its heart has ceased to beat; for it has been demonstrated by Prachet, of Lyons, Josat, and others, that life may be restored after the pulsations of the heart had ceased for more than five minutes.f This ability in the new-born child to resist asphyxia, explains why in cases of death of the mother it may be extracted alive from the uterus, through the Caesarean process, even after the parent has been dead for a longer period than half an hour. Dr. ProAvn-Sequard has shoAvn that, in these instances of post-mortem Caesarean section, if the mother die when the body is quite warm, the life of the child is in more danger than Avhen the body has become somewhat cold previous to dissolution. It is also Avorthy of being noted, that the asphyxiated infant should not be kept near a fire, for the colder the temperature of the air, the longer can asphyxia be resisted. * In an interesting article on "the Resuscitation of Children born-still," by ffm, C. Rogers, M.D., of Green Island, recently deceased, published in the American Medical Monthly, for February, 1860, there is a record, collected from various sour- ces, of twenty-four still-born infants resuscitated by artificial respiration, by baths hot and cold, by frictions, and by Marshall Hall's ready method, applied singly or jointly, from ten to ninety minutes, the average period intervening between birth and the establishment of respiration being thirty-five minutes, thirty seconds. In this article, also, allusion is made to the remarkable case reported by J. Foster Jenkens, M.D., of Yonkers, in which the funis was pulseless, for twenty-five minutes before delivery, and no attempt was made at respiration for thirty minutes after birth; more than two hours' constant attention was necessary to preserve the child's life. f This is in direct conflict with the opinion very emphatically expressed some years since by Sir B. Brodie, who wrote: " If the action of the heart, by which the circulation is maintained, should cease, as a consequence of the suspension of respira- tion, it can never be restored. This I positively assert, after having made it the sub- ject of a very careful investigation." [Lectures on Pathology and Surgery. 1846 p. 81.] LECTURE XXVI. The Third Stage of Labor; Expulsion of the Placenta—Mismanagement of Pla- centa—Dangers of—Function of Placenta, limited to a Certain Period—Natural Detachment of Placenta; How effected—What are the Evidences that the Detachment is going on? What that it is Accomplished?—The Mode of Extract- ing the Mass after its Separation from the Uterus—Rule to be observed after its Removal—Retained Coagulum and Puerperal Convulsions; Case in Illustration— After Extraction of Placenta, it should be carefully Examined—Retained Frag- ments of After-birth and Irritative Fever—Tractions on Umbilical Cord before Separation of the Placenta—Dangers of—How Detachment of Placenta is to be Aided when Uterus is Lethargic—Circumstances rendering it necessary to ex- tract After-Birth—Its excessive Volume—Spasm of the Os Uteri—Hour-glass Contraction—Morbid Adhesion—Convulsions—Hemorrhage—Opium and Bella donna; Difference in their Therapeutic Effects—How long after Delivery of the Child should the Extraction of the After-Birth be Delayed when there is no Com- plication ?—Permanent Retention of the Placenta, and Decomposition of the Mass —Does the Retained Placenta ever become Absorbed ?—Convulsions supervening on Retained Placenta; The Indication to be Fulfilled—Convulsions in this Case are Traceable to Irritation of the Uterus, and are of Eccentric Origin. Gentlemen—We are now to speak of the third stage of labor, which consists in the expulsion of the placenta. It is a cardinal error to imagine that, with the birth of the child, the dangers of parturition terminate. So far from this being so, you will discover, Avhen engaged in practice, that some of the most serious complica- tions of the lying-in room are more or less connected with mis- management of the after-birth—hemorrhage, inversion of the womb, prolapsion of this organ, laceration of the placenta, or um- bilical cord, are all so many accidents, most of them fearful in their consequences, resulting from this cause. I think one of the great eA'ils of the parturient chamber is a disposition on the part of the accoucheur to be officious with regard to the delivery of the pla- centa ; as soon as the child is born, he becomes impatient, and pro- ceeds at once to manipulations, which are not only premature and unnecessary, but, under the circumstances, altogether without jus- tification. I have repeatedly witnessed the sad effects of this meddling with nature ; and, therefore, I am the more solicitous plainly and distinctly to point out your true duties upon this sub- ject. Function of Placenta— When Terminated.—The placenta, -you must remember, has a function to perform only for a certain THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 373 period—this function consists in respiration, absorption of nutri- tious principles, and exosmosis of excreta during intra-uterine life; when this has been completed, and the foetus throAvn into the world, the office of the placenta has been fulfilled, and it becomes a deciduous mass, which is no longer a portion of the living mecha- nism, and, therefore, it is ejected. The mode of its ejection by nature is Avliat particularly interests us ; and Avhen once thoroughly comprehended, it will induct you into a conservative practice, which cannot but result favorably to your patient, and spare you much unnecessary embarrassment. Situation of the Placenta.—The placenta, you are aware, is in adhesion with the internal surface of the uterus, usually, as Avas generally maintained, near the fundus. According to the investi- gations of M. Naegele, Jr., it is found most commonly on the left side; next, on the right side of the organ. In two hundred and thirty-eight cases out of six hundred, the stethoscope indicated the placenta to be attached to the left side ; while in one hundred and forty-one cases it Avas at the right side. In tAventy, no sound could be detected ; in one hundred and sixty it Avas feeble, and so diffused as to be uncertain ; in seven instances, the placenta was attached to the fundus; in thirteen, to the anterior wall; and in eleven cases, there was placenta praevia. The folioAving are the results of the researches by Dr. Von Ritgen : he ascertains the seat of the pla- centa by measuring the distance of the rent in the membranes, made by the passage of the foetus, from the margin of the pla- centa ; in this way he found that the edge of this body rested on the os uteri in twenty-tAVO cases; at one inch in eight cases; be- tween one and two inches in twelve cases; tAvo inches in seven cases; betAA'een tAvo and three inches in sixteen cases ; three inches in five cases; betAA'een three and four inches in four cases; four inches in six cases; betAveen four and five inches in eight cases; five inches in three cases; six inches in six cases; eight inches in three cases. It Avould, therefore, appear that the placenta is usually attached much loAver than is generally believed.* Natural Detachment of Placenta.—The expulsion of the after- birth is, iu a normal condition of things, preceded by its detach- ment from the uterus, and the manner in Avhich this detachment is accomplished is through the contractions of the uterus itself. Five, ten, or tAventy minutes—the time varying from different influences —after the exit of the child, the patient Avill complain of pain, and the pain Avill be folloAved by a slight discharge of blood. These tAvo circumstances—the pain and discharge of blood—are the evi- dences that nature is engaged in the separation of the placenta. The pain is recurrent, like labor pain—in fact, it is a veritable labol * Brit and For. Med. Chir. Rev. ap. 1856. 374 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. throe ; it is a natural process, and must not, therefore, be interfered Avith. Put what is the evidence that the detachment of the placenta has been completed ? A very important question, the solution of which you must thoroughly understand, for it has much to do with the regulation of your conduct on this occasion. Under ordinary circumstances, Avhen the after-birth is completely detached from the uterine surface, it will be found resting over the mouth of the Avomb, either centre for centre, or a portion of its circum- ference will be felt, sometimes protruding into the vagina.* The direct result of the contractions of the uterus, after the expulsion of the fcetus, is necessarily a diminution of its general volume—the organ becomes shorter and narroAver, and the modus in quo of the separation of the placenta, under the influence of the contraction, is easily explained. Each successive contraction tends to diminish the respective diameters of that portion of the uterus Avith AA'hich the after-birth is in adhesion—but the diminution cannot take place Avithout a consequent detachment of this body, and this is the true exposition of the manner in Avhich the placenta becomes separated. Again : there is another interesting fact con- nected with this process—the detachment of the after-birth is usually folloAved by a closing up of the mouths of the utero-pla- cental A'essels—and, therefore, under these circumstances, there is no apprehension of hemorrhage. Removal of Placenta after its Detachment.—There are tAvo extremes, Avhich you are sedulously to avoid in the management of the placenta—the one is premature and officious interference Avith the operations of nature, the other a hesitation to act Avhen nature has achieved her part of the process, and calls upon you to interpose. This latter remark has special reference to the duty of the accoucheur, after the placenta has become detached from the uterus, and this organ is found contracted with the after-birth resting over the cervix, or protruding into the vagina. It often happens that the young practitioner remains at the bedside of the patient hour after hour, expecting every moment the expulsion of the after-birth—this does not take place, the patient becomes alarmed at the delay, and the only consolation she receives is the assurance that it will soon all be right. Another hour elapses, and no expulsion. A consultation is now proposed by the friends—■ this is of course acceded to, and when the consulting physician * I have already stated that the detachment of the after-birth is frequently com- pleted as soon as the child is expelled through the maternal organs, and this is the case when the uterus, in response to the exit of the fcetus, is found hard and con- tracted in the hypogastric region; when thus detached from the internal surface of the organ, and whether resting over the cervix, or panially in the vagina, there will be more or less recurrent contraction, simulating the throes of labor, the con- traction being induced partly by the presence of the separated after-birth, it being now a foreign substance in the uterus, and occasioning irritation of its parieteB. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 375 arrives, he proceeds like a man who understands his business; he finds that the uterus is contracted, introduces his finger into the vagina, feels the detached mass resting over the os uteri, or protruding into the vagina, and extracts it without delay in the following manner: The end of the cord being enveloped with linen, he makes tAvo or three twists of it around two of the fingers of one hand, while he introduces the index linger of the other hand (Fig-. 58), carrying it up to the mouth of the uterus, if the placenta have not descended into the vagina ; this fin- ger then seizes the cord close to the (Fig. 58.) after-birth, and makes traction downward and backward toward the sacrum in the direction of the superior strait; when the pla- centa has escaped from the womb, the extraction is to be made in the line of the axis of the inferior strait, always re- membering to AvithdraAV it by rotating it upon itself (Fig. 5D), in order that the membranes may be twisted into a cord, Avhich will ena- ble them to resist the pres- sure of the os uteri as they pass through, and thus there will be no fear of any frag- ments of them remaining in (FlG- 59* the uterine cavity, Avhich Avould often result in more or less annoy- ance to the patient—such as increased and distressing after-pains, and sometimes hemorrhage. When the placenta is found partially protruding through the os uteri, it AA'ill, perhaps, be better to seize it Avith the fingers, and thus bring it away; this mode of extraction will incur no risk of rupturing the cord, Avhich possibly might occur in making traction upon it Avhen the point of its inser- tion into the placenta cannot be detected by the finger. Removal of Coagnla.—As soon as the delivery of the after- birth has been accomplished, the finger should be carefully intro- duced into the vagina for the purpose of bringing away any coagula that may be there, and it should especially be ascertained whether there is a clot keeping the mouth of the womb open ; if so, it must be immediately removed. I have knoAvn very great dis- tress ensue to the patient from the neglect of this simple precau- 376 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tion, in consequence of the severity of the contractions induced by the irritation of the clot. In one case which I have now in my mind, I am very confident that the presence of a large coagulum, acting as an irritant upon the os uteri, was the sole cause of con- vulsions, which were near proving the destruction of the patient. It occurred in the person of a young primipara, of an extremely sensitive nervous organization; she had been in labor sixteen hours, Avhen she Avas happily delivered of a healthy living son ; soon after the expulsion of the after-birth, she Avas attacked violently Avith puerperal convulsions, although there had been no approach to a convulsive spasm during the progress of her labor. Her physician, a most worthy and conscientious gentleman, becoming very natu- rally much alarmed at the supervention of convulsions, requested me to see the case in consultation Avith him. Pefore I arrived, she had experienced three severe attacks, and soon after I reached the house, I noticed that she complained of distressing bearing doAvn pain, groaning piteously, and placing her hand upon the region of the uterus, indicating that the seat of her suffering Avas there. While the uterus Avas thus contracting, she Avas again taken Avith a convulsive movement. It occurred to me that there must be some- thing abnormal about the organ; Avith the concurrence of my medical friend, as soon as the convulsion ceased, I introduced my finger, and discovered a large coagulum of blood distending and fretting the os uteri ; it Avas immediately removed by gently insinu- ating the finger betAveen it and the internal surface of the dilated os. The removal of this clot proved a most efficient remedy—for AA'ith its AvithdraAval there Avas an entire cessation of the convulsions. Well, you may desire to knoAV Avhat possible connexion there could have been between the convulsions and the presence of the coagulum. The connexion, I maintain, was that of effect and cause. The os uteri became the seat of a jeositive irritation from the pressure of the clot; this called forth an undue refhex action from the spinal cord, Avhich resulted in the convulsive movement. This is an instructive case, and I hope you will bear it in mind. Put, you may ask, in objection to the explanation, AA'hy did the convulsions not occur Ayhen the head of the child AA-as making pressure on the mouth of the uterus of this delicate and sensitive lady? I reply—the fact that they did not occur, is the most decided evidence that the irritation Avas not sufficient to produce them. Examinatio?i of Placenta after its Removal.—You should never omit, after the delivery of the placenta, to examine it care- fully, iu order that you may be assured that no portion has been left AA'ithin the uterine cavity; it will sometimes be lacerated and divided, so that fragments of it will remain in the uterus. Under such circumstances, it will be your duty at once gently to intro- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 377 duce the hand, and bring these fragments away; a neglect of this rule will oftentimes result in more or less trouble—such as abnormal contractions of the Avomb, flooding, putrid discharge from decom- position of the fragments, and irritative fever. Danger of Tractions on the Cord.—It is a very common practice among accoucheurs, soon after the child is born, to seize the umbi- lical cord, and make tractions more or less forcible upon it, hoping in this way to expedite the expulsion of the after-birth. This is bad practice, and should never be had recourse to, until the placenta is detached from the uterine surface, for fear of the folloAving acci- dents, Avhich are some of the ordinary results of premature trac- tions on the funis: 1. Preaking of the cord; 2. Flooding from sudden separation of the placenta; 3. Inversion of the Avomb, pulling the Avomb inside out, which would be likely enough to ensue, in case the adhesion betAveen the organ and placental mass was sufficiently strong to resist the tractions; 4. Prolapsus, and even procidentia of the uterus. The rules, just indicated, apply to the management of the after- birth in cases of natural labor, when nature detaches the mass from the uterus, and the duty of the practitioner is limited to its mere extraction. How the Expulsion of the After-birth may be Aided.—There is one principle, connected AArith the question noAV under consideration, which you should keep constantly before you—the detachment and delivery of the placenta, like tlie delivery of the child, is a natural process, and should not be hurried, but submitted to nature, unless certain circumstances call for the intervention of science. It must, however, be admitted that in some cases in Avhich the contractions of the uterus are, as it Avere, lethargic, and not sufficient to cause the detachment, the accoucheur, in order to prevent unnecessary delay, can be of signal service; thus, he may place his hand on the abdominal walls, and not rudely, but gently, grasping the uterus, resort to frictions, Avhich xvill have the effect of stimulating the organ to contraction. As an important, and oftentimes a very efficient auxiliary to the frictions, a napkin saturated Avith ice-water may be placed over the region of the uterus, or a lump of ice applied directly to the sacrum. This latter alternative will occa- sionally be followed by very prompt and happy results. In these cases, too, ergot may be administered with advantage. I have, however, found nothing more efficient in these instances, and I emphatically commend it to you, as deserving both of recol- lection and trial, than the introduction of the index finger within the os uft ri, for the purpose of titillating it; this movement of the finger against the cervix evokes the tributary and important action of the spinal cord, and very readily accomplishes the object you haA'e in vieA\', viz., the contractions of the uterus. 378 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Artificial Extraction of Placenta.—Let us noAv consider some of the circumstances, which may render it incumbent for the accou- cheur to interpose and bring away the after-birth; or, in other words, the circumstances which, making abortive the ability of nature, and, at the same time, compromising the safety of the patient, call for prompt assistance. The folloAving may be enume- rated among the more prominent conditions requiring artificial assistance: 1. Excessive volume of the placenta; 2. Spasm of the os uteri; 3. Spasm or irregular contraction of the upper portion of the cervix, or body of the uterus, occasioning what is known as the hour-glass contraction ; 4. Morbid adhesion of the after-birth to the uterus; 5. Convulsions; 6. Hemorrhage. I. Excessive Volume of the Placenta.—You AA'ill sometimes re- mark that, subsequently to the birth of the child, notAvithsianding the vigorous contractions of the uterus, the placenta does not come away. In these cases, it may be that the cause of the delay is owing to the excessive size of the after-birth, or the increased volume may be occasioned by this body being doubled upon itself, or by an accumulation of coagula, or sometimes of the liquor amnii, pressing doAvn against the after-birth, and causing a sort of sac or pouch to present over the os uteri. How are you to know that the placenta is enlarged either positively or relatively? The diagnosis is not difficult. In the first place, the general volume of the uterus ■will be greater than under ordinary circumstances ; and, secondly, on introducing the finger as far as the mouth of the Avomb, the after- birth will be felt there in one of tAvo conditions ; either Avith a positive increase in size, or only relatively enlarged. In these in- stances of increased volume there will, oftentimes, be a protracted and unnecessary delay in its delivery, and the strength of the patient becomes exhausted in fruitless efforts to expel it. The course to be pursued, is at once to introduce the hand, grasp the after-birth, and carefully bring it aAvay. Put never forget one principle—in all cases in Avhich it may be- come necessary to introduce the hand into the womb for the purpose of extracting the placenta—the principle is this : Do not bring away the mass until you find the uterus beginning to contract, otherwise you loill expose your patient to hemorrhage. If, on reaching the os uteri, you should recognise the pouch of Avhich I have just spoken, it should be immediately ruptured for the escape of the coagula or liquor amnii, and thus the difficulty will be removed. II. Spasm of the Os Uteri.—Usually, Avhen the child has passed into the world, the mouth of the Avomb will be quite soft and relaxed, offering little or no resistance to any attempt, Avhich may be made to introduce the finger Avithin the cavity of the organ. Put you will sometimes observe a departure from this state of things; iu THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 379 lieu of relaxation, there will be such a contracted condition of the os as to render it extremely difficult to penetrate it; the contraction is irregular and spasmodic, occasioning more or less suffering to the patient, and preventing, of course, the expulsion of the placenta. These are the cases which so frequently lead to embarrassment on the part of the accoucheur; the Avomb contracts, the female suffers intensely, but there is no progress in the delivery of the after-birth. Patience, on all sides, is about exhausted; the doctor is puzzled, and he is, indeed, in nubibus. The question very naturally arises, is there any necessity for the embarrassment ? I tell you, gen- tlemen, there is none at all. If you will ascertain that there is some cause at Avork to interrupt the scheme of nature, and Avhat that cause is, you ■will have no great difficulty, under ordi- nary circumstances, in applying the appropriate remedy. Sup- pose, then, in attempting to introduce the finger into the os uteri, you discover a positive resistance, and that this resistance is much more marked during a contraction ; also, that instead of a uniform diminishing of the uterus Avhile under the influence of muscular effort, you find the effect limited almost entirely to the neck of the organ. With this state of things ascertained, nothing is easier than an accurate diagnosis. The Avhole difficulty is due to spasmodic con- traction, or, if you prefer it, to sjxism of the os uteri; and this is the true source of the delay in the expulsion of the placenta. In- deed, until the difficulty is removed, it will be physically impossible for this body to have egress. You see, therefore, how important it is for you constantly to keep progress Avith circumstances, as they may develop themselves in the lying-in chamber. While I am most anxious to impress upon you a profound respect for the consummate ability, whicli usually characterizes nature in the discharge of her varied functions during the parturient struggle, yet you must not be delinquent in early detecting any obstacle, Avhich, Avhile it may bid defiance to all natural effort, will the more urgeutly indicate the necessity of prompt action on your part. Well, how do you manage a case of spasm of the os uteri ? Some practitioners are in the habit of recommending, in a sort of stereotyped Avay, opium, as the great remedy in these cases. Opium, gentlemen, is one of the most precious weapons with Avhich Ave may hope to repel disease; but if it be precious and efficient, Avhen judiciously administered, it is equally injurious and fatal if given Avhen its use is contra-indicated. One of the therapeutic charac- teristics of this drug is, that it tends to cerebral congestion ; another, that it stimulates, through centric influence, the spinal cord ; another, that it constipates. Would it not, therefore, be madness to resort to opium as a primary remedy in cases of plethora; and Avould it not be equally improper Avhen the trouble Avith the 380 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. patient is habitual constipation? So much for the routine employ- ment of this remedy. Put Ave have in belladonna an efficient therapeutic agent for the difficulty in question; and it is interesting to know the modus in quo of its action. You might, perhaps, suppose that this remedy would be contra-indicated, for the reason that one of its essential attributes consists in its poAver of inducing muscular contraction. Its efficiency, however, in spasm of the os uteri is due, in the first place, to the fact that it diminishes the sensibility of the parts Avith which it comes in contact; and, secondly, it lessens the reflex poAver of the spinal cord. The spasm of the os uteri, remember, is a reflex spasm. Have prepared an ointment of belladonna, 3 i. of the extract to § i. of lard—let the os uteri be freely smeared with it, and, at the same time, attempt gently to introduce the finger Avithin the mouth of the organ—if you succeed in this latter effort, which, Avith proper perseverance, can generally be accom- plished, my advice is to alloAV the finger to remain there for some time, with a view, as it were, of fatiguing the muscular fibres of the part, and thus breaking up the spasmodic or irregular contraction. I have much confidence in this latter procedure. Indeed, I have in some instances succeeded, Avithout recourse to any other means, in overcoming the spasm by careful insinuation of one finger after another into the os uteri. An important remedy, also, in these cases, Avill be tolerant doses of ipecacuanha ; say \- to \ a. grain every fifteen minutes, as cir- cumstances may indicate—it has, at times, a poAverful effect in pro- ducing relaxation, and I regard it as one of the most certain of the antispasmodic agents. If the patient should be vascular, Avith a rigid muscular fibre, and a bounding pulse, the lancet Avill prove a resort of great efficacy. Take from the arm "f vi., "f viij., or 3 x. of blood, as the peculiar state of the case may justify. When the spasm is removed, then, if there should be any delay in the delivery of the placenta, the proper plan to be pursued is to introduce the hand, grasp the after-birth, and extract it. It is quite rare in these instances of irregular contraction of the uterus to haA7e, as a com- plication, hemorrhage; but, in such an event, especially when the hemorrhage endangers the safety of the patient, the pressing object is to arrest it; the remedies for this purpose we shall speak of in the succeeding lecture. III. Spasm, or Irregu7ar Contraction of the Upper Portion of the Cervix or Body of the Uterus—Hour-glass Contraction.—This is a peculiar condition of the organ, to which it is necessary to make some brief allusion. It consists essentially in such an abnormal con- traction as to occasion, in some portion of the long axis of the uterus, anarroAving—usually occurring at the upper extremity of the cervix, or in the body. This narroAving necessarily divides the organ THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 381 into two compartments or chambers, and hence it has been, with some propriety, denominated the hour-glass contraction (Fig. 60). It is not uncommon, AA'hen talking with a young physician, who has not been particularly fatigued by an extensive practice, to hear him exclaim, in speaking of a case of midwifery, Avhich he may have attended: "Well, sir, I had a hard time of it the other day; I had a case of hour-glass contraction, and it bothered me extremely, but I succeeded at last in getting through with it." This language is not, perhaps, so much the language of boast, as it is of erro- neous judgment. He no doubt supposed that he had veritably a case such as he described, and if you take these not unfrequent recitals of the in- experienced accoucheur as a basis of opinion, you will very naturally be misled as to the relative frequency of this abnormal condition of the uterus. The more you see of practice, gen- tlemen, and the more familiar you become Avith the revelations of the lying-in chamber, the more you will be convinced of the fact—that hour-glass contraction is comparatively of rare occurrence. With a fair share of observation in midwifery, and a constant desire to arrive, by rigid analysis, at just conclusions, I can positively assert that I have never met Avith but five cases of the true hour-glass contrac- tion—two in my own practice, and three in consultation. While, hoAvever, I am of opinion that it may be regarded as among the rare complications of labor, yet I would guard you against the statement of some writers, Avho maintain that the assumption of hour-glass contraction of the uterus is altogether without founda- tion, and that it exists only in imagination. Rare, however, as I believe it to be, it is material that you should understand, should a case of the kind present itself, how to manage it. The uterus, as I have stated, is divided into tAvo chambers, these chambers being separated by the narrowed or constricted portion of the organ; the placenta is lodged in the upper chamber, Avhile the umbilical cord is found to protrude through the strictured orifice, and thence into the vagina. Now, suppose yourselves by the bedside of your patient—the placenta is retained; you institute an examination for the purpose of ascertaining the cause of the delay; it may be that, not reaching the placenta Avith the finger carried as far as the os uteri, you will insinuate the hand into the cavity of the organ ; then, in your exploration, following the cord you will sud- denly come in contact Avith the orifice or stricture separating the two chambers; you feel the placenta in the upper chamber—in doing so you tremble, a deadly sickness comes over you, and, with 382 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. an agitation which no one but yourselves can fully appreciate, you AvithdraAv your hand ; the nurse, with her searching eye, reads in your haggard countenance that something is Avrong. She takes you one side, and in reply to her anxious inquiry you remark—Oh, nurse, the icomb is ruptured! The good nurse, different from others of her sex, cannot keep the secret, and in a very few mo- ments the household is informed of the melancholy discovery, which your sagacity has enabled you to make ! Instantly a con- sultation is proposed; in a brief time, some man of experience arrives; on examination, he finds that what you have mistaken for a rupture of the uterus is nothing more than the opening resulting from the division of the organ into tAvo compartments! Why do I, in this familiar manner, call your attention to this point ? It is because I am solicitous to guard you against so grave a blunder in diagnosis, and at the same time to admonish you that, Avithout adequate discrimination, feeling the placenta in the upper chamber might lead you to suppose that, through a laceration of the organ, it had escaped into the abdominal cavity. A moment's reflection would seiwe to sIioav you the error of such an opinion—for remem- ber, that Avhen the uterus undergoes rupture during parturition, the evidences of this appalling complication are, not only well marked, but they are almost simultaneous Avith the accident itself— such as vomiting, pallor, and sinking of countenance, cold perspira- tion, with a rapid and flickering pulse. The treatment of hour-glass contraction consists in a resort to remedies calculated by their relaxing effects to remove the stric- tured condition of the uterus, such, for example, as have been recommended in spasm of the cervix. As I haAre already remarked, I have great confidence, with a vieAv of removing this stricture and restoring the uterus to its normal state, in the efficacy of fatiguing the muscular fibres, and for this purpose I would suggest the fol- lowing plan: The hand should be in- troduced into the cavity of the organ in a conical form, and this form maintained while the hand remains Avithin the cavity; it is then passed up to the constricted portion (Fig. 61); and the fingers, repre- senting the summit of the cone, are made to push gently, but firmly, against the centre of the contracted orifice ; equable and continued pressure will thus tend to break the force of the spasm ; the stric- ture is overcome, and the after-birth can Fig. 6L then be removed Avithout difficulty. It will occasionally, however, happen that the hand becomes so severely cramped, and the resistance of the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 383 constricted portion so great, that the accoucheur is under the necessity of withdrawing his hand without accomplishing the object. Under these circumstances, I have on tAvo occasions had recourse to a method, which I do not remember to have seen men- tioned by any author, and to which I attach more than ordinary importance. It is this—take a small piece of prepared sponge, of a conical shape, well enveloped in soft linen, and completely saturated Avith olive oil, or simple cerate ; this is to be inclosed in the hollow of the hand, and then introducing the hand into the uterus, the apex of the sponge is applied against the constricted orifice; by firm and properly directed pressure, causing the sponge to act on the principle of a Avedge, the spasm is removed, and all difficulty at an end. I submit this method to the test of future trial, believing, as I do, that it will be found, under the circumstances, to subserve very satisfactorily the object in view. IV. Morbid Adhesion of the Placenta to the Uterus.—This is another form of placental complication which, if you are to rely on the statements of the young practitioner, is extremely common. Put, gentlemen, my OAvn opinion is that Avhat is truly understood by morbid adhesion of the after-birth is to be classed among the very rare occurrences of the parturient chamber. That it will, how- ever, occasionally be met with is unquestionable, and, therefore, there are some points connected Avith it, which it is necessary for you to understand. It has been by many doubted Avhether there exists any such thing as inflammation of the placenta—placentitis. Put the unerring demonstrations of the pathologist have abundantly shoAvn that the after-birth will sometimes become the seat of inflam- matory action, exhibiting both an acute and chronic type. One of the results of inflammation, as you well know, is an effusion of coagulable or plastic lymph; and it is now very generally conceded that this lymph is the special medium through which the morbid adhesion of the placenta to the uterine wall is effected. The adhesion may be partial or complete. In the former instance, in consequence of a separation of a portion of the placenta from the uterus, there Avill be more or less danger of hemorrhage. When, hoAvever, the adhesion is complete, there Avill rarely be hemorrhage unless the uterus be in a state of positive inertia, and even then the bleeding Avould be comparatively slight, for the reason that the mouths of the utero-placental vessels would be protected by the contact of the after-birth. This latter may be in cohesion with any portion of the uterine surface, depending upon the particular point of its original insertion. Hoav do you knoAV that morbid attachment really exists? One of the evidences will be the fact that, notwithstanding the contrac- tions of the uterus, the placenta is not expelled. This alone is a very feeble evidence, for the non-expulsion of the mass, in obedience 381: THE PRINCIPLES AND PRACTICE OF OBSTETRICS. to the contractile efforts of the Avomb, may be due, not to morbid adhesion, but to one of the conditions Avhich we have already examined, viz. Increased size of the placenta, spasm of the os uteri, or the hour-glass contraction. You see, therefore, you must have some more reliable testimony. That the delay is not caused by excessive volume of the after-birth, you learn from its absence over the mouth of the uterus; that it is not spasm of the os will be mani- fest from the facility of introducing the finger ; and that there is no hour-glass contraction is ascertained by the non-existence of the symptoms characteristic of this condition. The most certain evidence, I think, for an accurate diagnosis Avith regard to morbid adhesion of the placenta will be as folloAvs : 1. The uterus will be found presenting to the hand applied to the abdomen a larger volume than Avhen the after-birth is detached, and remains Avithin the cavity of the organ; 2. The failure of repeated and vigorous contractions to separate the after-birth ; 3. On introducing the hand into the cavity of the uterus, and following the umbilical cord as a guide, the placenta will be distinctly felt in connexion with the womb, either partially or completely. Having thus made up your diagnosis as to the real state of things, and ascertained that the delay in the expulsion of the placental mass is occasioned by its morbid attachment, the next point for consideration is—what, under the circumstances, is the course for the accoucheur to pursue ? This question is very important as well as interesting, and deserves attention. The plan to be adopted will depend upon Avhether or not there is hemorrhage—in the event of this latter, should it be such as to place in peril the safety of the mother—the treatment must be prompt and consist of those remedies of which Ave shall speak Avhen discussing, as we shall do in the succeeding lecture, the subject of flooding. If, on the contrary, there be no hemorrhage, or com- plication calling for the immediate delivery of the placenta, then, the case being less urgent, there is no necessity for hasty measures. It is Avell, however, to recollect that, although there may be no pressing motive for the prompt extraction of the after-birth, yet there is a certain limit beyond which it Avould be unsafe to allow this mass to remain within the uterus without resorting to legiti- mate means for its removal. There is ahvays more or less anxiety on the part of the patient and friends until the delivery of the pla- centa is accomplished, and until this takes place they do not regard the labor as complete ; in this opinion they are right. Put, gentle- men, in addition to the anxiety of the patient, there is another reason Avhy it is important that too long a period should not elapse before the extraction of this body. The placenta, you have been told, is called upon to perform only a limited duty, its function ceasing Avith the birth of the child. It THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 385 then, as a general rule, is separated from the uterus—its vitality soon becomes extinct, and it is converted into a deciduous mass, constituting no longer a portion of the living economy, and is sub- ject, therefore, to the mutation incident to dead structure, viz., decomposition. This latter condition may occur sooner or later, depending upon Ararious circumstances; in the event of such a con- tingency, the patient would be unnecessarily exposed to great danger. The rule, Avhich I would suggest, and which experience has proved to me to be the safe one, is not to allow—I am now alluding to cases in AA'hich there is no complication indicating prompt inter- ference—more than tAvo hours to elapse after the birth of the child Avithout attempting to bring aAvay the after-birth, and this applies to any case, whether of morbid adhesion, hour-glass contraction, or Avhether there be an entire absence of any abnormal symptoms. Again : I Avould enjoin upon you another rule, and, although it may sometimes impose rather a heavy tax on time and patience, yet it Avill be a Avise precaution, may save you much embarrassment, and prove a shield to your patient against serious danger: It is never to leave the chamber after the birth of the child, until the placenta has come away. If tAvo hours should have elapsed since the deli- very of the child, and you have discovered that the delay is owing to morbid adhesion; and, if frictions on the abdomen, or titillating the os uteri Avith the finger, should fail in inducing contractions sufficient to break up the adhesion, and detach the after-birth, then the broad indication is not to wait any longer, but proceed at once to extract it. With this view, the hand is to be cautiously intro- duced in a conoid form into the uterus, and following the cord as a guide, it AA'ill soon reach the placenta; the other hand should be placed upon the abdomen over the site of the placenta, for the pur- pose of steadying the uterus. This body AA'ill be either in complete adhesion Avith the womb, or Avill only be partially so. In the latter case, the fingers should be insinuated, with the dorsal surface toward the uterus, betAveen the latter organ and placenta, commencing at the point of separation. The hand is then made to glide betAA'een these two surfaces (Fig. 62), and by gentle manipulation, the detachment may be accomplished. x\fter the placenta has been separated, it should be withdrawn according to the directions to Avhich we have already alluded. Should it, hoAV- ever, occur that the hand cannot detach the body, then it should be brought away in fragments, and at the same time every reasonable attempt made to extract the whole of the mass. 25 386 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. When there is complete adhesion, the safer practice, in my opinion, is to introduce the hand, and stretching the fingers over the foetal surface of the placenta, as far as the peripheral edge, gentle traction should be made upon this edge by draAving the fingers toward the palm of the hand ; this someAvhat simulates the mode in Avhich the uterus, under the influence of contraction, pro ceeds in the separation. The plan just suggested is far preferable to that recommended by some authors, Ariz., to make tractions upon the cord Avith the hope that these tractions Avill result in the detachment of the after-birth. The danger of this practice must be quite evident to you, consisting in liability to rupture of the cord, inversion of the uterus, etc. For these reasons, it should not be resorted to, and I trust you will not forget this admonition. It will occasionally, however, happen that, not withstanding the best- directed efforts of the accoucheur, these morbid adhesions cannot be broken up ; and there is, for a longer or shorter period, retention of the after-birth. This is certainly an unfortunate condition of things; but like many other contingencies in practice, though not of your own choice, yet they are to be managed in the best possi- ble Avay circumstances will permit. One of the principal dangers of retained placenta, as you haA'e been informed, consists in the decomposition of the mass, and the constitutional disturbances, AA'hich are so apt to follow the absorption of the decomposed matter. When decomposition has occurred, much of the material passes off per vaginam in the form of a foetid discharge.* Absorption of retained Placenta.—Some writers maintain, and among others Xaegele, Salomon, Rigby, and Porcher, that it is pos- sible for the uterus to remoA'e a retained after-birth through the process of absorption; this is the explanation, AAdiich is given of those alleged cases in Avhich the placenta has been permanently retained, unaccompanied by any of the constitutional or local evi- dences of decomposition. You will find iu the books seA'cral instan- ces recorded of retained after-birth, the disappearance of Avhich from the womb could be accounted for only, according to these writers, on the principle of uterine absorption. I have never knoAvn a case of retained after-birth, which was not throAvn off, in part, at least, after decomposition, through the vagina in the form of a putrid discharge, Avhen occurring at full time; and I am inclined * In all cases, whether the placenta has been retained or not, in which, after deli- very, the discharge becomes foetid, it is very important to order the nurse to syringe the vagina freely several times a day with tepid water, and the suds made of Castile soap; and, also, the occasional use of the chloride of lime may be resorted to in the form of injection. If this discharge be allowed to accumulate in the vagina, besides its offensive odor, it will produce more or less irritation, and prove excessively annoy- ing to the patient. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 387 to regard most of the supposed examples of permanently retained placenta as apocryphal, for the reason that sufficient care has not been exercised to ascertain whether the mass may not have come aAvay during the absence of the accoucheur, either in a solid or fluid state. Still, there is very high authority on the other side of this question, asserting most positively that cases have occurred in Avhich the placenta has never passed from the uterus, and that its subsequent disappearance was the result of absorption. It may, therefore, be considered an open question—still subjudice—to be determined by the accumulation of future evidence. V. Convulsions.—The labor may have progressed and terminated most auspiciously; and, a few minutes after the expulsion of the child, that most formidable complication—convulsions—may ensue, OAving to irritation occasioned by the presence of the after-birth. When we treat in detail of puerperal convulsions in a subsequent lecture, we shall tell you that they may be produced by various causes, and among these, occupying a prominent place, will b< uterine irritation, either prior or subsequent to the birth of the child. If, therefore, you should have a case of convulsions result- ing from irritation of the uterus, and this local irritation you ascer- tain to be in consequence of the presence of the after-birth, there should be no doubt or delay as to what is to be done—the immedi- ate removed, of the after-birth is indispensable. It has, I am sure, often happened that human life has been sacrificed in these cases, by mistaking the true cause of the convulsive paroxysm. I need scarcely remind you that Avhen puerperal convulsions arise from irritation of the uterus, they do so through reflex influence, and are eccentric in their origin. I may here mention that, as soon as the placenta is removed, it Avill be proper, Avith a vieAV of calming the irritability of the uterus, to introduce an opium suppository, consisting of one or two grains of the drug, into the rectum, or from forty to fifty drops of laudanum in half a tumbler of tepid water may be used as an enema. Pella- donna ointment applied to the os uteri and vagina will also render important service. VI. Hemorrhage.—In the succeeding lecture, Ave shall speak of the management of the placenta in connection with hemorrhage. LECTURE XXVII. Management of Placenta in Flooding after the Birth of Child—Frequency and Morta- lity of Flooding—Statistics—Dangers of Post partum Hemorrhage—"What is Post- partum Hemorrhage, and how produced ?—Hoav is this form of Flooding divided? —External and Internal Flooding—Causes and Diagnosis of External Hemor- rhage ; how distinguished from Internal—Duty of the Accoucheur the instant the Child has escaped through the Vulva—Treatment of External Hemorrhage; the entire object is to produce Uterine Contraction—How is this to be accom- plished ?—Ergot not to be relied on as a Heroic Remedy in Perilous Flooding— Why ?—The Tampon; objection to its use in Post-partum Hemorrhage—Pressure and Cold the two Reliable Remedies in Uterine Hemorrhage—the Cold Dash; action of—A small piece of Ice introduced into the Vagina; its reflex influence— Mammae and Uterus—Sympathy between and Deductions from—Pressure of tho Abdominal Aorta—Electricity as a Remedy in Hemorrhage; Objections to— Injections of Vinegar, Lemon-juice, etc., into Vagina, bad practice—Internal Ute- rine Hemorrhage; how treated—Cephalalgia from Profuse Losses of Blood; how treated; how distinguished from Phrenitis—Transfusion as an Alternative after Excessive Hemorrhage—Dr. Blundell first to resort to it in the Puerperal Woman —Average Success of the Operation—Prof. Edward Martin, of Berlin—How does Transfusion accomplish Reaction ?—Is it by the Quantity of Blood transfused, or by stimulating the Walls of the Vessels and Heart ?—Brown-Sequard's Expe- riments ; Deductions from—Secondary Post-partum Hemorrhage; what does it mean ?—Treatment of Secondary Hemorrhage. Gentlemen—Xext in order of consideration is the management of the placenta in cases of hemorrhage or flooding. In discussing the question of hemorrhage, Ave shall limit ourselves, for the present, to that form of it which occurs subsequently to the birth of the child. It has been remarked by a Avriter on midwifery, that no physician should have the hardihood to cross the threshold of the lying-in chamber, who is not prepared promptly and efficiently to render the needed service in the moment of peril. This is the language of that emphatic,lucid, and practical author, Dr. Gooch. I respond most heartily, with all consciousness of its truth, to the value of the sentiment; and I would say to those who have never yet been engaged in the practice of the profession, that if there be any one thing more than another, in the whole routine of professional duty, calculated to strike terror into the heart of the practitioner, it is a case of flooding after the birth of the child. One moment of hesi- tation or doubt, and death speedily terminates the scene. Nature has opened her flood-gates, and, if they be not instantly and skil- fully closed, all chance of rescue is at an end. There is no time for ' THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 389 consultation here—no time for the perusal of books to see what is to be done—that inexorable enemy Death is pressing for his victim; and, but for the prompt interposition of science, the chamber of sickness AviU be converted into the gloom of desolation and heart- stricken grief. I wish I had the power to portray, with graphic truth, the lying-in room in a case of perilous flooding. There is your patient, she who has confided her life to your custody—she is delivered of a healthy, living child—her heart is full of a mother's hove—and, Avhile extending to you the sincere oblation of her thanks, and, perhaps, in the very act of receiving the tender congratulations of her happy and devoted husband, she is struck with sudden pallor— the gentle smile and beaming eye have given place to the sunken and ghastly cheek; she is speechless and unconscious; she knoAVS not the countenance of the agonized husband, Avho bends so fondly over her; his voice, once so familiar and Avelcome, falls without its echo; in a word, that Avoman is moribund. And all this change is but the Avork, as it Avere, of a feAV seconds. In this terrible emer- gency, every eye is turned toward you ; the hopes of that husband rest upon your instantaneous action. Overwhelmed and torn with grief, in the agony of his distress, he will exclaim, in tones Avhich Avill reach the very depths of your heart: " Doctor, doctor, save my Avife!" Should you, under this appeal, prove inadequate to the emergency because of ignorance of Avhat to do, that appeal Avill continue to ring in your ears, it will prove a Avithering comment on past neglect, and cause you to beAvail in tears of blood the fatuity, Avhich urged you thus Avantonly to sport Avith human life. Put, on the other hand, if the appeal be made to one, Avho is not only fully impressed Avith the sacredness of the obligation involved in the responsibility of ministering to the sick—to one who, *when he assumes the cares of the lying-in room, feels that he is competent faithfully and promptly to discharge his duty; and if, in the exer- cise of his knowledge, he rescue the patient from her impendino- danger, and restore her to her husband and child, then he will have accomplished one of the most glorious of all human triumphs. In these scenes of distress you must be careful not to permit the heart to exercise a sovereignty over the mind ; it is here that the heart of the physician must, for the moment, close up its fountains of sympathy. There will be no time for you to commingle your tears Avith those of .agonized friends; your duty will be to arrest the Avork of death. The danger is imminent; the friends are gathered round the couch of the dying relative; their sobs pene- trate the inmost recesses of your soul; and, in looks Avhich cannot be misinterpreted, they say that you are the only being under heaven on Avhom their last hope depends! It is in instances like these that promptness, decision, and energy must take the place of 390 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sympathy; and although your promptness may subject you to the charge of being rude, and your decision be mistaken for temerity, yet, if this promptness and decision -will enable you, under these trying circumstances, to save human life, restore a fond mother to her Avceping children, or a beloved wife to her husband, Avhat care you for the construction, which a selfish and heartless world may place upon your conduct ? Frequency and Mortality of Flooding.—The following statistics from Dr. Churchill will enable you to appreciate the frequency and fatality of hemorrhage in childbirth, under its three forms, viz. post-partum, accidental, and unavoidable* In 163,738 cases, hemorrhage occurred 1338 times, or about 1 in 122; out of 782 cases of hemorrhage, 126 mothers Avere lost, or about 1 in 6 ; out of 944 cases, 288 children Avere lost, or about 1 in 3. Further: out of 218 cases of accidental hemorrhage, 32 proved fatal, or 1 in 6; out of 261 cases of unaA'oidable hemorrhage, 71 proved fatal, or nearly 1 in 3^; and out of 3G5 cases of flooding after delivery, 25 proved fatal, or about 1 in 14. Flooding— What does it Mean ?—Pefore speaking of the reme- dial agents to Avhich you are to resort in order to arrest flooding, after the delivery of the child, let us first enquire Avhat is flooding, or, in other words, hoAV is it produced ? This is a very important question, and it is absolutely essential that you should have no loose or undefined notions upon the subject, but positive and accurate knoAvledge. Well, Avhen a Avoman has profuse hemorrhage after the expulsion of the child from the uterus, it is because this organ is in a state of relaxation—a state knoAvn as inertia. When inertia of the womb exists, the utero-placental vessels, instead of being closed, as they become under the influence of uterine contraction, remain open; it is these very vessels, Avhich constitute the flood- gates to which we have alluded, and through Avhich the life-current of the female is so rapidly, and, if not checked, so fatally passing. You see, therefore, if it be true—and there is no fact better esta- blished—that flooding is the necessary result of inertia of the uterus, if there be any force in logic, the irresistible deduction is—that the only means of arresting the hemorrhage is to make the uterus con- tract for the purpose of closing the mouths of the utero-placental vessels. I Avish you constantly to keep this broad fact before you, and you will find that, under its full appreciation, the dangers and anxiety connected Avith a case of uterine hemorrhage Avill be very much diminished. Divisions of Flooeling.—As I am desirous of placing this Avhole subject of flooding before you in the simplest possible manner—■ * ChurchilTs Midwifery, fourth London ed., p. 468. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 391 stripping it of everything that is adventitious, and reducing it to a positive tangibility—before telling you how you are to cause the Avomb to contract, I wish to call your attention to tAvo very essen- tial divisions of post-partum hemorrhage—divisions whicli you AviU recognise at the bedside, and Avithout a clear knowledge of Avhich it would be utterly impossible for you, Avith any hope of success, to attempt to afford the required relief. The divisions to which I allude are: 1. External hemorrhage; 2. Internal hemorrhage. When the hemorrhage is external, the blood passes from the uterus into the vagina, and thence into the world. When, on the contrary, it is internal, the blood does not pass out of the uterus; it is retained there because of some occlu- sion of the mouth of the organ—the occlusion being caused either by the detached placenta resting over the os, or the presence of a coagulum of blood. Noav, the point for you to remember—and on its recollection may depend the life of your patient—is that, Avhether the hemorrhage be external or interned, it is produced by the same cause, viz. inertia of the uterus; and, moreover, it is equally dangerous, for the reason that the blood is derived from the same source—the utero-placental vessels. 1. External Hemorrhage.—You have just been told that in this form of flooding the blood passes from the uterus through the vagina, and, therefore, you know that it exists from this latter cir- cumstance, as also from the exhausting effects which it soon occa- sions to the general system. One of the most certain elements of success in the management of uterine hemorrhage is a knoAvledge of its very inception. When death ensues from this cause, it does so very promptly ; and, Avithout proper vigilance, the Avork of destruction AviU be more than half accomplished before the accoucheur is aAvare that danger is at hand. Let us suppose, by way of illustration, that you are engaged in a case of midwifery; things have progressed favorably, the child is born, the mother i8 most happy, the nurse full of merriment; in a Avord, there is, for the moment, a little gala scene in the lying-in chamber. You apply the ligature, cut the cord, surrender the infant to the nurse, and, taking for granted—it is too often a fatal assumption—that every- thing is as it should be, you scat yourself by the fire, have your joke with the good nurse, Avho is complimenting you upon your skill, Avhen all of a sudden your attention is attracted to your patient; she, who a feAV minutes previously Avas calm and happy, and full of thanks for your kind ministrations, is moribund ! With- out the slightest suspicion on your part of such a melancholy epi- sode, you find the poor Avoman, Avho relied on you to conduct her saiely through her confinement, exsanguinated, bloodless, an*d abso- lutely in articulo mortis ! You become bewildered by this sudden and unexpected change; reason totters, judgment is Avorthless; at ■ >V'l THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the very moment when, of all others, you should be firm and col- lected, you are reduced to a mere machine, Avithout thought to guide you. Under these painful circumstances, death triumphs, and revels Avith scornful mockery at your imbecile pretensions to check his progress. There is nothing, gentlemen, exaggerated in this picture; it i-s but too faithful a daguerreotype of many a sad scene in Avhich the heartstrings of affection have been broken, and the domestic hearth converted into a domicile of unutterable grief. In order, therefore, to guard against this surprise, and be pre- pared to apply the proper remedies the instant the hemorrhage commences, remember and scrupulously carry out the rule I gave you, when speaking of your duties during the passage of the child through the maternal organs, viz. the moment the child has made its exit into the world, place your hand on the hypogastric region of the patient, with a view of ascertaining whether or not the uterus is contracted ; if so, you need have no fear of hemorrhage; if, on the contrary, it be not contracted, but is more or less flaccid, this is an evidence of inertia, and therefore hemorrhage ensues. Under these circumstances, instead of permitting time to pass, so precious for the safety of your patient, you proceed Avithout delay to arrest the bleeding by having recourse to the means most effi- cient in bringing on uterine contraction, and consequently remov- ing the inertia. Treatment of External Hemorrhage.—Flooding may occur AA'hen the placenta is completely or partially detached, and yet Avithin the uterine cavity, or after this mass has passed from the organ. It is a very singular fact that many practitioners imagine the sine qud non of success, in the management of hemorrhage, to be the removal of the placenta; and hence in these cases the very first thing attempted is to extract this body, under the impression that Avith its delivery the flooding will cease. There never was a more perfect delusion. Why, gentlemen, the after-birth, in strict truth, has nothing to do Avith the hemorrhage, it is not a bleeding surface, and AA'hether it be Avithin or Avithout the uterus is a matter of utter indifference, so far as the great object is concerned—the inducing uterine contraction. The practice is founded upon vague and indefinite notions with regard, in the first place, to the true cause, and secondly, to the true source of the hemorrhage. Ergot.—Another frequent, and, in my judgment, oftentimes fatal error, is to rely on the action of ergot; hence, as soon as it is ascertained that hemorrhage exists, this remedy is resorted to under the conviction that it will provoke contraction, and thus arrest the flooding. The cardinal objection to this practice is, that although ergot does unquestionably exercise a positive and marked influence on the muscular action of the uterus, yet its effects are not immediate ; frequently, ten, fifteen, and twenty minutes elaps- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 393 ing before there is the slightest therapeutic manifestation. With this agent, therefore, as the sheet-anchor of hope, death Avill often ensue before the remedy acts ; and I have no hesitation in saying to you that ergot should not be classed among the heroic agents in the treatment of uterine hemorrhage after the birth of the child. There can be no harm in administering it, but do not let it take the place of other and more reliable means, to Avhich Ave shall presently allude. Tampon.—Again : there is an unfortunate and far too common belief that the great remedy for hemorrhage is the tampon; Avith this conviction, many physicians have recourse to it the moment they are aAvare that flooding exists. The vagina is immediately plugged up, and in order to make matters doubly sure, a T bandage is employed for the purpose of retaining the tampon in situ. AVith the slightest possible reflection, the absurdity of this practice as a remedial means, under the circumstances, must be too apparent to need comment, for do you not at once perceive that it can have no effect Avhatever in producing the only thing that will arrest the bleeding—contraction of the uterus ? Put, gentlemen, there is something more than absurdity in the application of the tampon in these cases; there is positive danger, Avhich almost ahvays results fatally to the unhappy patient. Look at it for an instant. When the child is delivered, and the tampon resorted to for the purpose of relieving the hemorrhage, the only effect is, by occluding the mouth of the Avomb, to convert an external into an internal flooding. It is true, the blood ceases to floAv through the vagina, and this may afford you momentary con- solation, under the erroneous impression that, because there is no longer any external sign of bleeding, therefore, all danger is at an end. Delusive and fatal hope! It will not, hoAvever, be long that you Avill be permitted to indulge in this fiction, for the evidences of exhaustion will be fast accumulating; the strength of the patient becomes more and more dilapidated, and you AA'ill soon be brought to a full, but melancholy appreciation of your folly, by seeino- her sink at the very time you imagined you Avere rendering a most essential service ! Alv advice to you is—never resort to the tampon as a means of checking hemorrhage after the birth of the child, for the reason that it exercises no possible good in accomplishing the important object in view—the contraction of the uterus—but, on the contrary, its direct and necessary tendency is to convert an external into an internal hemorrhage, thus lulling the practitioner into false hope, and insidiously, but most certainly, destroying the patient; for, as I have already remarked, Avhether the flooding be internal or external, if it be not checked, the tendency is the same—death. Pressure and Cold.—Having disposed of those measures, which 394: THE PRINCIPLES AND PRACTICE OF OBSTETRICS. have an unmerited popularity, and which are not the measures science can recognise as the Aveapons fitted for this terrible conflict, I shall noAV proceed to point out Avhat, in my judgment, are the more reliable and effective means to be adopted. Kemember, there is no time for compromise, no time for capitulation—the enemy, with bold front, and intent upon destruction, has laid his grasp upon the victim, and the issue of life or death Avill be deter- mined by the promptness and character of the resistance.* There- fore, Avhat you are to do, in the management of hemorrhage, is this—introduce your hand,f Avithout a moment's delay, into the uterus, carry it up to that portion of the organ to Avhich the pla- centa is partially attached, or from Avhich it has been completely separated ;J with the expanded dorsum of the fingers make gentle but uniform pressure against the bleeding utero-placental vessels, and Avith the other hand applied to the abdomen, make counter pressure. Should the AA'omb not contract, have recourse immedi- ately to the cold dash—let a pitcher of ice water be throAvn from a height—say tAvo feet—suddenly and Avith impulse upon the abdomen, and repeat it Avithout hesitation should it be necessary. Such are the heroic, substantial, and common-sense remedies in these cases of desperate hope, and they will often serve you faith- fully in the hour of need. As soon as the uterus begins to con- tract, gather up the afterbirth in your hand, should it be Avithinthe organ, and keep it firmly in your grasp until, by powerful contrac- tions, it together Avith the hand is expelled. Striking benefit Avill be derived from the introduction of a small piece of ice into the vagina or uterus—the contact of cold, thus suddenly applied, Avill oftentimes occasion immediate contraction of the organ, by the sti- mulus imparted to the excitor nerves of the part, inducing the full influence of reflex movement. Injections of iced Avater into the rectum will also act poAverfully upon the uterus through reflex * It must be understood that I am now speaking of that form of profuse and perilous flooding, which calls for the most positive and prompt measures. It will often happen that there will be a post-partum loss in consequence of what may be termed the want of complete contraction of the uterus; the organ, although not in a state of general inertia, has not, as it were, properly responded to the birth of the child; and, as a consequence, there may be more or less hemorrhage. In these cases, gentle frictions on the abdomen, the application of cloths wet with cold water to the abdomen, sacrum, and vulva, will usually suffice to control the bleeding. \ It has been objected to this practice of introducing the hand, for the purpose of making pressure, that it will occasion metritis. I have repeatedly had recourse to this expedient, and in no instance has such a result followed. Admitting, however, the force of the apprehension, would it not be better to incur the hazard of inflam- mation, than to allow the patient to die from exhaustion ? X If the placenta be in partial adhesion with the uterus, following the cord will enable the accoucheur to ascertain the particular place of its attachment; if, on the contrary, it should have become separated from the uterine surface, the mouths of the utero-placental vessels will indicate the point of detachment. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 395 agency. Iced water as a drink will occasionally display great effi- cacy in uterine inertia, causing contraction of the organ, through its impression on the pneumogastric nerve, Avhich is also an excitor of the uterus. From the well-knoAvn physiological relation betAveen the mammae and uterus, it has been recommended, Avith a vieAV of arresting hemorrhage, to apply the infant's mouth to the nipple, and thus excite an action in the spinal nerves, which is immediately trans- mitted to the medulla spinalis; the latter becoming the seat of irritation, imparts to the motor nerves of the uterus an influence which induces contraction of this organ. This may do in moderate hemorrhage, but it is not to be relied upon in those cases in which life is menaced if the flooding be not promptly arrested. Compression of the Abdominal Aorta.—Compression of the aorta has been proposed as an efficient means of checking uterine hemorrhage; but it seems not to have met Avith general favor. Tavo objections have been urged against it: 1. In Avomen loaded Avith adipose matter, it Avill be difficult to make, through the abdo- minal parietes, the necessary pressure ; 2. Compression of the aorta will more or less obstruct the circulation in the vena cava. Let us, for a moment, examine these objections: as to the first, it is undoubtedly true that it ■will be difficult to press upon the aorta through the abdominal walls of some Avomen; but this certainly has nothing Avhatever to do Avith the application of the rule Avhere the objection does not exist; and secondly, Avith the simple recol- lection of the relative disposition of the aorta and A'ena cava—the former on the left, and the latter on the right—it Avould be quite easy to avoid making pressure on the vein. Put admitting the possibility of pressure on the vein (which Avould never be complete), it Avould in no way prevent the success of the operation. I, there- fore, regard compression of the aorta, provided it be properly made, as a sovereign remedy ; not merely as is generally supposed because there is no more blood reaching the uterus, but for another reason Avhich has been demonstrated by the experiments of Dr. E. Prown- Sequard, that there is no more certain mode of producing contrac- tion of the womb than by the arrest of the arterial circulation. Injection of Cold Water into the Umbilical Vein and Canity of the Uterus.—It is proper to mention that the injection of cold water into the umbilical vein, in cases in which a large portion of the placenta is still in adhesion Avith the uterus, has been resorted to successfully; the Avater should be injected in full quantity. The throwing of cold Avater into the cavity of the uterus, as a means of arresting hemorrhage, has been seriously opposed under the appre- hension that it Avould result in metritis or peritonitis. On the other hand, we have the authority of Scanzoni,* Avho says he has employed * Lehrbuch des Geburtshilfe, p. 509. 1855. 396 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. these injections with success in more than one hundred cases, and in no instance was there any evil resulting, or an approach to inflammation either of the uterus or peritoneum. Various other remedies have been suggested. Electricity, for example, has been much lauded by certain English authorities; but you must at once recognise a very serious objection, Avhich is the delay necessarily connected Avith its application, simply for the rea- son that the apparatus is not at hand, and often, before it could be obtained, death will have claimed his victim. I need scarcely cau- tion you against the unjustifiable and dangerous practice commended by some authors, of injecting vinegar, lemon juice, and other irri- tating substances into the cavity of the uterus; they arc all perni- cious in their tendency, without a solitary advantage in their favor* In brief, I Avish to reiterate in the most emphatic manner, that in cases of perilous flooding, the two great and efficient remedies are pressure and cold, to be employed as already indicated; and I will further state, that if my experience be worth anything, they will prove, if thoroughly carried out, perfectly trustworthy, even in instances of apparently more than desperate hope. Allow me to remind you that Avhen it has become necessary to resort to refrige- rants for the purpose of bringing on uterine contraction, the mo- ment this latter object has been accomplished, and consequently the hemorrhage arrested, no time should be lost in imparting warmth by tlie application of bottles of hot water, warm flannels, etc., but, in doing this the patient is not to be moved, for the slightest exertion would be likely to produce fainting. Let me here enjoin upon you in cases of exhaustion after flooding, to make it a rule, Avithout an exception, never to permit the patient, even for an instant, to assume the upright or sitting position. More than one example of sudden death from this cause could be recorded, the explanation being that the brain becomes deprived of its blood, and fatal syn- cope is the result. Treatment of Exhaustion from Flooding.—We Avill noAv sup- pose that you haA'e succeeded in causing the uterus to contract, and the bleeding is checked. If, Avith the attainment of these two results, you imagine that the battle is over and victory complete, you will sometimes find yourselves sadly in error; under this delu- sion, your patient may still sink for want of proper attention on your part. From the excessive loss of blood sustained, her strength Avill be gone, the vital powers so entirely prostrate that she Avill exhibit the aspect of a moribund woman—deadly pallor of coun- * Although we have the high authority of Outrepont, Kiwisch, and others, in uvor, in some instances, of employing a solution of the muriate of iron with the cold water, as an injection into the cavity of the uterus, yet my own opinion is, that the cold water alone will be equally efficient. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 397 tenance, cold surface, no pulse to be detected in the radial or tem- poral arteries, the beatings of the heart so feeble that they cannot be appreciated. In these cases, Avhich so closely simulate dissolu- tion, there is no time for inaction ; every second unimproved for the benefit of the patient is so much abstracted from her chances of restoration. Instead, therefore, of regarding her as beyond relief, and participating in the confusion and soitoav of those who sur round her couch, your duty is at once to have recourse to those measures best calculated to produce prompt reaction. For this purpose, the various stimulants are to be employed—brandy, milk punch, strong coffee Avith laudanum, etc., but a due degree of care is to be exercised in their administration, for remember, after a momentary revival, the patient is again apt to fall into collapse. It is as it Avere, but the last flickering of the light in the socket, there is but one spark left, and if it be too rudely blown it brightens for the instant only to become for ever extinct. When reaction is established, the strength must be sustained by animal broths, arrow-root, tapioca, jellies, etc. On the other hand, it is not to be forgotten, that the reaction in these cases, groAving out of the free use of stimulants, 'will sometimes be more than the system can sustain, and hence serious congestions may arise requiring prompt attention. Pressure on the Main Arteries of the Extremities.—After the hemorrhage has ceased, and Avith a vieAV of rallying the sunken forces, we have a most important remedy in properly directed pres- sure on the main arteries of the limbs, by means of the tourniquet or hand. In this Avay a large amount of blood is kept circulating in the principal organs of the body—the brain, lungs, and heart. 2. Interned Hemorrhage.—You have been reminded that, when the hemorrhage is internal, it is so because the mouth of the womb is closed up either by the detached placenta or a coagulum of blood, thus constituting Avhat is described as internal or concealed flooding. Whether the hemorrhage be external or internal, the object of treatment is precisely the same—the bringing on contrac- tions of the uterus; and the means for accomplishing this end are also identical. Internal flooding, I have told you, is oftentimes insidious, because there is no blood escaping from the vagina. The practitioner is not apt to suspect that anything is Avrong, and the first admonition of danger will be the exsanguinated condition of his patient. Put you, who I trust noAV fully appreciate the abso- lute necessity of guarding against a surprise of this kind, will not omit to observe the direction of ascertaining Avhether or not the uterus be contracted after the child has made its escape. It may, hoAvever, liappen that, notwithstanding the birth of the child, the uterus Avill still be large, and yet there is no flooding. This may be in consequence of a second foetus occupying the cavity of the womb, and the diagnosis can be readily made out by carrying your 398 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. finger to the os uteri. In the event of a second child, some por- tion of it will be felt. If, on the contrary, the uterus be enlarged in consequence of being distended by the accumulation of blood— internal hemorrhage—the organ will be found more or less soft on pressure, imparting to the hand a sensation as if pressing upon a pilloAV, and there will be all the evidences, too, of prostration. The folloAving case is not without instruction ; the recollection of it may serve a useful lesson. It is a sorroAvful, melancholy tale, and well do I remember hoAV deeply it affected my feelings, and Iioav freely it caused me to sympathize with those Avho Avere the heart-stricken Avitnesses of the harroAving scene: Some years since I was sent for in great haste by a gentleman to meet him in consultation in the case of a lady, who had just been delivered of a child. As soon as I reached the house, Avhich Avas done Avithout delay, he informed me that shortly before my arrival he had delivered the patient of a fine son, and he remarked that there Avas another foetus in the womb. Finding his patient glow- ing weak, he thought it advisable to send for assistance. This Avas all the information I received, AA'hen, on being introduced into the room, I Avitnesscd a scene AA'hich I have not language to describe. The husband and two female relatives were standing by the bed- side of the dying Avoman; her tAvo little children, Avho had been asleep in an adjoining chamber, aAvakened by the confusion, be- came alarmed, and rushed into their mother's apartment. The moment I beheld the patient I became convinced that all was over ! There she lay, pulseless and speechless, Avith death in graphic let- ters Avritten on her countenance. In placing my hand on the abdo- men, I observed it immensely distended; it Avas soft on pressure, and hi an instant I arrived at my diagnosis ; it was a case of inter- nal hemorrhage. Without delay, I introduced my hand for the purpose, if possible, of inducing contraction of the womb. The placenta was detached, and rested immediately over the mouth of the organ, thus effectually preventing the escape of blood externally, and leading the practitioner to a fatal error as to the actual condi- tion of his patient. As soon as I had introduced my hand, the unhappy lady seemed to experience a momentary resuscitation ; she opened her eyes, wildly gazed on those around, asked for her children, and instantly expired ! Comment here can scarcely be necessary. Error of judgment as to the nature of the difficulty had thus suddenly swept from earth an interesting woman—it had converted a house of joy into one of mourning, and deprived the young and helpless of a mother's love and devotion. Such scenes are indeed agonizing; they are cal- culated to make a lasting impression on the minds of all, who feel the necessity of accurate knowledge, and the fulness of professional responsibility. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 399 Treatment of Interned Hemorrhage.—The manner of treating a case of internal hemorrhage, 1 repeat, is precisely the same asAvhen the hemorrhage is external. The hand is to be introduced into the uterus for the purpose of making pressure against the utero-placental vessels. Pay no sort of attention to the detached after-birth or the coagulum of blood, which may be the cause of the occlusion of the mouth of the organ; but carry the hand up at once, pushing the placenta or coagulum one side, and seek for the bleeding surface; and then you are to proceed as has already been indicated when speaking of the management of external flooding. There is a circumstance connected with profuse losses of blood in the puerperal woman Avhich, in a practical point of view, is of essential moment, and I do not think sufficient value has been attached to it. I allude to tAvo morbid phenomena which may be regarded as the ordinary sequelae of this ansEmic condition of system: Intense Headache, loith Intolerance of Light.—The cephalalgia and intolerance of light are features associated Avith exhausting hemorrhages in every Avay worthy of consideration. An error in diagnosis here will be at too heavy a cost, and, therefore, in such cases, a careful judgment should be exercised that the truth may be developed. In order to illustrate this question, and present it to you in the most tangible and practical manner, let us suppose that you have, by prompt and efficient action, safely conducted a patient through an attack of perilous flooding. When you make your first visit the next morning, you find the room in total darkness, and, on inquiring of the nurse why she has so completely excluded the light, she answers: " Oh ! doctor, madam has been raA'ing Avith her head; she says it feels as if a knife Avere piercing it, and she has made me darken the room because the slightest light almost sets her crazy." You approach the bed, and the suffering invalid, in a feeble voice, requests you to do something to relieve her head. "If I am not relieved, doctor, I shall die." I have more than once heard this very language ; now for the point. The two prominent symptoms Avhich occasion so much distress, viz., the headache and intolerance of light, are the very symptoms of phrenitis, or inflammation of the brain. If, therefore, you should make a false diagnosis and imagine that your patient is absolutely affected Avith this latter disorder, you Avill proceed with your antiphlogistic course to arrest it. The lan- cet, leeches, purgatives, and blisters will be called into requisition, and too soon you will discover that you have been attacking a phantom, and the sad penalty of your blunder will be the death of your patient! * The headache and intolerance of light, so far from * It is well to bear in mind that slight congestion of the brain is not always incom- patible with more or less profuse losses of blood; and the vigilant practitioner will occasionally find that, when the exhaustion is not1 extreme, this congestion may 400 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. being the products of inflammation, are the results simply of tho exsanguinated state of the system. The indication, therefore, is to restore to the blood its lost albumen by appropriate tonic treat- ment, such as nutritious diet, small doses of quinine, etc. In conjunction with this treatment, a most essential object is to calm the irritability of system, revealed by the general restlessness and more or less jactitation of the patient—what she most needs is gentle sleep. The following combination I have found efficient: Pulv. opii., gr. iii. Carbonat. ammoniae, gr. xij. Extract, hyoscam. gr. xv. Ft. massa in pil. dividend.!, vi. One pill every tAvo or three hours, as circumstances may indicate. Transfusion.—It will be proper, in connexion with the question of uterine hemorrhage and its results, to make a few passing obser- A-ations on the subject of transfusion, AA'hich consists in restoring the vital energies by injecting into the A'enous system of the patient blood taken from another individual. This practice is not of modern origin, for you will find it both spoken of and adopted by some of the Avriters of the sixteenth century. Dr. Plundell, from nume- rous experiments on animals, convinced of its efficacy in certain cases of exhaustion, deserves the credit of being the first to resort to this alternative in the puerperal Avoman, Avhich he did in 1825 Avith complete success; but in doing so he AA'as not Avithout bitter opposition. There are a number of cases recorded by authors in Avhich life Avas saA'ed under circumstances Avhere every other effort had failed in bringing on reaction.* When the doctrine of transfu- sion Avas first suggested in the sixteenth century, it Avas supposed exist, and will yield to the application of two or three leeches to the temples; or, what I have tried with good effect—dry-cupping behind the neck. * In an interesting monograph on transfusion, which has recently appeared, by Edward Martin, Professor of Midwifery in the University of Berlin, it is stated that there are fifty-eight known cases in which this alternative has been had recourse to in women exsanguinated during childbirth, forty-six of which resulted in complete recoveries, and these instances of exhaustion were such as to inspire no hope what- ever of success. In most of the remaining twelve cases, the fatal issue was traceable to diseases and occurrences having no connexion whatever with the operation. Pro- fessor Martin truly observes that there has been much discussion, and the question is yet unsettled, whether the transfused blood acts by restitution in absolutely sup- plying the lost blood, or by stimulating the walls of the vessels, and more especially the heart, so as to prolong the activity of the latter until the lost quantity of tlie vital fluid is otherwise produced. He rather inclines to the opinion that to botli of these influences may be ascribed the restorative result; Avhile he thinks, however, the stimulation of the walls of the vessels and heart is the more important, for the reason that the small quantity of blood transfused is altogether inadequate to account for the reaction. It has also been proved that the red corpuscles of the blood are the proper restoratives, although their action is materially assisted by the serum. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 401 that a great boon had been granted the human family ; the old men and Avomen Avere to find in this expedient more than the philoso- pher's stone ; years and decrepitude Avere to yield to this Avonder- ful discovery; and you will read in the writings of that century directions for rejuA'enation—for example, an old man, in order to recover his adolescence and vigor, Avas advised to suck, after the fashion of the leech, blood from the arm of some youth. With the hypothesis of rejuvenation—about as difficult to accomplish as per- petual motion—you may well imagine the popularity of transfusion, and the Avild enthusiasm Avith Avhich its advent Avas greeted. Put these chimerical notions soon died away, for they had nothing on Avhich to rest but imagination. Not so, however, Avith regard to the fact—that the throAving of blood from the system of a healthy individual into the veins of a patient, exhausted by hemorrhage, is really a means of saving life. It Avas the opinion of Dr. Plundell that, in order to insure perma- nent success in this operation, it is essentially necessary that blood of the same species of animal should be employed. He found from experiment that a dog, bled almost to death, could recover, even if blood of a mammal of another species be transfused into its veins; but, after a feAv days, death always ensues; Avhile, on the contrary, in employing the blood of another dog, the animal Avould be permanently restored. Prevost and Dumas have also con- tended for the same principle, and, indeed, if I am not in error, this Avas the prevailing doctrine until very recently. That eminent and sagacious physiologist, Dr. E. Prown-Sequard,* Avho is now so deservedly, through his rich contributions, attracting a large share of attention from the scientific Avorld, has made numerous experi- ments upon this subject, from Avhich he deduces the folloAving important conclusions: First.—That arterial or venous blood from an animal of any one of the four classes of vertebrata, containing oxygen in a sufficient quantity to be scarlet, may be injected, without danger, into the veins of a A'ertebrated animal of any one of the four classes, pro- vided that the amount of injected blood be not too considerable. Second.—That arterial or venous blood of any vertebrated ani- mal, being sufficiently rich in carbonic acid to be almost black, can- not be injected into the veins of a Avarm-blooded animal Avithout producing phenomena of asphyxia, and most frequently death, after violent convulsions, provided that the quantity of injected blood be not below one five-hundredth of the Aveight of the animal, and also that the injection be not made too sloAvly. Dr. Sequard observes, the reasons why Plundell, Pischoff, and others, have failed in securing permanent success after the transfu- * Comptes Rendus. Nov. 1857, p. 925. 26 402 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sion of the blood of an animal of a species different from that of the transfused one, are: 1. That the blood used Avas not fresh; 2. That it was in too large a quantity ; 3. That it Avas injected too quickly ; 4. That it Avas too rich in carbonic acid, and too poor in oxygen; the chief cause of failure being the last one, and next to it the quantity of blood. From his experiments, he has arrived at the conclusion that there is no danger in employing the blood of dogs, cats, and other mammals in transfusion in the human species; and, moreover, he agrees Avith Dieffenbach and others that defibrinated blood is just as good as blood containing fibrin. Four or five ounces, he thinks, would be as much as Avould be needed for an adult man or Avoman. It is not necessary to Avarm the blood, although it may be useful to do so in some instances. The blood to be transfused, either that of man or mammal, should be received into a large open vase, and immediately Avhipped, then passed through a thick cloth. If not injected at once it must be either whipped again, or at least agi- tated, to recharge it Avith oxygen just before transfusion. The injection must be extremely s1oa\', and if, after tAvo or three ounces are throAvn in, there is great increase of the respiratory movements, it will be proper to suspend the operation for ten or fifteen minutes before completing the transfusion. The middle basilic vein is usually selected for the operation. This Arein is laid bare to about an inch in extent, and isolated from the surrounding parts; a small opening should be made on its anterior Avail, and the end of the syringe carefully introduced. An ordinary brass syringe, air-tight and in good Avorking order, ■will ansAver every purpose. It is not to be forgotten that one of the essential requisites for the ultimate success of transfusion in cases of exhaustion from uterine hemorrhage is, that the womb must first be in a state of contrac- tion, otherAA'ise all that might be gained by the operation, Avould be instantly lost through the open mouths of the utero-placental vessels. Secondary Hemorrhage.—There is a form of hemorrhage con- nected Avith childbirth to which as yet I have made no special allu- sion. It may occur, at any time after delivery, from two hours* to tAvo or three Aveeks, and has received the name of " Secondary Hemorrhage." Some authors have given a much greater latitude of time to this character of flooding, and mention instances in Avhich it has taken place as late as two or three months after the expulsion of the fcetus. Put these latter cases should not, I think, be regarded as connected Avith the deUvery. Their more appropriate place would * In some instances, after the uterus has contracted subsequently to the birth of the child, it will become relaxed, the effect of which will be more or less bleeding These, although exceptional cases, should not elude tlie vigilance of tlie accoucheur. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 403 be under the head of passive hemorrhage. When "Secondary Hemorrhage" occurs, it will generally be traceable to some portion of the membranes, placenta, or a coagulum of blood having been retained in utero ; in these cases, the first thing to do is to ascertain which of these causes may exist. If it should be discovered that the flooding is due to one or other of them, the indication is to remove the substance, whatever it may be, and Avith its removal the hemorrhage Avill usually cease. Again: the bleeding may be the result of an atonic condition of the uterus, not amounting to positive inertia, but occasioning a partial flaccid state of the organ, giving rise to hemorrhage. Fnder these circumstances, you may administer, with much confidence, ergot; for here the flooding is not so profuse as to require the more heroic treatment of which we ha\c spoken ; in connection Avith the ergot, a capital remedy will be the injection into the rectum of half a pint of cold Avater night and morning. In plethoric women, the bleeding will be sometimes due to congestion of the uterus. In these cases, it will be of signal benefit to abstract a few ounces of blood from the arm, administer saline cathartics, and keep the patient upon strictly abstemious diet. In every case of " secondary hemorrhage," after the uterus has been cleared of the fragments of placenta, membranes, etc., Avhich may have remained in it subsequent to delivery, I would advise, as an efficacious remedy, the application of the child to the breast, for the reason that this, through reflex influence, Avill impart to the uterus a marked tonicity. You will read Avith much interest and profit an excellent paper on the subject of " Secondary Hemorrhage," by Dr. McClintock, of Dublin.* * Dublin Quarterly Journal, May, 1851. LECTURE XXVIII. Management of the Puerperal Woman and her infant, during the Montli—Applica, tion of the Binder; rules for—Object of the Binder; napkin to tlie vulva—Stimu- lants not to be administered to the newly delivered "Woman; why?—Ablution of the infant: rules for—Dressing of the Umbilical Cord—Examination of Infant to ascertain Existence or not of Deformity—Toilet of the Child; pins not to be used —After-pains; how managed—Anodynes and Individual Idiosyncrasies—Bed- pan ; motives for its use—Physicking and Cramming the Infant; Objections to— Argument from Analog}-—When should the Child be put to the Breast ?—Colos- trum; uses of Meconium—A Flat Nipple; how remedied—First Visit after deli. very ; when to be made—What the Accoucheur is to do at this Visit—Retention of Urine; how managed—Retention and Suppression ; difference between—The Catheter; mode of introduction—Obstacles to Passage of the Catheter; what are they?—Incontinence of Urine; causes of—Vesico-vaginal, and Urethro-vaginal Fistulas—the Lochial Discharge; what it is; derangement of—When Infant can- not take the breast, how to be Nourished—Substitute for the Colostrum—Reten- tion of Urine in Infant; causes of; Milk in Breasts of new-born Infants—Gubler's Observations—Milk Fever—Blot's Researches on Diminution of Pulse in Milk Fever —Constipation of Infant; causes of—Occlusion of Anus; how managed—Puru. lent Ophthalmia; causes of—Sore Nipples—Mammary Abscess—Paraplegia; causes of in recently delivered women—Sloughing of Umbilical Cord—Pain in Uterus when Child is put to the Breast; Explanation of. Gentlemen—The management of the puerperal Avoman, after the birth of her child, is an interesting, and, at the same time, a very important subject. It is, however, so closely interwoven Avith the management of the neAA'-born infant that I deem it more expedient, instead of discussing the tAA'o questions under distinct heads, to pre- sent them to you conjointly; and, Avith this vieAv, Ave shall noAV proceed to point out the wants of the lying-in chamber, during the month. Application of the Binder.—As soon as the after-birth is removed, and the uterus contracted, the abdominal bandage should be applied. Some practitioners are in the habit of using the binder, as it is termed, the moment the child is in the Avorld. There is no advantage in this practice, but much inconvenience, especially Avhen there is delay in the expulsion of the placenta, for, in these instances, it will often- times become necessary to remove the binder, and thus subject the patient to additional annoyance. The bandage should consist of a double fold of linen about fourteen inches Avide, and sufficiently long to encircle the body tAvice. The object of applying it at all is simply to afford gentle and equable support to the abdominal parietes, Avhich have been in a state of great distension ; and now THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 405 that the child has left the uterus they are, on the contrary, in a remarkably relaxed condition. I am generally in the habit of attending myself to the first adjustment of the bandage; it is a simple matter, but still there is sometimes harm done for the Avant of proper care in its application. The patient should not be per- mitted to make the slightest effort to assist in the arrangement of the binder; she should be turned on her back, and the bandage rolled up; you then unroll a small portion of it, Avhich Avith your hand you gently insinuate under the back of the patient next to the naked body, at the same time instructing the nurse to stand at the opposite side, and draAV that portion of the binder toward her. In this way, Avithout in the least disturbing the lady, you have suc- ceeded in the first part of the operation ; the bandage is then to be arranged so that it comes doAvn Avell over the hips, and after encir- cling the body tAvice Avith it, it is to be attached by means of pins. The almost universal fault with nurses is, that they draAV the binder too tight, and unfortunately this is oftentimes oAving to the direc- tions of the patient herself, Avho is most anxious that her beautiful figure should be preserved. Little does she think that this earnest solicitude for the preservation of her fine figure may cost her the" destruction of life, the undue pressure thus exercised on the uterus sometimes giving rise to inflammation, Avhich, in rebellion to the best directed efforts, frequently terminates in death. Napkin to the Vidva.—When the bandage is arranged, the next thing is to have a Avarm napkin applied to the vulva, for the pur- pose of protecting the patient against the discharge Avhich, in more or less quantity, will necessarily pass from the uterus. And here allow me to inculcate upon you the recollection of a good rule—let the nurse occasionally, before you leave the chamber, examine the napkin, and tell you Avhether the discharge is right, or Avhether it is too profuse. The recollection of thisAvill sometimes save you much trouble, for, although the uterus may be contracted, yet there may be too much oozing occasioned by some of the causes to Avhich I have already referred. The course for you to pursue, under the circumstances, is to proceed at once to ascertain what the true difficulty is, and remove it. If the patient be confined on a cot, I do not suffer her to be dis- turbed for at least tAvo hours; at the end of this time she will have recovered someAvhat from the fatigues of the labor, and, perhaps, been refreshed by sleep ; then she should be carefully placed in her bed, Avithout being permitted to make the slightest effort herself. Let tAvo assistants remove her, being cautious to keep her in the horizontal position. loddies and Caudh.—It is the custom with certain practition- ers, almost immediately after the birth of the child, to have re- course to some stimulating drink for the patient, under the belief 406 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. that it is absolutely necessary. Toddies and caudle arc the favorite beverages. In my opinion, they are not, as a general principle, at all needed, and they oftentimes do harm. A cup of tea, or some warm gruel, tapioca, or arroAV-root, are far more in keeping Avith the condition of the patient; and, unless there should be something to indicate the use of Avine, etc., I should advise you not to have recourse to it. The thing a neAvly delivered Avoman is most in need of, and AA'hich Avill prove an effectual restorative, is repose; and, therefore, she should be scrupulously guarded against intruders at the time, and the chamber kept as quiet as may be consistent with circumstances. Washing and Dressing the Child.—Noav let us turn our atten- tion, for a moment, to the infant. You Avill recollect, Avhen sepa- rated from its parent by the section of the umbilical cord, it Avas Avrapped in flannel, and placed, for the time being, in a spot of safety. The first want of the little stranger is a thorough Avashing. The nurse should provide a vase of Avarm Avater, some Castile soap, and a piece of delicate sponge, or soft flannel. She should then seat herself'in a Ioav chair, and commence the work of ablution. " The surface of the new-born infant's body is usually covered more or less Avith an unctuous or sebaceous material, and in order to have this properly removed, it will be necessary, before using the soap and Avater, to direct the nurse to rub the entire surface gently Avith fresh SAveet oil, or, Avhat answers a very good purpose, the yolk of an uncooked egg. As soon as this is done, the soap and water should be well applied by means of the sponge or flannel; but be careful that the nurse, in her ambition to perform her duty well, does not, as sometimes Avill be the case, exceed the limits of pro- priety, by alloAving the soap to come in contact with the eyes of the infant. This is a fruitful source of that annoying, and often danger- ous affection, purulent ophthalmia. When the ablution has been properly attended to, the child should be carefully dried with a Avarm and soft linen. The next object is the dressing of the cord, which is done as folloAvs, and AA'hich should not be left to the nurse, but attended to by the practitioner. Take a piece of linen three inches square, double it, and cut a hole in the centre, through Avhich the cord is to be drawn. The cord is then enveloped in the linen, turned upward and to the left on the abdomen. A circular band is applied, Avhich will retain the dressing in place, and also afford comfortable sup- port to the child. Pe careful that the bandage is not too tight. The common practice Avith nurses is to use pins for the purpose of attaching the infant's dress. I much prefer the needle and thread, for the pins are apt to become loose, prick the child, and may thus give rise to serious consequences, evoking convulsions, or other troubles. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 407 Is the Infant deformed?—After the circular band has been adjusted, an examination should be made to ascertain Avhether there is any deformity, such as occlusion of the anus or urethra— Avhether there exists any malformation of the mouth, AA'hich may prevent the child taking the breast. It is proper that these defor- mities, should any of them be present, be recognized at this time, in order that prompt measures may be adopted to remedy them, and not delay until the infant's life is placed in peril, and too often Avithout the cause of the danger being even suspected. Having become assured of the existence or absence of these deformities, the child is then to be dressed, which may be done by the nurse, Avithout much supervision. The child, its toilet being completed, may in a short time be placed by the side of its mother, if she be awake; to gaze upon it Avill cheer her heart, and prove a rich com- pensation for the sufferings she has encountered in bringing it into the world. After-pains.—So far, then, Ave have succeeded in making the patient comfortable ; the Avashing and dressing of the child have also been accomplished. The practitioner has not yet left the chamber, nor should he do so until these matters have been attended to. Soon after the placenta has been removed, the patient Avill complain of more or less pain, closely simulating the throes of labor; and she will sometimes become alarmed, imagining she is about to give birth to another child. These pains are Avhat are knoAvn as after-pains ; they are nothing more than the contrac- tions of the uterus ridding itself of the fluids contained Avithin it, and at the same time, through these contractions, gradually return- ing, as far as may be, to its pristine state. After-pains, therefore, in lieu of being regarded as morbid or pathological, are to be classed among the usual and necessary phenomena of childbirth. In a Avoman Avith her first child—a primipara—these pains are ordi- narily slight; in a multipara, on the contrary, they are oftentimes severe and harassing. The reason of the difference is that, in the former case, the uterus is invested Avith vigor and tonicity, and consequently soon becomes restored to its original condition ; Avhile, in the latter, its walls are flaccid, and the contractions, therefore, more protracted. Pefore leaving the patient, it will occasionally, from the severity of these pains, become necessary to give something to break their intensity. Put, unless they prove so annoying as to occasion much disquietude and prevent sleep, I would advise you not to interfere by medication with this natural process. In administering medi- cines under any circumstances, be careful, as far as you can do so, to ascertain Avhether or not the patient is affected Avith any striking idiosyncrasy; I mean by this Avhether she is morbidly sensitive to certain remedial agents. You have no right, gentlemen, to assume 108 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. any thing touching the peculiarities of those, Avho may seek your professional counsel. For example, let us suppose that, Avithout observing the precaution to which I have just alluded, you should order for your patient, in case of after-pains, ten grains of Dover's powder. Well, the prescription is filled, and the medicine taken. In a very short time afterward you are sent for, and you find the patient delirious, absolutely crazy. When she returns to her senses, the first thing she will say to you will be something like this: " Oh ! doctor, Avhy did you not tell me you had ordered Dover's powder ? I took it once and it nearly killed me!" Therefore, ahvays inquire whether such peculiarity of system exists, regarding any remedy Avhich you may propose to administer, and should there be an idiosyncrasy, substitute in its stead something else. If, in your judgment, it become necessary to order an anodyne* prepa- ration, any of the folloAving may be given Avith the reservation just mentioned: R.. Syrup, papav. f. 3 iv. Mucil. Acaciae f. 3 ij. Sol. Sulphat. Alorphise (Magendie) gtt. xij. A tablespoonful every half hour, until the suffering is mitigated. The above is a favorite prescription Avith me. R,. Misturse Camphorae f. 3 ij. Syrup. Simp. f. "5 j. Tinct. Opiif. 3j. The half of the mixture, and if not relieved in an hour, give the remaining portion. R,. Pulv. Doveri, 3i. Divide in chartulas ij. One poAA'der in some sirup, and, if necessary, the second in an hour or two. Or, from ten to fifteen drops of the solution of morphia may be given in a dessert-spoonful of cold Avater. Directions to the Nurse.—So much for the patient as to contin- gent remedies; but, before making his adieu after the birth of the child, there are some other directions not to be neglected by the practitioner. The nurse must be strictly enjoined not to allow the patient, if she desire to pass her Avater or evacuate her boAvels, to sit on the chamber. A bed-pan must be used. This will be some- what inconvenient at first, but any annoyance in this Avay will be amply repaid by an immunity from those troubles so apt to * I have repeatedly met with cases in which the after-pains were characterized by more than ordinary intensity, and traceable to the presence of a coagulum in the uterus. If, as sometimes will be the case, the clot be felt by the finger carried to the os uteri, it should be immediately removed. Should the coagulum be out of reach, a stimulating injection into the bowel will oftentimes aid in its expulsion, after which an anodyne may be administered. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 409 folloAv too early sitting up after delivery, such as prolapsus uteri, procidentia of the organ, or prolapsus of the vagina. Physickln.g and Cramming the Nexo-born Infant.—The absurd and mischievous practice obtains, too generally, of giving the little infant oil or some other medicine almost simultaneously Avith its birth, and of filling its delicate and much-abused stomach—a sto- mach Avhose powers of assimilation are extremely feeble—Avith food of domestic manufacture; and hence the " pap boAvl" is a fixture of the lying-in room. This practice, AA'hich is one of the products of remote but regular tradition, is fruitful in bad consequences, often- times proving the starting-point of disease and death. Why, gen- tlemen, is it not strange that, with all our boasted intelligence, we should be so inferior to the brute creation in the management of the young ? Do you see the slut, Avith nothing but instinct to guide her, guilty of these absurd practices? Here, there is no medicine given, no pap forced doAvn the throats of her innocent little offspring. The pups as soon as they come into the Avorld, seek each one the teat of its parent, and from these teats they extract both medicine and nutriment. They groAV and become developed ; they are healthy, and rarely do they need the services of the physieian, for the reason that they observe the ordinances of nature. Learn, then, a lesson from analogy, and remember that the identical necessity exists in the infant of the human being to observe faithfully these same ordinances. My rule, therefore, is, as a gene- ral principle, to give the new-born child nothing, for the reason that it needs nothing but the material Avhich nature has so carefully and elaborately prepared for it; and that material is the mother's milk. When should the Infant be put to the breast?—Instead of admi- nistering medicines, and cramming its stomach Avith food it cannot digest, if nothing should contra-indicate it, have the child put to the breast as soon as the mother has recovered someAA'hat from the fatigues of the labor, say in two or three hours. Put you may urge as an objection to this practice, that there is very little milk at this early period in the breast. Well, admit, for argument sake, the fact; still this early application of the child is one of the efficient promoters of the milk secretion; the tractions made upon the nipple invite the milk to the breasts, and the child at this early period extracts Avhat is known as the colostrum, an element pos- sessing purgative qualities, and which readily and efficiently removes from the intestinal canal the meconium—a black viscid material found in greater or less quantity in the boAA'els of the neAv-born infant, and Avhich appears to consist of a mixture of bile and pro ducts secreted by the intestinal mucous surface. Let me here enjoin upon you the necessity of cautioning the mother against having her infant in bed Avith her Avhile she sleeps. It is stated on the author- 410 THE PRINCIPLES ANI) PRACTICE OF OBSTETPJCS. ity of Osiander, that in England, between the years 1G8G and 1799, 40,000 children were destroyed by being overlaid by their parents. A Sunken or Flat Nipple—How Remedied.—Owe more direction before taking leave of your patient, and a very essential one it is, too—let the nurse examine the breasts, and tell you Avhether or not the nipple is well formed. It sometimes happens that it is quite sunken and flat, so much so that it will be impossible for the child to grasp it in its mouth: the consequence AviU be that the mother is fretted and fatigued by the negative efforts of the infant, and this latter will be defrauded of what it has a birthright claim to—its natural nourishment. In order to overcome the difficulty take an ordinary pint bottle Avith a long neck, fill it with hot Avater, then pour out the water, and apply the mouth of the bottle immediately over the nipple ; as the bottle cools there is a tendency to a vacuum, and thus a powerful but equable suction is produced, Avhich results in elongating the nipple. The bottle is then removed, and the child applied. The First Visit after Delivery.—These various .matters having received attention, you bid good-day, or good-night, as the case may be. Whenever you can do so, it should be your general practice not to alloAV more than tAvelve hours to intervene, from the time of delivery, before you pay your next visit. During this visit, you will learn hoAV things have progressed since you left. Has the patient had a comfortable sleep ? Has she been much annoyed by the after-pains ? Has she passed her water ? Hoav is her pulse ? Is it right, or is it accelerated and bounding, indicative of inflam- matory action, and if so, where is the inflammation ? Is the quick- ened pulse merely the result of your presence, and, therefore, tran- sitory ? Is there pain in any portion of the abdomen ? If so, is it constant, or is it recurrent ? If constant, is it the result of inflam- mation, or of intestinal flatus, or of a distended bladder? Is there any febrile excitement ? This is a running schedule of the ques- tions, AA'hich Avill suggest themselves to the mind of an intelligent and vigilant physician, anxious to be prepared in time in the event of danger, and equally anxious to knoAV that every thing is pro- gressing as he Avould desire. The nurse may tell you that the lady has suffered a great deal of pain in her bowels; and will also, perhaps, inform you that the slightest pressure aggravates the distress; the nurse at the same time giving to her agreeable countenance a sort of doleful expres- sion, wishing you to understand that she by no means likes the appearance of matters. Xow, under these circumstances, what are you to do? Are you suddenly, and Avithout cause, to become a convert to the misgivings of the nurse, and alarm your patient by sad omens and a long face; or, as a conscientious physician, will you not at once subject every thing connected Avith your patient to THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 411 a searching analysis, and ascertain in this Avay what really is the matter—Avhether there is a substantial something, or whether the apprehension of the nurse is a mere phantom. What, then, is the pain in the bowels ? It may arise from the contractions of the uterus, and, therefore, it is simply due to the after-pains; it may arise from distended bladder, or from a flatulent condition of the intestinal canal, or from a collection of faecal matter in the lower bowel making undue pressure on the uterus, or from inflammation either of the uterus itself, or the peritoneum. Diagnosis.—In " after-pains " the distress is not constant, but paroxysmal or recurrent, and there is between the paroxysms an interval of decided calm. The pulse is usually not disturbed, nor is there febrile excitement. If the difficulty be caused by distension of the bladder, the organ will be found enlarged, stretching over the hypogastric region, and imparting to the hand a sense of hard- ness. In addition, you will have learned from the nurse that madam has not passed her water since the birth of her child. Sometimes, and I have seen such cases, when the retention of urine is complete, so that none whatever escapes from the bladder, and this state of things has continued for tAvo or three days, the abdo- men becomes enormously distended, presenting the aspect of ascites; in these aggravated instances the pulse will run high, 120 in the minute ; and there will also be coma, more or less profound, from the accumulation in the blood of the urea, Avhich should have been ex- creted from the system through the urinary apparatus, constituting a case of blood-poisoning—uraemic intoxication. If it be a case of flatus in the intestinal canal, there will be the sound of resonance under percussion, together with distension of the abdomen, and an occasional eructation of gas through the oesophagus, or a passage of it per rectum. There Avill also be an alternation of increase and diminution in the size of the abdomen, depending upon the quantity of flatus, which may find exit. The pulse will generally be undis- turbed. If the lower bowel be distended with faeces, you will have o-0od reason to suspect that this is so, if the patient informs you that she has been more or less constipated during the latter period of her pregnancy. Lastly, if there really be inflammation, the Avhole system at once becomes involved; the pulse is rapid, 120 to 130 beats in the minute; febrile excitement, excessive tenderness on pressure, pain constant, pallor and anxiety of countenance, Avith a general arrest of the secretions. Thus, gentlemen, you proceed Avith your analysis, and, having discovered the truth, you AA'ill thenknoAv what to do. Retention of Urine.—This is not a very unusual attendant upon the delivery of the child, and calls for the proper attention of the accoucheur. I desire to remind you, for the moment, that there is 112 THE PRINCIPLES A^'D PRACTICE OF OBSTETRICS. a very important distinction between retention and suppression of urine. The former implies that condition in Avhich the urine is secreted by the kidneys, and passes through the ureters into the bladder, and there becomes retained, accumulating, and thus pro- ducing inordinate distension of the viscus. In suppression, on the contrary, it is not the bladder, but the kidneys, Avhich are at fault, there being little or no urine secreted. With this distinction before you, Avhat Avould you think of the practitioner, Avho, being called to a case of retention, should administer diuretics; and yet, gen tlemen, this has been done, and the vicious practice ■will continue until physicians are brought to think and analyse. Routine practice is one thing; but the tracing of effects to causes, and the applica- tion of appropriate remedies to those causes, indicate the scientific practitioner. A very common cause of retention of urine after childbirth, is paralysis of the bladder above the sphincter, thus dis- qualifying the organ from contracting sufficiently to expel its con- tents ; Avhile, on the other hand, paralysis of the sphincter itself gives rise to an opposite condition—incontinence of urine. The paralysis in either case is usually not of long duration; and -will generally pass off in a feAv days. The object, in retention, is to unload the bladder; and this may be done sometimes by the application of hot cloths to the vulva and hypogastrium. I someAvhere read years ago of the practice in these cases of pouring, Avithin the hearing of the patient, AAaterfrom a vessel sloAvly into a pitcher; and I can vouch for its efficacy in several cases in Avhich I have had recourse to it. Should, hoAvever, this expedient, and the warm fomentations fail, then we have a certain remedy in the catheter. It is a curious, but interesting circumstance that, occasionally, after the patient has made vain attempts to relieve herself, and after the failure of the ordinary remedies, the moment the accoucheur suggests the necessity of having recourse to an instrument for the purpose of draAving off the water, madam, alarmed at the idea of an instrument, tells the nurse in an undertone,—" Oh, I think I can relieve myself now;" the nurse brings the bed-pan, and sure enough the bladder is evacuated. This is a striking illustration of the operation of mind upon matter; and I have Avitnessed its happy effects in more than one instance. Mode of Introducing the Catheter.—This, like many other opera- tions, is very simple, if you knoAV hoAV to perform it; but simple as it is, it very often happens that the practitioner fails in his attempt from ignorance or carelessness, and such failure is not Avithout sad consequences to his reputation. The first point in the operation is to find the meatus urinarius, or outer opening of the urethra, and this should be accomplished Avithout in any way exposing the person of the patient. PT can have my choice, I prefer THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 413 the patient on her back, lying near the edge of the bed, with her thighs slightly separated, and flexed upon the pelvis. The index finger of one hand, lubricated Avith oil, is then directed to the vagina. The rules for recognizing the meatus may be classed as follows: 1. Let the radial surface of the index finger be carried up to the anterior portion of the vagina; here it is brought in contact with the lower wall of the urethra; then, taking the urethra as a guide, draAV the apex of the finger along this Avail in a forward direction ; this necessarily brings you to the outer extremity, or meatus ; 2. Place the apex of the index finger at the superior commissure; here will be found the clitoris, and, in draAving the finger perpendicularly downward along the vestibulum, the meatus AviU be reached just at the base of this triangular space; 3. Place the end of the finger on the summit of the pubic arch; very near, and a little beloAv this point, you Avill, by gently moving the finger about, come directly in contact Avith the orifice of the urethra. If either of these rules be properly observed, there AviU, unless in case of some deformity of the parts, be no difficulty in easily recognizing the meatus urinarius. The Avater-passage in the female, as was mentioned Avhen de- scribing the external organs, is remarkable for its shortness and great dilatability; and its direction is slightly oblique from beloAv upAvard. Having found the meatus, keep the point of the index finger upon it to serve as a guide for the introduction of the catheter. This instrument is constructed of various materials, silver, peAvter, or caoutchouc. I prefer one of silver; it should be at least six inches in length, and slightly curved. Pefore introducing it, let it be Avell lubricated Avith oil, and this is better than lard or butter, for either of these latter may close up the little openings on the side of the terminal extremity of the catheter, and thus prove an obstacle to the free passage of the urine. As soon as the instru- ment is Avithin the meatus, I Avould advise you immediately to glide the finger, Avhich has been passed as a guide, within the vagina, keeping it on the loAver Avail of the urethra, Avhich will enable you not only to feel the catheter through the Avail, but also to prevent laceration of the part. One point ahvays bear in mind, in the intro- duction of the instrument—never attempt to sttbstitute brute force for skill; and Avhen you recognize an obstacle to its free passage, you may depend that something is AA'rong, and that Avrong is not to be remedied by physical force. If the secrets of the lying-in room could betmmantled, and the drapery of concealment removed, among other melancholy disclosures Ave should.have many a tale of sorrow touching lacerations of the urethra, bladder, and vagina, from the clumsy and unpardonable employment of the catheter. The instrument, then, being Avithin the. urethra, a very gentle movement is to be imparted to it obliquely from beloAv upAvard. 414 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. The catheter having reached the bladder, the stiletto is withdrawn, and, as a general thing, there will be a copious flow of urine, but Avhere will the urine fall? Why, on the bed, Avithout a question, occasioning a verv agreeable and interestingcondition of things, if you should have neglected an essential point ia the operation—bidding the nurse to have in readiness a boAvl in which the urine is to be received as it passes through the catheter. It should be a small bowl, placed betAveen the thighs of the patient; as soon as it is filled, let the contents be emptied into a vase, Avhich should be at hand, being careful Avhile emptying it to place the finger on the mouth of the catheter to check, for the moment, the running stream. It may sometimes occur that, after the catheter is intro- duced, no urine Aoavs ; this is an embarrassing state of things, and may arise from various causes: 1. Although you may imagine the catheter to be in the bladder, yet it is not there, but simply in the vagina; 2. The holes at the end of the catheter, or the body of the instrument itself, may be obstructed by flocculent matter or mucus floating in the urine; 3. The instrument may not be suffi- ciently far introduced, having passed merely to the neck of the organ. Obstacles to the Ingress of the Catheter.—There may exist cer- tain obstacles to the free ingress of the catheter into the bladder ; for example, the various malpositions of the uterus.* In prolapsus, the organ may make such pressure against the neck of the bladder as completely to prevent the passage of the instrument; the remedy is A'ery simple—introduce the finger into the vagina, gently elevate the prolapsed uterus, and then Avith the other hand pass the catheter. The fundus of the Avomb may be in a state of ante-ver- sion, the fundus resting upon the bladder; this also is to be remedied by pushing the fundus backAvard, thus liberating the bladder from the pressure; or the uterus may be retroverted, the fundus having fallen backAA'ard ; in this case, the cervix of the organ will be thrown forAvard, and, as a consequence, more or less pres- sure exercised against the neck of the bladder. In order that the catheter may pass under these circumstances, it AA'ill be necessary to relieve the bladder from the pressure by pushing the cervix of the Avomb backward toward the centre of the pelvic excavation. In procidentia of the uterus, the organ has fallen beyond the vagina, and is situated between the thighs of the patient; Avhen this mal- position of the organ occurs, the bladder will, of course, be brought doAvn more or less Avith the uterus, and, in consequence of this latter circumstance, the direction of the meatus urinarius will be so changed, that it will look more or less upAvard ; if this fact be not recollected, the practitioner will be foiled in bis effort to intro- * It is possible that some of those malpositions may be coincident with a recent delivery, and, therefore, I mention thein in this connexion. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 415 duce the instrument. An attempt should ahA'avs be made to reduce the procidentia, and return the organ Avithin the vagina; it should then be retained in situ, enjoining upon the patient the absolute necessity of the recumbent position, Avith the hips slightly elevated. Incontinence of Urine.—After a protracted labor, it is not unusual for the patient to be unable to hold her AA'ater, as the phrase goes; and this is almost ahvays dependent upon the severe pressure, Avhich has been exercised by the head or presenting por- tion of the child upon the neck of the bladder, producing a paralysis of the sphincter, and thus incapacitating it from retaining the urinary secretion. Ten drops of the tincture of cantharides in a Avine-glass of flax-seed tea tAvice a day, will prove a good remedy in these cases ; or the application of a small blister to the upper portion of the sacral region will answer equally Avell. I need not remind you that the modus operandi of this treatment is readily explained—the cantharides, Avhether administered internally, or through its absorbent action, Avhen applied as a blister, has often- times a specific effect on the neck of the bladder, producing Avhat is known as strangury, and in this Avay it becomes an important therapeutic agent, Avhen it is desirable to stimulate, through nervous influence, the muscular fibres of the sphincter vesicae. Here, it is right to tell you that it is possible you may form an erroneous opinion Avith regard to the incontinence of urine. For instance, the nurse may inform you that madam cannot hold her water; well, this may be the case, but there are other conditions besides paralysis of the neck of the bladder, Avhich will occasion this difficulty. A vesico-vaginal, or urethro-vaginal fistula, consti- tuting rents betAveen the vagina and bladder, or the urethra and vagina, may be the cause of this constant dribbling away of the urine; under these latter circumstances, it Avould amount to no- thing short of stupendous folly to hope, through the action of cantha- rides, to remove the difficulty. Therefore, gentlemen, be careful in your diagnosis. Flatus in the Intestinal Canal—Women, soon after delivery, will occasionally suffer great distress from an accumulation of flatus in the boAvels; and I think I have observed this more particularly after severe floodings. This distended condition of the canal has sometimes been mistaken for inflammation, and it is very important that you should understand the distinction. In tympanites, slight pressure Avill produce pain, but increased and long-continued pres- sure will afford relief; should there be inflammation—and this is frequently accompanied by a flatulent distension of the intestines— the greater the pressure the more marked and severe will be the pain ; besides, the various phenomena indicative of inflammatory action will be present. Great benefit will be derived in cases of 416 TnE PRINCIPLES AND PRACTICE OF OBSTETRICS. flatulence, from a combination of turpentine and castor oil; half an ounce of each may be given by the mouth ; or the folloAving draught may be ordered : Olei Terebinth., f. 3 ss. Mucil. Acacia1, f. § iss. Tine. Opii f. 3 ss. M. In these cases, too, relief will be derived by the application to the abdomen of a Avarm flannel sprinkled aa ith turpentine. A Loaded Condition of the Lower Bowel.—This is another not unfrequent cause of distress to the recently delivered woman, and AA'ill be apt to lead the practitioner astray, unless he exercise due A'igilance in his diagnosis. Most Avomen neglect their boAvels under almost all circumstances, and this very neglect proves a severe tax on their health ; but more particularly are they careless in the latter months of gestation, and hence, soon after the birth of their child, they oftentimes suffer great pain from an accumulation of faecal matter in the colon and rectum. When this state of things is ascer- tained to exist, immediate recourse should be had to an enema, Avhich "will bring away the mass of excrement, and thus give present comfort to the patient, and, perhaps, save her from serious subse- quent trouble. A good injection for this purpose will be the follow- ing : A pint and a half of soap-suds, one ounce of castor oil, four large spoonfuls of molasses, with one of table salt. This will form a capital enema for the occasion. You Avill, I am sure, excuse me Avhile upon this subject, in calling your attention to a simple, but in reality a very important point, and it is this—you direct the nurse to administer the enema as above prepared, she does so—at least she thinks she does—but instead of throAA'ing the contents of the syringe into the bowel, it Avill oftentimes happen that they lodge in the bed, and for the reason that the pipe of the instrument has merely been placed in the vicinity of the anus, instead of being properly introduced. Therefore, Avhen this practice becomes neces- sary, unless you have an intelligent and reliable nurse, who under- stands and appreciates the difference betAveen right and wrong, perform the operation yourselves. If the remedy be indicated, it is as much your duty to see that it is properly administered, as it would be in applying a ligature for aneurism to be sure that you had embraced AA'ithin the ligature the artery instead of the nerve. There is, hoAvever, another form of constipation, Avhich you AA'ill sometimes meet with in the puerperal Avoman, Avell worthy of atten- tion. It Avill resist the administration of cathartics by the mouth, and Avill be equally beyond the control of enemata. It is constipa- tion traceable to paralysis of the rectum—the nerves regulating the functions of this portion of the intestinal canal having, in consequence THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 417 of a protracted and severe labor, undergone a degree of pressure, Avhich deprives them of the ability to control muscular action. There is an interesting case of this kind reported by M. Martin, of Lyons, in which the faecal matter was retained for a period of more than twenty days. He Avas compelled to introduce into the rectum a scoop, and thus bring aAvay the masses of hardened faeces ; and it was not until the lapse of twenty-nine days that the intestine recovered its tonicity.* The Lochia! Discharge.—One of the ordinary accompaniments of the puerperal Avoman is a discharge from the uterus, which con- tinues for several days, and sometimes weeks,f after childbirth, and is knoAvn as the lochia ; it is nothing more than the oozing from the mouths of the utero-placental vessels, together Avith the passing off of the decidua, Avhile the uterus is returning to its original condi- tion.J At first, the discharge is sanguineous, and it may assume this character for tAvo or more days after delivery; then the color is changed, partaking more or less of a serous nature, and presents a greenish hue; it then becomes Avhitish, and ultimately ceases altogether. After the first day or tAvo, there is a sort of sui generis smell, and AA'hich I have remarked striking, or, in other Avords, more offensive in women of dark complexion, hair, and eyes—the brunette. The lochial discharge Avill sometimes need attention ; and you should be careful, in the first visit to your patient after delivery, to inquire of the nurse Avhether or not the discharge be right. The nurse may tell you, to use her own expression, that "it is very scant," or that there is none at all. This state of things will be apt to give rise to disturbance, especially in plethoric Avoruen, and in * It will occasionally happen that, after a labor of protracted duration, and more especially when the perineum has been subjected to long-continued distension, the muscles of this part will become partially paralyzed—giving rise to great difficulty in defecation, from embarrassment in voluntary movement; and this condition of things may continue for months, and in some instances for life. I have, in two cases of this kind, experienced the best effects from the internal administration of minute doses of strychnine. This being an example of reflex paralysis, and, consequently, not traceable to congestion or injury of the spinal cord, the strychnine constitutes a valuable remedy. f Galen taught the curious doctrine that the foetus appropriates to itself the best part of the blood for its own nourishment, and leaves the rest; and this is the reason why pregnant women are troubled with bad humors, which are thrown off after delivery. The following is his language : " Feetum in se meliorem, qua nutriatur, sanguinis portionem trahere, deteriorem relinquere; quae causa est prsegnantibus cacochymice, quam natura post-partum evacuat." This post-partum evacuation he describes as the lochia. X Hippocrates held that when the infant is a female, the lochia usually continues forty-two days; if a male, thirty days. Nam et purgatio a partu fit mulieribus ut plurimum, in puella quidam concepta, duobus et quadraginta diebus. In masculo vero purgatio diebus triginta contingit. 2. De natur puer, cap. 5. Vol. V., p. 314. It is needless to remark that this is simply an opinion without anything substantial lor its basis. 27 418 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Avomen of more than ordinary nervous susceptibility. In the for- mer, occasioning fever, flushed countenance, headache, a bounding pulse, all of Avhich, if permitted to pass unchecked, not only portend, but Avill actually result in mischief. In the latter, there will be restlessness, jactitation, and sometimes even convulsive movements. Again : the lochial evacuation will occasionally be too profuse, pros- trating the patient, and, in this Avay, laying the foundation of future trouble. You see, therefore, gentlemen, Iioav important it is to have an eye to the lochia. When it is scant or entirely suppressed, I have found much benefit from a Avarm flax-seed poultice, put into a flannel bag, Avith Avhich should be incorporated 3 ii- of powdered camphor. The poultice thus prepared to be laid over the vulva, and repeated every hour or tAvo, if necessary. When, on the con- trary, the discharge is too profuse, a teaspoonful of the tincture of ergot in a Avine-glass of cold Avater tAvice a day will generally be folloAved by good effects. When what is called the milk fever comes on, Avhich is about the second or third day after delivery, the discharge usually ceases for a few hours, but returns as soon as the fever passes off. The nurse should be directed to have the vagina pro- perly cleansed by injections of tepid Avater two or three times a day. Attentions to the Infant.—We are not to forget the little infant in this first visit; and, therefore, let us devote a few moments to its welfare. Has it been put to the breast, as you directed ? Have its boAvels been moved, and has it passed its Avater ? The nurse will, perhaps, say that everything is perfectly right—it has taken the breast freely, it has had several dark-colored evacuations—the meconium—and it has passed its Avater. Well, all this is as it should be, and of course renders the exercise of your skill unneces- sary. On the other hand, the child may have been put to the breast; but, in consequence of there being no milk, it has had no nourishment; and as it has not been able to extract from the breast the colostrum, its natural and efficient cathartic, it has not been purged ; it may also be that it has not passed its Avater. Here, then, is a state of things Avhich calls for prompt action. The first matter to be attended to is, to give the infant a teaspoonful of olive oil, or a little broAvn sugar dissolved in Avater, or equal parts of molasses and Avater. Either of these will generally suffice to pro- duce a cathartic effect. You must remember that if the meconium be allowed to remain in the intestines, bad consequences may ensue; and I am quite confident that convulsions in the neAV-born infant are often the result of this neglect. The meconium becomes an irritant, and in this way is the cause of eccentric nervous disturb- ance. You cannot too faithfully recollect this fact. Feeding the Infant.—The child, until it is enabled to obtain nourishment from its mother's breast, may be fed Avith diluted cow'a milk. This is a near approach to human milk. Should it THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 419 become necessary, from the indisposition of the parent, or other circumstances, to bring the child up by the bottle, as it is termed, it will be found useful to restrict it exclusively to this form of diet for at least two months.* Its powers of assimilation are extremely frail, and it needs, for the first six or eight weeks after birth, the blandest possible nourishment. After this period, it may partake of farinaceous articles, such as oatmeal with milk. There is one caution especially important for the first four or five months—the food should be thin and taken through a teat. This will prevent that stereotyped evil—stuffing the young infant. Pe careful, also, * In the American Journal of Medical Sciences for July, 1858, Dr. Cummings has given us an interesting and practical paper "on Natural and Artificial Lactation" from which I make the following extract: Cow's milk contains, While human milk contains Butter 38.59 Butter 20.76 Casein 40.75 Casein 14.34 Sugar 53.97 Sugar 75.02 Water 866.69— Water 889.88 " Cow's milk, therefore, contains nearly three times as much casein as human milk, but less than twice as much butter. In cow's milk, the butter is to the casein as 100 to 105; in human milk as 100 to 70. If then, by dilution, we reduce the butter to 20.76, we shall have 21.92 of casein, or 50 per cent, more than in human milk. With such an excess of casein we cannot hope to succeed. If, by a further dilution, we reduce the casein to 14.34, we have only 13.58 of butter, or less than two-thirds of the proper proportion. Such milk may, for a season, seem to suit the child, but before long it will be found that it does not thrive. The reason is plain. The right proportion of butter is 20.76; this warms a child, and supplies nervous energy. But, by withholding one-third, you lower the temperature of the body, and deprive the nervous system of one-third of the special nerve-food, the indispen- sable lecithin. In a short time pallor and languor supervene, and health evidently declines, &c, &c. It is thus evident, that by no mode of dilution can ordinary cow's milk be made a substitute for human. There will be, in every case, an excess of casein, or a deficiency of butter. So long as the butter is to the casein as 100 to 105, instead of as 100 to 70, so long must dilution fail to adapt it to the wants of the child. But if this original proportion could be changed to that existing in human milk, we might have hope of success. And we proceed to show how this may be done. If we leave at rest for four or five hours ordinary cow's milk, and then remove and examine the upper third, we find in it 50 per cent, more butter than it at first contained. In round numbers, its butter is no longer to its casein as 100 to 105, but as 150 to 105, or as 100 to 70. If then, by dilution of this milk, we reduce the butter to 20.76, we have 14.34 of casein, as in human milk. By using the latter half of the milk furnished by the cow, we have 54 of butter, to 38 of casein, the right proportion exists, and by proper dilution, it may be made to resemble, in its chemical constitution, human milk." Milk. Water. Sugar. For a child from 3 to 10 days old, 1000 2643 243 For a child 1 month old, . 1000 2250 204 For a child 2 months old, 1000 1850 172 For a child 5 months old, 1000 1000 104 For a child 6 months old, 1000 875 94 For a child 11 months old, 1000 625 73 For a child 18 months old, 1000 500 63 420 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. that the nurse does not fall into the absurd error of supposing that every time the child cries, it is hungry, and, therefore, must be fed. If we could have the correct statistics upon this question, the con- verse of the popular belief would be found to be true, viz. that the child far more frequently cries from being overfed, than from the Avant of adequate nourishment.* The Infant has not Passed its Water.—The little stranger has not passed its Avater—at least, so says the nurse. I have often been told this, and quite often, too, found that the nurse, Avithout intending to deceive, Avas altogether mistaken. In these alleged cases of non-micturilion, I am in the habit of examining the child's diaper, and generally I have discovered the evidences of a free stream. Would it not be cruel, to say nothing of the danger, to subject the infant to medication for this supposed trouble, Avhen, in fact, it did not exist ? It Avill occasionally be the case, hoAvever, that micturition has not been accomplished; and the first point to be ascertained is, Avhat is the cause of the difficulty. The infant, like the adult, may fail to pass its water because of suppression or retention of the urinary secretion ; and, therefore, before prescribing, the intelligent practitioner will be careful to ascertain to which of these condi- tions the trouble is due. Suppression and Retention of Urine in the Infant.—Suppres- sion is, I think, very rare in the neAV-born infant; for, as the kid- neys are organized at comparatively an early period of embryonic existence, their function is also early developed. Retention, on the contrary, is of more frequent occurrence, and may arise from various circumstances, such as congenital malformation, a collection of mucus in the urethra, spasmodic contraction of the neck of the bladder, etc. In retention, there is a circumscribed hard tumor in the hypogastrium ; while, in suppression, there is no such tumor, for the reason that as there is an absence of the urinary secretion there is consequently no distension of the bladder. Occasionally, in retention of urine in the neAV-born infant, the bladder becomes enormously distended; and, in this affection, death may ensue from rupture of the organ or ureters, inflammation of the peritoneum and abdominal viscera, or coma. In suppression, a feAV drops of sweet spirits of nitre in a little sweetened water, may be given ; or, Avhat will be found a good remedy, will be parsley tea, to which the nitre may be added. In retention, the treatment will, of course, depend on the particular cause which produces it. If the urethra be obstructed by the pre- sence of mucus, the introduction of a small bougie will suffice to * When the infant shows evidence of weakness, or indicates a scrofulous condi- tion, benefit will be derived from mingling with its food a small piece of butter, or mutton suet. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 421 remove it; if, as is sometimes the case, the obstruction be occa- sioned by a membranous band, incision of this latter Avill be the remedy ; should it be that there is a spasmodic stricture of the neck of the bladder, the warm bath and the bougie Avill be indicated. Milk in the Breasts of the New-born Infant.—There is a circum- stance connected Avith the neAA'-born infant well worthy of atten- tion. I allude to the presence of milk in its breasts ; for, without being cognizant of the fact that this secretion does really exhibit itself, you would very likely be embarrassed if consulted upon the subjeot. It in no Avay involves either the comfort or health of the infant, and the secretion ordinarily ceases at the end of the first month. I have repeatedly met with such cases; and all I recommend is to protect the breasts against the pressure of the dress, and, if necessary, to lubricate them tAvo or three times a day with olive oil. An interesting paper has recently appeared from the pen of M. Gubler, entitled* " La Secretion et la Compo- sition du Lait chez les Enfants nouveau-nes des deux Sexes." M. Gubler founds his memoir on observations made on 1200 neAV-born children. The secretion is very rarely observed in notable quan- tity, and only exhibits itself as a serous fluid for the first tAvo or three days of extra-uterine life. On the fourth day the glands are larger, and there frequently escapes under pressure a dense and opaque fluid. The number of infants in Avhich the secretion exists, as also the quantity of the fluid itself, gradually increase until the eighth day, when it seems to attain its maximum. From the ninth to the tenth day, in sixty-five children, there Avas one in Avhich the secretion AAras not observed. The increase in the volume of the breasts and the secretion usually continue, to a certain degree, until the tAventieth day. One hundred and forty-nine out of one hundred and sixty-five infants, from tAvelve to tAventy-one days old, exhibited the secretion in variable quantity. At the end of a month, it is extremely rare for the secretion not to have ceased altogether. In four instances, hoAvever, M. Gubler observed it to continue for two months. The milk of the new-born infant, accord- ing to this writer, assisted by the able chemist, M. Querenne, is more alkaline than the milk of the adult Avoman and of animals. It would seem that there is a striking identity betAA'een the milk of the infant and the ass. The following is the analysis of M. Que- renne : Milk of Woman. Infant. Ass. Putter,.........2.60 1.40 1.40 Casein,.........3.90 2.80 1.70 Sugar, and extractive matter, . . 4.90 6.40 6.40 Water,.........88.60 89.40 90.50 * For an analysis of this memoir, see " Appreciation des Progres de la Physiolo- gic," by E. Brown-S'^quard, Journal de la Physiologie, vol. ii., p. 410. 422 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. It is proved by this analysis that the liquid secreted in the breasts of the infant is really milk. It, therefore, is to be regarded a demonstrated fact, from the combined observations of M. X. t into one in Avhich it may become necessary to determine whether it would be more judicious to resort to instruments, or terminate the labor by the hand. These accidents are as folloAvs : exhaustion, hernia, prolapsion of the umbilical cord, Jtemorrhage, convulsions, multiple pregnancy. 1. Exhaustion.—The young practitioner, Avhose experience in THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 459 the lying-in room has of course been limited, must be on his guard touching this word exhaustion ; it is a very equivocal term ; unless properly defined and thoroughly appreciated, it will oftentimes lead to erroneous decisions. In order that you may have a clear understanding of its true import, and of the indications it involves, I shall divide it into tAvo forms—relative and positive exhaustion. For practical purposes, this is, I think, a sound and important divi- sion, and if a just distinction be made betAveen these tAvo grades of exhaustion at the bed-side, all possibility of embarrassment AviU be at an end. Relative Exhaustion.—I have scarcely ever attended a case of labor, unless its duration was extremely brief, in Avhich, during the throes of parturition, and more especially during the expulsive effort, the female did not exclaim, " Oh! lam so weak, I shall die if I have another pain." This, or something kindred to it, is, I may say, the stereotyped language of the parturient woman. Xow, gentlemen, if you give this phraseology a literal translation, if you take your patient at her Avord, you Avill at once conclude that a storm is gathering, and, in your anxiety to do something, you may be guilty of officiousness, which will be quite likely to compromise the safety of the Avoman and her child, and do no great credit either to your judgment or skill. When you reflect, for a moment, on the seA^ere sufferings occa- sioned by childbirth, and the commotion to which the nervous system is subjected during a forcing labor-pain, you can readily conceive Avhy all this should beget a feeling of momentary prostra- tion, causing the female to believe that the recurrence of another pain Avill utterly annihilate her! Put how delusive this opinion of the patient, Avhose standard of danger is the amount of physical suffering she endures. Not so, however, Avith the enlightened accoucheur, whose duty it is to distinguish between fiction and reality, and to arrive at conclusions not from mere appearances, but from substantial facts as they may present themselves to him in the aggregate. The testimony of the patient, under the circumstances of which Ave speak, is the testimony simply of feeling, and not of judgment, and therefore it becomes useless as a guide for practice. As soon as the pain has passed over, the poor woman, Avho a moment before Avas admonishing every one about her that she Avas exhausted and Avould certainly die, not only becomes tranquil, but engages in conversation, and even Avill laugh Avith good heart at a merry jest, Avhich the accoucheur of tact will know so Avell how to introduce for the purpose, as it Avere, of detaching her mind from herself, and giving it temporary occupation in some other channel. Again: the pulse is good, the countenance is not haggard, there is no evi- dence Avhatever of a dilapidated condition of the vital forces—in a word, the prostration of Avhich the patient complained, and Avhich 460 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. she supposed to be the harbinger of inevitable death, is but the flitting of the April cloud over the sun, causing for the instant a slight obscurity, in order that the glorious orb may become still more effulgent. This, gentlemen, is what I term relative exhaus- tion, and is entitled to no consideration whatever, so far as being an indication for interference on the part of the practitioner. Positive Exhaustion.—Positive exhaustion, however, is alto- gether a different thing, and, except through opportune and skilful interference, will inevitably lead to death. Here there is no ima- gination, no fiction—all is a solemn, emphatic reality. The patient, after a pain, does not rally. The sunken countenance, flickering pulse, the cold and clammy perspiration, the pallor of the general surface, indicate Avith unerring certainty that the system is at a Ioav etb_that it is fast approaching utter dilapidation. There is no, or, if any, but a momentary response to stimulants. The forces Avill not react. In these cases, Avhich fortunately may be regarded as rare, eA-ery successive pain has a direct tendency to increase the prostration, and if something be not promptly done to meet the emergency, the patient sinks. This something consists in delivering her Avithout delay. Should the head of the child have passed through the mouth of the uterus, or be in the pelvic excavation, recourse should be had to the forceps. If, on the contrary, the head be still at the superior strait, and the mouth of the womb sufficiently dilated to permit the introduction of the hand, the alternative is version. The particular reasons for this choice will be fully stated Avhen Ave speak of the indications and rules for turning. Ilernia.—If a woman in labor be affected with hernia, Avhether it should have pre-existed, or be the result of extreme uterine effort, it will equally need the attention of the accoucheur. For example, suppose a case of femoral hernia: each successive pain may so increase the protrusion, as to give rise to the apprehension of its becoming strangulated. This latter contingency Avould necessarily subject the life of the patient to more or less hazard. In all cases, therefore, of hernial protrusion, one of the first duties of the prac- titioner should be, if possible, to reduce it, and then, by judicious support, to prevent its return. If, hoAvever, the hernia become irreducible, and increase during the pains of labor so as to place in jeopardv the safety of the patient, common sense at once tells you that the broad indication is to proceed without delay to artificial deliverv, according to the rule to Avhich Ave have just referred under the head of positive exhaustion. Prolapsion of the Umbilical Cord.—This a very serious com- plication of labor, not that it subjects the life of the mother to any hazard, for it in no Avay compromises her safety ; but it is of extreme danger to the child. Mortality and Frequency.—According to the statistical tables of THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 461 Dr. Churchill,* in 722 cases of prolapsion of the funis, 375 children were lost, or more than one half. Many of the cases, however, it must be remembered, are taken from the records of Hospital prac- tice, and as a large number do not seek admission until some time after the occurrence, when the chance of a safe delivery is dimi nished, and some not until the cord has ceased to pulsate—it folloAV that this mortality cannot be regarded as a true exponent of the results of private practice. In 152,574 cases, prolapsion of the cord occurred 629 times, or about 1 in 218. You observe, therefore, from these tables tAvo facts: 1. That prolapsion of the cord is hap- pily not of very frequent occurrence. 2. That it is extremely fatal, proving destructive to the child in more than one half of the cases. Causes.—There are certain causes, Avhich strongly predispose to this accident, and may be enumerated as folloAvs: a pelvis, Avhich is preternaturally enlarged ; the insertion of the placenta near the mouth of the uterus; a cord, Avhich is longer than ordinary ; the sudden escape of the liquor amnii, especially Avhen this latter is in unusual quantity; a shoulder, foot, or breech presentation, thus affording more space for the prolapse of the funis, and because, also, in these latter presentations the fcetal extremity of the cord is nearer the inferior portion of the uterus; a contracted brim, preventing the descent of the head, and consequently predisposing the cord to pass into the vagina. To these may be added obliquities of the uterus, the tendency of Avhich would be to incline the presenting portion of the fcetus toward one or other of the borders rather than toward the centre of the superior strait, which would necessarily from the increased space predispose to a descent of the cord. Pro- lapsion of the funis is more frequent in Avomen Avho have borne several children than in the primipara, and this arises from the fact that, in the former, the uterine Avails have measurably lost their tenacity, and are more relaxed, and, therefore, facilitate the pro- lapsion. The above are some of the more prominent causes, which fiwor this complication. Diagnosis.—The diagnosis is not difficult, and may occasionally be determined before the rupture of the bag of waters, although, as a general rule, it is more readily arrived at after the escape of the liquor amnii. In the former instance, the cord may be felt, during the interval of the uterine contraction, through the membranes, and the fact that Avhat you feel is the cord may be ascertained by the important and characteristic circumstance that the pulsations are not synchronous or in accordance Avith those of the maternal heart, but are much more rapid.f Consequently, this * Churchill's Midwifery, 4th London Edition, p. 454 f Scanzoni notes an interesting circumstance which, without an explanation, might lead to incorrect diagnosis, viz. that the umbilical arteries, before entering the cord, may pass for a greater or less distance along the membranes—insertio funiculi 462 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. will demonstrate very unequivocally that the beatings, if any be felt, are not connected with the arterial system of the mother. The same rule will enable you to distinguish betAveen the pulsa- tions of the umbilical arteries, and those ramifying on the lower portion of the uterus. After the rupture of the membranous sac, the loop or fold of the prolapsed funis can be distinctly recognized by the touch, and, therefore, all doubt as to the nature of the diffi- culty will be remoA'ed. Cause of Death in Prolapsion of the Cord.—What is it that causes the death of the child in prolapsion of the funis ? This is a question about AA'hich there has existed a difference of opinion. Some haA^e supposed that it Avas in consequence of the blood becom- ing coagulated in the descended portion of the cord ; but it is noAV very generally conceded that death ensues from the compression exercised upon the funis, thus interrupting the circulation betAveen the mother and child. One moment, if you please, upon this point of compression, and arrest of the circulation. You are not hastily to conclude, because the circulation is arrested, that, therefore, the child must necessarily be destroyed. It Avill sometimes happen that no pulsations can be detected in the cord for several minutes; the labor may advance, and by a change of position in the present- ing portion of the foetus, the compression Avill be removed, and the circulation re-established. It is well, therefore, to remember that compression of the cord, with an absence of pulsation, does not, as an inevitable consequence, imply that there are no longer any throes of the fcetal heart. Dr. Arneth, of Vienna, mentions four cases under his notice, in Avhich no pulsations had been detected in the cord for half an hour previous to delivery, and in each instance the child Avas born living. From what has been already stated touching the fatality of this complication to the child, it AA'ill become a paramount duty, in all cases of funis protrusion, at once to announce, not to the patient herself, but to her husband or some other relative, the apprehen- sions you experience as to the safety of the foetus. In doing this, you will have done nothing more than your duty; and Avhether the child be saved or perish, you will have liberated yourselves from all responsibility, which concealment of the fact Avould have im- posed. Frankness is an essential and very necessary element in the character of a medical man ; and while the object of his pro- fession is to save human life, and palliate human suffering, yet it is equally incumbent upon him, when he finds himself surrounded by dangers placing in imminent peril the safety of his patient, can- didly to disclose to those most interested in the issue of the case his doubts and fears. umbilicalis velamentosa—so that their pulsations may be felt, and yet the cord not be prolapsed. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 463 At what Period of Labor is Prolapsion most likely to Occur?— Prolapsion of the cord may occur at any period of labor—before the os uteri is much dilated, after it is fully dilated, or before and after the escape of the liquor amnii. The tendency of its descent, hoAvever, is greater after the rupture of the membranous sac, and this circumstance, therefore, is an additional motive Avhy great caution should be exercised not prematurely to interfere Avith the integrity of the bag of Avaters. Treatment of a Prolapsed Funis.—What is to be done in cases in Avhich the cord is prolapsed ? This is an interesting interroga- tory, and is worthy of consideration. If you imagine that the mere prolapsion of the umbilical cord is an indication for inter- ference on the part of the accoucheur, you will labor under serious error, and be quite likely, Avith this vieAV of the subject, oftentimes to do mischief. There are three conditions in Avhich this accident may present itself, each A'arying from the other, and requiring a different kind of management: 1. There may be no pulsations, and, at the same time, irresistible evidences of the death of the fcetus from incipient decomposition of the cord. 2. The pulsations may continue strong and vigorous, showing that there is as yet no undue compression. 3. The pulsations, from being strong and vigorous, may become more and more Aveak, indicating that the pressure exercised upon the cord is endangering the circulation betAveen the placenta and foetus. If you will bear in mind these three conditions, and give full appreciation to each one of them, your duties in this form of com- plication will not only be simplified, but Avhat is very important they will be Avell defined. In the first place, therefore, if no pul- sations be detected, and there be palpable evidence that decompo- sition of the cord has commenced, then the proof is positive that the child is dead. Under these circumstances, it Avould be unne- cessary for the accoucheur to interfere ; on the contrary, the labor, all other things being equal, should be confined to the efforts of nature, for you have already been told that, in funis presentations, the only danger is to the child, the safety of the mother being in no Avay involved. Surely then, the important fact being ascer- tained—the death of the child—it would not only be uncalled for, but altogether unjustifiable to have recourse to artificial delivery, unless there be some circumstance, other than the prolapsion of the cord, rendering interposition necessary. Secondly, as long as the pulsations in the cord are strong and A'igorous, there is no indi- cation of peril to the child, for the reason that the true element of danger consists in the interruption of the circulation through com- pression. While, then, the force of the pulsations is natural, it is 464 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. manifest that there is no undue compression ; therefore, it is unne- cessary to do more than merely place the cord—if it should have fallen beyond the vulva—high up in the vagina, for the purpose of protecting it from exposure to the atmosphere. The third condi- tion, hoAvever, presents different indications, and something must be attempted to prevent the effects of the compression, which are shoAvn by the fact that the pulsations lose their ordinary force, and become more and more Aveak. Here, if the compression continue, there is very serious hazard to the child, and noAV the question arises—What, under the circumstances, is to be done ? Much has been said about the reposition of the prolapsed funis, and, Avith a view to accomplish this object, numerous instruments have been constructed. I have very little confidence in any of these contrivances. They may sometimes succeed in dexterous hands, but very frequently they fail; and, more than this, the very attempt made to replace the fallen cord is oftentimes followed by injury, not only to the cord itself, but to the adjacent soft parts. It is amusing to hear some persons talk of the facility with which the reposition of the funis can be effected by the aid of these con- trivances. Put, gentlemen, it is one thing to talk, and quite another thing to act. I have knoAvn many a plausible theory to give Avay and prove utterly negative, Avhen tested at the bedside of the patient. The very best instrument, in my opinion, for replacing the cord, is the fingers of the accoucheur. Let the middle and index fingers be gently introduced Avithin the vagina; they are thus brought in contact with the fold of the cord ; this latter should be directed tOAvard one of the lateral and posterior points of the pelvis—most frequently tOAvard the left sacro-iliac symphysis, for the reason that at this point there is usually more space, in conse- quence of the greater frequency of the first vertex position of the head. In this Avay it is sometimes possible to replace the cord within the uterus, and thus remove the compression to which it has been subjected. If this can be done, much good will have been accomplished, and the labor may then be committed to the resources of nature. It must be recollected that the attempt to replace the cord should be made only when the os uteri is well dilated, the head or presenting portion of the fcetus at the superior strait, and not after it has passed into the pelvic excavation. In this latter case, we have a more efficient and prompt remedy in the immediate delivery of the child by the forceps.* * I should not omit to mention an ingenious plan, suggested by Dr. T. Gaillard Thomas, for the reposition of the cord. It consists essentially in what he terms postural treatment. The woman, in case of funis prolapsion, " is placed on her knees, with the head down upon the bed " Dr. Thomas observes " that the causes of this accident (prolapsion of the cord) reduce themselves to two, the slippery nature of the displaced part, and the inclined plane offered it by the uterus, by THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 465 According to Dr. Arneth, the funis is always replaced in the Vienna Lying-in Hospital Avhen the operation is practicable. The plan adopted, when the head presents, and is movable at the brim, the os uteri being fully dilated, is to push the funis upward, and lay it in the hollow of the neck of the child. There are forty- three cases recorded in the hospital register of this reposition, and in thirty-eight the children were born alive; in three of the remainder, the cord Avas almost pulseless when returned; in one instance, the forceps Avas resorted to in consequence of inertia of the uterus. Put suppose the reposition of the funis cannot be brought about, are we then to do nothing ? To remain satisfied with the failure to replace the cord, and to consider the abortive attempt as the full measure of your duty, when the evidences of compression are beyond all peradventure, would be to consign the child to great peril, if not to certain death. Such conduct would not only be highly reprehensible, but Avould very properly subject you to merited rebuke, unless you had a good and justifiable reason for non-interference. There are tAvo alternatives to which recourse may be had in a contingency of this kind—version and delivery by the forceps. It is extraordinary that there should exist among Avriters on mid- Avifcry such diverse opinions touching the propriety of these two alternatives ; and it is equally unfortunate for the young accoucheur that these opinions should be recorded in the books, Avhich are supposed to contain correct rules of practice, and, therefore, regarded safe guides in the hour of doubt and embarrassment. One author, for example, inculcates the necessity of proceeding at once to the termination of the delivery by version "if the child be liA'ing, and the presenting part remain high up in the pelvis." The language just quoted is that of Denman, Avhose name deservedly carries Avith it great Aveight. Xo less an authority on the general question of obstetrics, Dr. DeAvees, of whom our country has reason to be proud, holds that " Turning may be had recourse to, if the uterus be sufficiently dilated or dilatable for the operation, the head being still inclosed Avithin the uterus, and there is no deformity of the pelvis." I might array before you the names of other dis- tinguished men in favor of the operation of turning, as a conserva- tive measure in prolapsion of the cord. Put to do so, Avould, I apprehend, be of little moment. It is more important, I think, to examine, for the instant, the universal propriety of the rule incul oated. which to roll out of its cavity; and, second, that the only rational mode of treat- ment would be in inverting this plane, and thus turning to our advantage not onlj it, but the lubricity of the cord, which ordinarily constitutes the main barrier to ouj success. [Transactions New York Academy of Medicine, Vol. II., Part II.] 30 466 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. The ostensible and only justifiable argument in favor of version in cases such as are iioav under consideration, is that it will afford the child the best means of safety. Put while, on the other hand, we are prompted to do so much for the child, we are not to forget that the safety of the mother has claims equally urgent, Avhich cannot be lightly regarded by the accoucheur. How often is the life of the mother involved in peril in the operation of version, and hoAV often, alas, does this peril terminate in her death ! You see, therefore, that in selecting the alternative you must be governed not by the abstract fact that the funis is prolapsed, but by a due consideration of all the surrounding circumstances. You are to consider Avhether, in full vieAV of all the facts of the case, turning presents the greatest promise of safety to the child, Avithout com- promising the life of the parent. If my own opinion be worth anything on this question, I should advise you, no matter how imminent may be the danger to the child, never to have recourse to version, except under the folIoAAnng conditions : 1. The head at the superior strait not having descended into the pelvic excavation; 2. The mouth of the uterus soft and dilatable, readily permitting the introduction of the hand ; 3. The pains must not be characterized by great vigor, for this would not only be a serious obstacle to the introduction of the hand, but would prove a substantial ground Avhy version should not be attempted, for the reason that efficient and regular contractions Avould be likely to terminate the delivery more rapidly than it could be done by turning; 4. There should be no pelvic deformity, or, at all events, very slight. It must also be borne in memory, that, in version, the child is not unfrequently. sacrificed, and often- times its death is traceable purely to compression of the cord during the manipulations, necessary to the accomplishment of the opera- tion. If the head should haA'e passed into the pelvic cavity, and more especially if it should have reached the inferior strait, then the indication would obviously be to deliver Avithout delay by the forceps, care being taken so to adjust the instrument as not to make pressure on the cord. Hemorrhage.—Hemorrhage or flooding before the birth of the child, Avill constitute, under certain circumstances, an important cause of artificial delivery. Your attention has already been directed to hemorrhage after the birth of the foetus; Ave shall now speak of this accident as it sometimes presents itself previously to the expulsion of the child. As associated, therefore, with the question of ante-partum flooding, we shall proceed to consider that form of it, Avhich is more or less directly connected with placenta praevia. Py a a pr:i7 deaths iu 938 cases, or 1 in 3'95. The mor- tality after turning, according to Prof. Simpson, is 144 in 421 cases or 1 in 2'9 ; that afford.si by l'rof. Trask's record is 1 in 3 4. 472 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. fortify a perturbed spirit, and reanimate a drooping heart! It is highly necessary that constipation should be guarded against, for the very act of straining in the effort at defecation will have a ten- dency to increase the bleeding. Under the circumstances, should a movement be indicated, I should greatly prefer to enemata, the fol- lowing solution, a tablespoonful of Avhich may be taken once in two hours, until an aperient action is produced : Sulphat. magnesiae 3 i. Infus. fol. Rosar. f. § viij. Ft. sol. This is a combination, Avhich I have employed with signal advan- tage in cases such as AA'e are now considering. The patient should be restricted to cold drinks, nothing better, if it agree with the stomach, than iced lemonade. The diet bland and unstimulating. After the bowels have been gently acted on, I have recently experienced in two cases, in which the hemorrhage occurred at the sixth and seventh months respectively of gestation, decided benefit from the administration of the sulphate of the peroxyde of iron, the haemo- static properties of which are noAv well established; from five to fifteen drops, three times a day, in a Avine-glass of cold water. To prevent injury to the teeth it should be taken through a glass-tube. One point you are not to neglect—when the bowels are to be moved, or the urine evacuated, a bed-pan must be employed. On no account is the patient to be permitted to use the chair; the very effort may be folloAved by serious trouble in consequence of in- creased hemorrhage. Well, these are the preliminary measures to be adopted; but suppose the bleeding, notwithstanding these measures, should continue, and so profusely as to affect the strength of the patient, and involve apprehensions as to the general issue. Then, in addition to Avhat has already been suggested, it Avill be proper for you to institute a careful vaginal examination with a view of ascertaining the condition of the os uteri, which will either be sufficiently dilated to enable you to accomplish delivery, or it will not be so dilated. In the latter case, the bleeding continuing in exhausting profuseness, and the os uteri not at all or but slightly dilated, you have an important remedy in the tampon. I cannot understand why some clever and practical authors are opposed to the employment of the tampon in an emergency of this kind, for the arguments they urge are certainly, in my judgment, without the slightest basis. As a principal objection, they maintain that this instrument will be likely to produce internal hemorrhage, and thus destroy the patient. Those who raise this objection do so, I think, Avithout sufficient thought, for it is quite evident that although internal flooding might possibly follow the employment of I THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 47S the tampon in accidental hemorrhage, yet there is no ground for apprehension that it will ensue in placenta praevia, for the reason that the bleeding surface is below, and the blood does not accumu- late within the cavitg of the uterus, but collects between the tampon and that p>or tion of the cervix from ichich the placenta has, in part or totally, become detached. So far, therefore, from this agent prov- ing injurious, I regard it as one of the most efficient alternatives to Avhich, under the circumstances, the accoucheur can have recourse. The very principle, too, on which the tampon exercises a salutary influence is one, Avhich is directly opposed to the occurrence of internal hemorrhage ; for, by a uniform and gentle pressure, it causes a coagulum which acts for the time as a check to further loss of blood. Thus, you see, you possess in this agent an admirable tem- porary remedy. If the os uteri be undilated, and the bleeding con- tinue profusely, the patient must of necessity sink unless there can be something to hold it in check. For this purpose, I repeat, my great faith is in the tampon, or plug, as it is sometimes called. Now, an important question arises—Hoav long is the plug to be employed ? My ansAver is until the os uteri is sufficiently dilated to enable you to introduce the hand, turn, and deliver. Version I hold to be the cardinal remedy in placenta praevia, if the head of the foetus be still at the superior strait, and the mouth of the Avomb will alloAV the introduction of the hand ; on the con- trary, if it should have descended into the pelvic excavation, the indication is at once to resort to the forceps. Put how are you to knoAV—if you employ the tampon—that the os uteri has undergone dilatation sufficient to justify artificial delivery ? This fact can only be ascertained by occasionally removing the tampon, and making a digital examination; the time as Avell as the necessity for doing this should be regulated by the frequency and character of the pains. There is an additional advantage in the employment of the plug, and it is this—its very pressure against the lips of the uterus Avill excite action of the organ, and thus promote contractions Avhich, of course, Avill tend to hasten the opening of the os, an object so desirable in cases such as we are noAV discussing. The tampon may consist of small pieces of old linen, or fine sponge, or Avhat is still better, if at hand, carded cotton-wool—and they should be gently introduced into the vagina, piece after piece, until the entire passage is filled—the Avhole to be retained in place by means of aj bandage. There are several modes of introduc- ing the plug. I adopt the following: the index finger of one hand being introduced into the vagina, the palmar surface upward, I seize Avith an ordinary calculus forceps a small piece of the mate- rial to be employed, and direct it along the finger as far as the os uteri, against which I exert slight pressure; and so suc- ceeding pieces are introduced until the canal is quite filled up. 474 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. When necessary, they are to be removed, and replaced by other pieces. An efficient tampon will be the india-rubber bag, filled with ice- water (the colpeurynter). Let us hoav suppose that, on AvithdraAving the plug, it should be ascertained that the mouth of the womb is soft and dilatable, per niitting the introduction of the hand Avithout the fear of violence; hoAV are you to proceed AA-ith the delivery ? I recommend, in case you should undertake the version of the fcetus, to proceed as folloAvs : Carry your hand cautiously through the vagina to the mouth of the uterus —here, of course, you come in contact Avith the placenta, which is resting, more or less, over this portion of the organ. In a Avord, it occludes the opening through which your hand is to enter the uterine cavity. Make a slight circuit Avith your finger around the dilated os, and if you can find a portion of the placental surface which has become detached from the cervix, then, Avithout hesitation, select this as the point of entrance, and immediately introduce the hand for the purpose of bringing doAvn the feet. Put, on the contrary, if you cannot detect the point at which the detachment has occurred, then my advice to you is at once to carry the hand immediately through the body of the placenta;* having thus gained admission into the cavity of the uterus, seek for the feet, bring them doAvn, and thus terminate the delivery. What is there objectionable in this practice ? You must remember, in the first place, that tAvo lives are in serious peril—time here is everything, and the sooner the deli- very is accomplished, the greater will be the chances of safety to both mother and child. If, therefore, by prompt and successful extraction of the foetus, you cause the uterus to contract—and this, under ordinary circumstances, will be the natural result—have you not, by .thus efficiently closing the mouths of the utero-placental vessels, achieved the very object most essential to the safety of mother and child—the permanent arrest of the hemorrhage ? As I have already stated, the true and only danger of placenta praevia is in the losses of blood it occasions. Therefore, is it not the part of Avisdom, the moment the opportunity occurs, to do that very thing Avhich, under the contingency, is most likely to accom- plish the greatest amount of good—the prompt withdrawal of the foetus from the uterine cavity ? I think so, and it is for this sub- * I am aware that in this advice I differ with most of the standard authorities; but I am quite sure I am right. The objections urged by them to the practice inculcated are two-fold: 1st, The difficulty of penetrating the placenta ; 2d, The increased risk to the child from lacerations of this body. In reply to the lfrst objec- tion, I need only say that I have encountered very little difficulty in penetrating the mass; and to the second, I would simply remark that the child is exposed to the most imminent peril by delay, and the best alternative in these cases is immediate delivery. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 475 stantial reason that I commend the practice just alluded to. With a due degree of caution, the well-instructed accoucheur, as soon as he has seized the feet of the child, and during the progress of his tractions, Avill be enabled to guard against inertia of the uterus, and having accomplished the delivery of the fcetus, he will, through proper attention to his duties, have the gratification of finding the source of the hemorrhage arrested by the proper contraction of the organ. Put suppose you deem it necessary to thrust your hand through the placenta, or you should be enabled to detect a portion of its border separated from the cervix, and select this as the point of entrance into the uterine cavity, in either case the interesting question arises—What are you to do Avith the placenta? My advice is—to pay no sort of attention to it; bring down the feet, deliver the child, and then, if the exptdsion of the after-birth should not promptly follow, carry up the hand and bring it away. Artificial Detachment of the Placenta.—It is proper that I should here allude to the plan of artificial detachment of the pla- centa, suggested by Dr. Simpson. This eminent practitioner, in cases in AA'hich turning cannot be had recourse to, inculcates the practice of separating the after-birth from its surrounding attach- ments ; and he seems to have been led to this mode of procedure from contrasting the diminished mortality in cases in Avhich the placenta Avas spontaneously detached and expelled previously to the birth of the child—it being much less than under the operation of version. It does seem to me that Prof. Simpson, in his estimate of artificial separation, has not taken sufficiently into view the wide difference betAveen spontaneous and artificial detachment. The former is the Avork of nature—the act she accomplishes through the force of uterine contraction, and it is, also, through these very contractions that the mass, after being spontaneously detached, is in the same manner expelled. It is not strange, therefore, that, under these circumstances, this spontaneous effort of nature should prove an admirable haemostatic adjuvant in the profuse bleeding of pla- centa praevia. Does not the very same thing occur in ordinary labor, so far as the separation of the after-birth is concerned ? Pray, hoAv is this mass detached, no matter Avhere it may be situated Avithin the uterine cavity, except through the successive contractions of the organ ?—And do not these very contractions, because they are in perfect consonance with the mechanism of nature, guard the parturient woman against an attack of hemor- rhage ? Put suppose, Avith a view of illustrating this point more fully, the accoucheur, after the birth of the child, should attempt, by premature and forced tractions on the umbilical cord, to hurry the operations of nature, and thereby cause an artificial detach- ment ; Avould there not, as a necessary consequence, in ninety-five cases out of one hundred, be more or less profuse bleeding ? fjn- 476 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. doubtedly such would be the result, and there is, in my judgment, a striking analogy betAveen the tAvo instances. Prof. Simpson is also of opinion that the detached portion of the placenta constitutes almost exclusively the bleeding surface, and it is mainly on this hypothesis that is founded the practice he recommends ; but if he be right in this conjecture, hoAV are Ave to explain the occurrence of profuse post-partum hemorrhage after the placenta has been expelled? Will it be argued that, in pla- centa praevia, AA'e have one kind of bleeding surface, and in hemorrhage after the expulsion of the after-birth, another ? The great bleeding-suriace, as I haA'e already told you, consists essentially of the utero-placental vessels, and is, therefore, strictly uterine, and not placental; at least it seems to me that this is the main source of the hemorrhage the quantity of blood passing from the separated portion of the after-birth being quite insignifi- cant. The view that the hemorrhage is derived almost entirely from the detached portion of the placenta, and not from the utero- placental vessels, Avas also maintained by the late Professor Hamil- ton, of Edinburgh.* It is proper, hoAvever, to remark, that the opinions Avith regard to the source of the hemorrhage in placenta praevia are conflicting, although the general belief is that it is derived from the uterus. Without mentioning other authorities, it may be well to state that Dr. Pobert Lee, of London, is one of the sturdiest advocates of the doctrine that the blood proceeds from the uterine sinuses, AA'hileDr. Radford, of Manchester, believes that it comes both from the placenta and uterus, although the larger quantity is furnished by the latter organ. One thing, hoAvever, is very certain, that the treatment of pla- centa prsevia—more especially since the suggestion of Professor Simpson of detaching the placenta as a remedial resource—has pro- voked a Arery bitter controversy—indeed, in some instances, the contest has assumed unmistakable evidences of Avhat, in plain lan- guage, may be called strong personalities, a feature ahvays to be avoided in scientific discussions. In the fierce conflict of the political arena, such episodes are more or less in keeping Avith the subject-matter, but they should find no foothold in a profession like ours, intended, through the development of truth, to confer health and blessings on the human family. Dr. Parnes, so well knoAvn through his important contributions to obstetric science, is opposed to any attempt at forced effort for the purpose of detaching the placenta, and we are happy to find him so conservative on this interesting point. Nothing, in my opinion, will justify a forcible introduction of the hand into the uterine cavity—for violence, under these circumstances, will incur * Practical Observations, 2d Ed., p. 312. TnE PRINCIPLES AND PRACTICE OF OBSTETRICS. 47? the serious peril of rupture of the organ—and Avell may it be asked cui bono? I Jut Dr. Parnes, Avhile opposed to artificial detachment of the entire placental mass, strenuously inculcates the advantage of partial artificial separation as a means of arresting the hemorrhage. It strikes me, hoAvever, that by thus increasing the area of the bleeding surface, Ave must necessarily increase the profuseness of the hemorrhage. His arguments are quite ingenious, and his essay Avell Avorthy of attention ; * but it does really appear to me, after a careful perusal of his excellent monograph, that the lesson he teaches is not without objection. At all events, I may be per- mitted to express the opinion that the views of Dr. Simpson Avith regard to the entire separation of the after-birth, and those of Dr. Parnes touching its partial detachment, are questions to be deter- mined, not by the reasoning of clever minds, but by the positive results in practice, which the future may disclose, either affirma- tively or negatively. The plan of artificial detachment of the placenta Avas suggested to Dr. Simpson from a consideration of the high mortality of the operation of turning compared with that following cases of sp»onta- neous detachment or expulsion of the placenta previous to the birth of the child ; the mortality in the latter case being but one in fourteen. Cessation of hemorrhage took place in these cases imme- diately, for the most part, upon the detachment of the placenta; and believing that the same result Avould foliow its artificial detach- ment, he suggested this as a resort in all cases of labor thus com- plicated, in Avhich, from rigidity of the os uteri, or extreme exhaus- tion of the patient, turning could not be prudently resorted to. It has been objected to Dr. Simpson's statistics, that they embrace cases not adapted for comparison, including, as they do, cases occurring at every age, subjected to every variety of treat- ment, and some to no treatment at all; also cases complicated with rupture of the womb, convulsions, contracted pelvis, tfec. To meet this objection, Prof. Trask, in his essay already alluded to, has collected all the published cases to Avhich he had access, together Avith others communicated to him. He has analysed them Avith a vieAv of presenting, as far as possible, the influence of various circumstances and conditions of the patient in determining a suc- cessful or fatal result. Anxious to give the reader the benefit of Dr. Trask's researches, and of affording Prof. Simpson the full benefit of his conclusions, I shall briefly allude to some of the most interesting and important, which are as folioavs: "The teachings of the best authorities are confirmed, that the period of greatest danger is betAveen the seventh month and the completion of pregnancy. Of the presentations in the 353 cases, 113 Avere of the head, or the head complicated Avith descent of the * The Physiology and Treatment of Placenta Previa. By Robert Barnes. 1857 478 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. funis or hand; _1 of the superior extremity; 22 of the pelvic extre- mity, and 2 of the umbilicus ; the remainder Avere probably, for the most part, of the head, but the proportion of unnatural presentations is Aery marked. " From Table I., embracing cases subjected to ordinary modes of treatment, or dying undelivered, Ave learn that there Avere 141 recoveries and 59 deaths, or a mortality of 1 in 3.4." The influence of hemorrhage previous to delivery in affecting the result is thus shoAvn: "If we now compare the 84 cases in Avhich the hemorrhage Avas Arery severe, among the recoveries after artifi- cial delivery, Avith the 12 in Avhich it was moderate, Ave find the cases of ' moderate' bear to those of profuse hemorrhage the pro- portion of 1 in 8 of the whole. Among the fatal cases after artifi- cial delivery, the proportion of moderate to severe hemorrhage is 3 in 47, or about 1 moderate to 16 severe. Of cases requiring arti- ficial delivery as a whole, there Avas 1 case of moderate to 11 of severe hemorrhage, Avhile of those delivered spontaneously there was 1 moderate to 5£ seA'ere. There is also a correspondence between the degree of presentation and the necessity for artificial delivery. Among cases of spontaneous expulsion of the child, there Avas a much larger proportion of partled presentations, and, as a consequence, less hemorrhage, and therefore a loAver rate of mortality. " Adding the cases of Drs. Lever and Merriman to the cases in the table, we get a total of 96 saved, and 166 lost, or 1 in 2.7 of the Avhole saved. The mortality to the child in the cases of the practi- tioners of Ilesse-Cassel is even greater, 85 having been born living, and 251 dead, or 1 3.9 of the whole saved. "Table II. embraces 36 cases of spontaneous expulsion of the pla- centa; in these but 2 deaths are noted, both from diarrhoea subse- quent to labor." Dr. Trask adds to his cases others recorded by Dr. Simpson, and of the whole, 59 required manual assistance, while 78, or 57 per cent. were delivered by natural effort. Of cases embraced in the first table only 17 per cent, were delivered spontaneously; the inference is that " cases in which the placenta is expelled before the birth of the child, as a class, are characterized by a tonicity of the Avomb and a vigor of uterine contraction which Ave do not find in ordinary cases of the accident." There were 140 recoveries and 11 deaths, or a mortality of about 1 in 14. Dr. T. next proceeds to inquire what success has attended artificial detachment of the placenta, as an exjiedient for putting an end to hemorrhage. " In Table III. are recorded the histories of 66 cases. The mortality of cases thus treated is stated to have been 1 in 4.6. The gross mortality, after its performance in the cases composing this table, is therefore someAvhat less than the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 479 general mortality under ordinary modes of treatment, and espe- cially after turning ; but it is very much greater than after sponta- neous expulsion of the placenta. In explanation of this, our author proceeds to show that the proportion of complete presentations Avas considerably larger among these than among cases constitut- ing the first table ; that the proportion of cases in which the hemorrhage was very alarming Avas much greater, and that alarm- ing exhaustion occurred in a much larger relative number than among cases in the first table. In other words, cases in which detachment was resorted to were, for the most part, at the time of the operation in a far less favorable condition for recovery than Avere the cases in which artificial delivery Avas resorted to. This circumstance is, of course, entitled to great weight in comparing the results of the tAvo modes of practice. " About one in three of these cases was delivered by spontaneous expulsion of the child, a much larger proportion than among cases of the first table. This fact, Avhich is apparently at variance with the statement as to the unusual severity of the cases we are consi- dering, receives a happy explanation in the following facts. In the spontaneous deliveries, after spontaneous separation of the placenta, the child folloAved the placenta, in more than half the cases, in ten minutes or less, Avhile in the spontaneous deliveries after artificial detachment, the child followed the placenta after a more or less protracted interval. In the first case the contractions of the womb expelled placenta and child nearly together, but in the cases of artificial detachment, the hemorrhage having ceased in consequence of the detachment, the vital poAvers have rallied, and, at A'arious intervals from one-half hour up to eighteen hours, have expelled the child. " This table gives abundant eA'idences of the haemostatic poAvers of artificial detachment. Of 66 cases, in 35 hemorrhage ceased immediately and entirely, and in the remainder, Avith scarce an exception, it continued but a short time and in triflino- degree. " Fifteen children were saved and thirty-two lost, or a trifle less than one in three saved. It is evident that unless delivery soon folloAv this operation, the life of the child must almost necessarily be sacrificed. The result here given does not differ much from the results folloAAdng turning and spontaneous expulsion of placenta, in which a trifle less than one in three Avere saved. It is quite proba- ble that, as suggested by Dr. Parnes, the detachment, in at least some of the instances in Avhich the child was saved, had been only partially effected. " The plan of partial detachment, as recommended by Dr. Parnes, is designed to meet the objection to total detachment which arises from the peril in which it places the child; sufficient connexion 480 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. with the mother still remaining to alloAV of changes in the blood required by the child." Ergot—the secale cornuturn—is a remedy much employed by many practitioners in placenta 2wa?via. The Avell-knoAvn influence exercised by this agent in the production of uterine contraction has caused, I fear, a too indiscriminate resort to it. I have great conBdence in ergot, under its judicious administration, but I must protest against its empirical employment. I am opposed to its use in placenta praivia in the folloAving conditions: 1. If the mouth of the uterus be sufficiently dilated to enable the accoucheur to haA'e recourse to artificial delivery, the administration of ergot will, through the increased contraction it occasions, seriously interfere with the birth, whether it be accomplished by version or the for- ceps ; 2. If there be a cross-presentation of the foetus, then the remedy should not be given, from the very fact that the increased force of the uterus may, under the circumstances, cause rupture of the organ. On the other hand, should the presentation be right, and the hemorrhage continue, notAvithstanding the tampon, which sometimes may be the case, then I should advocate ergot, even if the os uteri were not dilated. Under ordinary circumstances, one of the fundamental condi- tions justifying a resort to this drug is—that the mouth of the Avomb shall have undergone a measure of dilatation. Put in the case under discussion I take exception to this rule, and for the very obvious reason that the os, although not dilated, will, from the quantity of blood lost, be more or less relaxed and dilatable; and, therefore, the action of ergot, in lieu of mischief, will, through the increase of contractile effort, promptly accomplish the required dilatation, and oftentimes most happily promote the delivery. One word regarding the rupture of the membranous sac in pla- centa praivia. If the hemorrhage be profuse, not controlled by the tampon, and the os uteri undilated, the rupture of the membranes will not be bad practice; for here, too, the os, though not dilated, is more or less relaxed in consequence of the depletion ; the escape of the amniotic fluid Avill impart activity to the contractions, and if it be found necessary, the moment it can be done, introduce the hand and terminate the delivery ; or, if the head should have passed into the pelvic cavity, the forceps Avill be the resource. Put Iioaa', in placenta praevia, Avith an undilated os uteri, is the sac to be rup- tured? The best mode of doing this, is cautiously to penetrate, by means of a small catheter, the placenta, and allow the fluid to pass off through the instrument. Accidental Hemorrhage.—The character of flooding, Avhich Ave have just been describing, is, as you have been informed, known as unavoidable, for the reason that it is in close relation with the implantation of the placenta over the cervix uteri. Accidental THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. 481 hemorrhage, on the contrary, is in no Avay connected Avith placen- tal presentation, but occurs when this body is in union AA'ith other portions of the uterus. It may present itself at any period during gestation, or at the time of labor. We have already spoken of this form of hemorrhage in the earlier months of pregnancy, when dis- cussing the interesting subject of abortion. To-day, Ave shall con- fine our remarks to accidental flooding in the later months, or second half of pregnancy, also, after the parturient effort has com- menced. The true pathology of this form of bleeding is a partial or complete separation of the placental mass from the internal sur- face of the uterus ; and the causes capable of inducing the detach- ment may be enumerated as folloAvs: premature contractions of the uterus; external violence, such as falls, bloAvs, carrying heavy bur- dens, etc.; mental emotion, sudden congestion of the womb, or undue pressure on the hypogastric region ; riding on horseback, or in a carriage, especially over rough roads or streets; among these causes, too, Ave are not to omit to mention the fascinating, but oftentimes dangerous polka and Avaltz. One of the severest, and, for the time being, most perilous exam- ples of accidental hemorrhage I have ever attended, was in the person of a lovely young married AA-oman, Avho, although in most other matters, a sensible and refined lady, Avas so Avedded to the dance, that, at a brilliant reunion, she could not resist the tempta- tion to " take a turn," though nearly seven months pregnant! In half an hour afterward, she was attacked with flooding, and the scene was soon changed. She was transferred from the gay hall of fashion to the sick chamber, which was near proving to her the chamber of death ! Py constant and untiring effort,! succeeded in carrying her to the eighth month of her gelation, and then was fortunate enough to deliver her of a living child. I doubt, with the sad experience of her folly, whether she will again, under simi- lar circumstances, be induced to "take a turn." It will occasionally happen that, from some morbid condition of the after-birth, a portion of it will become detached from the ute- rus, thus giving rise to hemorrhage. I have met with a fair share of such cases. A good observer, and an eminent practitioner, Dr. Pobert Lee, of London, maintains with much positiveness,'that another cause of accidental hemorrhage is a shortenino- of the cord by being twisted around the neck of the child, thus inducing a par- tial detachment of the placenta. With all the respect I entertain for this d.stinguished writer, and with, I hope, a due appreciation of his courtesy on my visit to London some five years since, I must say that my experience does not accord with his on this point I have seen many cases in which the cord encircled the neck of the child—indeed, it is by no means a rare occurrence—but I have never known a single instance of hemorrhage arising from this cir- 31 482 THE PRINCIPLES AND PRACTICE OF OBSTETRIC. cumstance. The thing, I admit, is possible, but not very probable, and for this reason, perhaps, it may be enumerated among the causes of the accident. Scanzoni also participates in the opinion of Dr. Lee on this point. There is one fact to Avhich I desire especially to direct attention, as an agent in the production of accidental flooding, and to Avhich L do not think authors have attached sufficient importance. I allude to habitual and obstinate constipation. I could cite more than one instance in which I am quite satisfied the violent straining induced by this condition of the boAvels has occasioned detachment of the placenta in some portion of its surface, and consequent hemorrhage. Therefore, remember it is essential, for this as Avell as for other reasons, that the bowels of the pregnant female be pro- perly regulated. Is it possible to confound accidental hemorrhage in the latter months of gestation with a discharge of blood altogether uncon- nected Avith a detachment of the after-birth ? This question is not without interest, and needs a moment's consideration; it necessa- rily involves the inquiry, whether a pregnant woman at this period of gestation can lose blood from the uterus, and the ovum preserve its full integrity of union with the organ. There can be no doubt that this may occur ; you have already been told that some women menstruate, although pregnant; again, certain morbid conditions of the uterus may give rise to hemorrhage, and none of more importance, so far as a correct diagnosis is concerned, than polypus or a sub-mucous fibrous tumor of the organ. The diagnosis in such cases would not be difficult, and it is scarcely necessary for me to dwell longer upon the point than merely to remind you of the possibility of such contingencies. The placenta may become detached in tAvo Avays, even when its separation from the uterine surface is only partial; for example, the detachment may be more or less slight at some point of its cir- cumference ; this is the ordinary form of separation, as connected with accidental hemorrhage, and the bleeding is usually not pro- fuse; it may occur several times during the pregnancy at an inter- val of some days, and it is generally of but little significance so far as the safety of the mother or child is in question. In these cases, rest in the recumbent posture, and a quiet mind, together Avith cold drinks at the time of the bleeding will generally suffice, and the patient be carried to the completion of her period. Yet a different state of things occasionally presents itself in this special form of placental detachment—the hemorrhage being most profuse, and menacing the lives of both child and parent. Here, the tampon should not be employed, for it cannot reach the source of the flood- ing, and its only tendency Avould be the conArersion of an external into an internal hemorrhage. If the bleeding should not yield to • THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 483 ' the means already cited—rest in the recumbent posture, elevation of the hips, cold drinks, etc., then there should be no scruple as to the course to be pursued—premature labor should be brought about Sometimes, the partial detachment of the after-birth, and the consequent hemorrhage, AA'ill be the result of premature contraction of the uterus, this being induced by some moral or physical cause. In such an event, the attention of the practitioner should be directed, if possible, to the lulling of these premature efforts, and for this purpose opium in some one of its preparations may be resorted to. I have great confidence in these cases in an opium suppository, one or two grains, introduced into the rectum, or thirty or forty drops of t lie tincture in a Avine-glass of tepid water thrown up as an injection. There is, hoAvever, another form of accidental flooding connected AA'ith partial detachment of the after-birth, most insidious in its inception, and at the same time fearful in its results—I allude to that condition of the placenta in which its entire peripheral border continues in union with the uterus, and the separation is limited to its central portion. Here there will be a species of pouch formed, into Avhich the blood will be pouring from the utero-placental ves- sels ; in this case, hoAvever, there is no external eA'idence of hemor- rhage ; the blood does not, for it cannot pass from the uterus. It is veritably a concealed or internal hemorrhage, and the work of death may be accomplished before the practitioner even suspects the cause of the danger. Indeed, I am much disposed to refer some of those cases of sudden and supposed inexplicable dissolu- tion, which occasionally occur in the latter part of pregnancy, to this jieculiar, but happily not common form of hemorrhage. As I have just remarked, the blood does not escape externally, and therefore you are deprived of this physical proof; the only and oftentimes fatal evidence of the central separation of the placenta will be the exhaustion of your patient; the face grows pale, the heart becomes Aveak in its pulsations, the countenance presents the appear- ance of serious dilapidation, and, if some check be not speedily given to the bleeding, the patient sinks. In instances like these there is ne- cessarily much embarrassment; and it is difficult to know AA'hat to do. Usually there are no striking premonitory symptoms, and the counsel of the practitioner is not demanded until the mischief is far advanced. If, hoAvever, you should be called to a case of sudden prostration in the latter months of gestation, unexplained by any antecedent circumstances, it will be well to think of the possible connexion between this exhausted condition and central detachment of the placental body; and if you should be satisfied that the rela- tion of effect and cause really exists, then, in my judgment, the only hope will be in the prompt evacuation of the uterus, in order that, through efficient contraction, the bleeding vessels may be closed. Under these circumstances, I should not hesitate, at once to intro- duce a catheter into the uterus, and puncture the membranes with ' 484 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. a vieAv of allowing the liquor amnii to pass off, and thus evoke the needed effort. This Avould probably be the promptest and most certain method of accomplishing the object. Accidental Hemorrhage at the time of Labor.—If this character of hemorrhage should occur during the progress of labor—it cannot be reo-arded a frequent complication—it AviU need all the attention of the accoucheur. If it be profuse, and cannot be checked by the application of cold to the abdomen, or the introduction of a small piece of ice into the A'agin a, or injections of ice-water into the rectum ; and it be ascertained that one of the extremities of the fcetal ovoid presents, the element of hope Avill be in the rupture of the membranous sac, and, if this should not suffice to promote strong uterine contraction, recourse may be had to ergot. Should the hemorrhage, in defiance of these means, still continue—a rare circumstance—the labor must be terminated artificially either by the hand or the forceps. In the event of a cross-presentation, which, as I have just said, Avould contra-indicate both ergot and rupture of the membranes, the finger should be introduced into the os uteri, and gentle efforts made to dilate it. This species of titil- lation Avill oftentimes be followed by the happiest effects, and more- over, it must be recollected that, in these cases of loss of blood, the rigidity of the muscular fibre of the uterus is very much reduced, and, as a general rule, the dilatation of the mouth of the organ by means of the finger is more or less readily accomplished; the moment it is sufficiently open to permit the introduction of the hand, the indication is to proceed Avithout delay to turn the child by bringing doAvn the feet; for, the earlier version is attempted in cross-births—all things being equal—the greater the probability that the operation will be successful. Sometimes, when the hemorrhage continues Avithout dilatation of the os uteri, and it is not characterized by such abundance as to compromise the safety of mother or child, great benefit will be derived from the judicious administration of anodynes, nothing better in these cases, if the stomach will tolerate it, than Dover's powder, in fh'e grain doses as circumstances may indicate. Should nausea or vomiting preclude its administration, morphia or opium, should there be no contra-indication, may be substituted.* It will be perceh'ed that I have said nothing touching the use of stimulants in the exhaustion so apt to accompany these losses of blood, whether from placenta praevia or accidental hemorrhage. The great object of treatment is to arrest the bleeding by the vari- ous means indicated; at the same time, it vvilI be necessary to sustain the strength by a judicious employment of laudanum, brandy, milk punch, etc.; and never omit, in these anaemic conditions, by means of hot flannels or hot water in bottles, to preserve, as far as may be, a proper temperature of the extremities. * Opium will, however, in some cases, have a tendency to increase the vomiting. LECTURE XXXII. Puerperal Convulsions, the different periods of their Occurrence—Muscular Action, on what is it dependent ?—Nervous Disturbance, Centric and Eccentric—Causes of Eccentric Disturbance—Modus Operandi of these Causes—Treatment of Eccen- tric Convulsions oftentimes empirical—Cases in Illustration—Irritation of Uterus as a Cause of Puerperal Convulsions during Pregnancy, at Time of Labor, and sub- sequent to Delivery—Convulsions during Pregnancy more frequent in the Primi- para ; why ?—Period of Life at which Convulsions are most apt to occur—Blood- letting and Opium oftentimes rautine in Treatment of Convulsions; just Distinc- tions essential—Opium, when a Stimulant, and when a Sedative—Fatality of Stereotyped'Practice—Excessive Blood-letting; how it produces Convulsions— Treatment of Convulsions based upon their special Cause—Sulphuric Ether as a Therapeutic Agent—Convulsions and Head Presentations; relation of—Artificial Delivery, when indicated in Convulsions—Divisions of Convulsive Diseases; Epi- leptic, Hysteric, Cataleptic, Tetanic, etc.; how distinguished—Hysteria much more frequent in earlier months of Pregnancy—Symptoms, Diagnosis, and Prognosis of Puerperal Convulsions. Gentlemen'—We noAv approach the consideration of one of the most formidable and perilous complications of the lying-in-chamber —puerperal convulsions. They may occur during pregnancy, at the time of labor, or subsequently to delivery. Under any circum- stances, their presence is fraught with more or less hazard to the mother and child, and, therefore, they claim the earnest thought of the accoucheur. As I am especially anxious to explain to you, as far as may be, the true pathology of convulsive movement, based upon a sound and rational physiology, you will permit me to recall to your recollection two great fundamental truths, for which Ave are indebted to the researches of Flourens and Marshall Hall. The former has demonstrated that muscular action cannot be produced by irritation, either of the cerebrum,* cerebellum, or purely cere- * There is no doubt that strong mental emotion, accompanied by cephalalgia, obscure vision, etc., will sometimes be the starting point of convulsions both in the pregnant and parturient woman. All practitioners of observation have recognized this fact; but it must not, therefore, be concluded that the convulsion is the product, simply, of cerebral irritation, for this is adverse to a well-established physiological principle. The brain, in a variety of ways, may become the primary seat of some irritating cause, whether from congestions, slight effusions, or some toxaimic influ- ence, such as uremic intoxication, etc.; but this irritation cannot generate a con- vulsive movement, until it has affected the spinal cord, the great motor centre of the economy. It is an interesting fact, as pointed out by Andral and Brown-Sequard, (hat rigid spasms sometimes follow inflammation of tlie brain. 486 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. bral nerves, if the irritation be strictly confined to these portions of the nervous mass; and he has further shoAvn that muscular move- ment is the product of irritation—either direct or indirect—of the true spinal cord* and muscular nerves. It cannot be questioned that this is one of the most important developments of modern physiology. This great revelation, however, needed one more fact to impart to it its full interest, both in a physiological and pathological sense. The fact, as I haA'e before remarked, has been supplied by Marshall Hall, who has demonstrated that irritation of the spinal cord may be induced through certain incident excitor nerves. Previously to the disclosure of this latter principle, it was supposed that all ner- vous aberrations, involving irritation of the spinal cord, Avere cen- tric, or, iu other words, the result of an influence applied directly to this nervous centre. I may, perhaps, be Avrong in the remark that Marshall Hall Avas the first to call attention to this interesting fact, for the circumstance had been previously recorded by Whytt, Pedi, Prochaska, Unzer, and II. Mayo; but I think it must be conceded that, Avithout the practical application made by him of this great physiological truth, its benefit to science would have been extremely restricted. To him, therefore, belongs the honor of having faith- fully and perseveringly insisted, not only upon its importance, but its indispensable necessity for the proper diagnosis and treatment of disease. Noav that the action of the incident excitor nerves is. understood, we have another division of nervous disturbance, viz., eccentric, in which an irritation is produced on the peripheral extre- mity of one or more nerves, and the impression thus made is con- veyed by the nervous trunks to the spinal cord; the impression, altogether independent of mind, becomes a sensation, which results in a motor impulse ; this latter is transmitted to certain muscles, and hence an abnormal movement of these muscles is the result. This is what is knoAvn as reflex action. All nervous aberrations, of Avhatever grade, may very properly be divided into two classes—centric or eccentric ; and you Avillfind that this arrangement is not only founded upon a correct physi- ology, but will greatly contribute to the elucidation of that impor- tant chapter in your studies—nervous diseases. It is, therefore, under this classification that I propose to discuss the important question of puerperal convulsions, whether during pregnancy, as a complication of labor, or subsequently to the birth of the child. In either of these aspects, it is a question Avell entitled to the profound consideration of the medical man. * It must always be borne in mind that the spinal cord, physiologically consi- dered, is not the medulla spinalis of the anatomist; on the contrary, the true spinal cord consists of the medulla spinalis, medulla oblongata, pons varolii, crura cerebri, and the tubercula quadrigemina. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 487 Eccntric causes. These act on the true spinal system through excito-motory influence, by the transfer of an undue or pathological impression. These causes may be enumerated as follows : 1. Indi- gestible food in the stomach ; *2. Morbid matter of any description in the intestines, whether vitiated secretions, unassimilated food, or collections of ficccs ; :). Irritation of the bladder or rectum ; 4. Irri- tation of the uterine organs and vagina. It is important to bear in recollection that these various causes, under uiven circumstances, are capable of evoking an attack of con- vulsions ; so that, when called to a case of this serious nervous disturbance, your minds may be prepared, almost Avith the quick- ness of thought, to comprehend the relation of effect and cause, Avhich may at the time exist betAveen the convulsive movement and either of these specified agents. In this Avay, your diagnosis, sound at the very start, will enable you more successfully to meet the therapeutic indication. There is a vast deal both of routinism and empiricism in the treatment of puerperal convulsions, and this, lam quite confident, is mainly to be attributed to the fact that the practitioner in the hurry or, perhaps, alarm of the moment, suffers himself to regard the convulsion as a primary or idiopathic affection, instead of recollecting that in ninety-nine instances in a hundred it is but the product or result of some antecedent. 1. Indigestible Food in the Stomach.—Let us noAv inquire how it is that indigestible food in the stomach is capable of producing convulsions. It is not sufficient for you to knoAV the fact; on the contrary, you should be content—Avhen demonstration is possible— with nothing short of demonstration itself. Therefore, I noAV tell you, as a principle Avell settled, that in these cases the irritation is first produced upon the terminal branches of the ptieumogastric* nerve, and is thus corn-eyed through that nerve to the spinal cord, constituting, as I have already stated, an interesting and striking example of eccentric influence. You are Avell aware, gentlemen, of my fondness for practical, bedside truths ; in contrast Avith mere hypothesis, they constitute so many gems for the medicaL, man. With this conviction, you AviU pardon me, I am sure, for intro- ducing to your attention the folloAving instructive case, the history and sequel of Avhich are, in my opinion, the best comments I can offer touching the treatment of convulsions dependent upon gastric repletion: Late in the evening of January 1, 1857,1 Avas summoned in great haste to attend a young married lady, Avho Avas then in the eighth month of her pregnancy—a primipara; the messenger, her brother, told me she had just been attacked Avith a fit, and he desired very urgently that I AA'ould lose no time in hastening to the house. On • The physiologist has shown that the pneumogastric is an excitor, and, at tho same time a motor and ganglionic nerve. 488 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. my arrival, I learned she had been in excellent health up to that evening throughout the entire period of her gestation ; but about half an hour before I reached the house, she had, Avhile in agreeable conversation Avith her husband, been attacked with convulsions. I had scarcely entered -her room before another paroxysm occurred, developing all the ordinary phenomena of eclampsia. The first question naturally presenting itself to my mind was, Avhat does this mean, or, in other Avords, Avas there any special and extraordinary cause for this alarming state of the patient? Immediately, I made running inquiries as to her previous health, etc., which, as I have just remarked, had been most excellent. On questioning the hus- band closely, he informed me that hisAvifehad partaken of a hearty tea, indulging freely in preserved quinces, and in addition, she had eaten a large quantity of plum-cake. Precisely two hours after this repast, the convulsions ensued. What, gentlemen, Avith these facts before you, Avould have been your judgment of the cause of the paroxysm, and what your treatment ? Would you have applied a ligature to the arm and abstracted blood—the remedy of all others, in the opinion of some Avriters, Avhich constitutes the sine epua non, the very sheet-anchor of hope in puerperal convul- sions—or would you, as I attempted to do, have taken a common sense view of the case, and referred the perturbation of the nervous system to the presence in the stomach of the preserved quinces and plum-cake, acting as an irritant on the pneumogastric nerve, and thus, through eccentric agency, causing the convulsion ? This Avas my diagnosis, and, as you Avill presently learn, my therapeutics were in perfect accordance Avith it. Without loss of time, I administered twenty grains of the sulphate of zinc in half a tea-cup of tepid water, Avith a vieAv of a prompt liberation of the stomach from its offending contents. In less than three minutes the emetic began to take effect, and the lurking enemy, under the guise of quinces and plum-cake, Avas very soon ejected. The quantity of these substances throAvn from the stomach nearly half filled an ordinary AvashboAvl. The effect Avas all that could be desired ; I remained AA'ith the patient four hours, there Avas no recurrence of the conAmlsion, and she lapsed into a SAveet and undis- turbed sleep ; respiration natural, pulse soft and equable, and the countenance indicative of tranquillity. The most positive directions Avere given as to the necessity of adhering scrupulously to a simple and bland diet.* This lady passed on to her full time, Avhen I had * I took very good care—a practice I have been in the habit of pursuing—to test the urine for the purpose of ascertaining whether it contained albumen ; there w.ch not a trace of this element This, therefore, was an example of convulsions purely due to nervous irritation induced by the presence of undigested food, and in no way connected with albuminuria or renal troubles. ~\\'o shall, before completing tho question of convulsions, discuss fully the subject of albuminuria. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 489 the pleasure of presenting her Avith a fine boy. There was nothing whatever untoward during the labor, and her convalescence Avas not interrupted by any accident. Is it going too far to surmise that, Avithout the prompt action of the emetic, according to every law of professional calculation, the patient and her child would have both been sacrificed ? I think not. Put what prompted the administration of the emetic ? Why, the obvious and imposing fact, previously ascertained, that the essential and only cause of the convulsive movement was the undi- gested mass in the stomach. 2. Intestinal Irritation.—Should the convulsions be traced to intestinal irritation, either from collections of faecal matter, undi- gested food, or vitiated secretions, the indication would be speedily to remove the offending cause by resort to a stimulating enema or a brisk cathartic. 3. Irritation of the Bladder or Rectum.—It may, however, hap- pen that the true cause of the nervous paroxysm is 'rritation either of the rectum or bladder. An aggravated case of hemorrhoids, or a collection of faeces in the loAver boAvel may give rise to convulsions. In the instance of hemorrhoids, my advice to you AA'Ould be, not to hesitate an instant, but at once to disgorge them by a free puncture Avith the lancet. No tampering, negative treatment aaill do here; the life of your patient is in serious peril, and every returning paroxysm makes the peril greater. In the event of the irritation arising from masses of faeces in the rectum, they should be dis- lodged by the aid of an active enema, If the cause of the con- vulsion be traced to irritation of" the bladder, the first object of the practitioner should be to make a just discrimination as to the special character of the irritation, for it maybe the result of various influences—retention of urine, or its extreme acridity, calculus in the bladder, or strangury. The indication of treatment, therefore, Avould depend upon what might be ascertained to be the true source of the disturbance. The following case has a practical bearing on the question hoav under consideration, and I shall cite it as an illustration of the necessity of thorough vigilance on the part of the medical man : In June, 1856, I was requested by Pr. P. W. Johnston, of Long Island, to visit a lady with him, in the sixth month of her gestation. Four days before I saw her, she had been attacked with pneumonia. She was a strong plethoric Avoman, and the disease was in its very inception of a grave character; the doctor, on being called to her, very properly resorted to the lancet, and abstracted § xvj. of blood with decided temporary benefit; it became necessary, how- ever, to repeat the bleeding in four hours; jf viij. more were drawn ; the patient was freely purged, and, through the administra- tion of minute doses of tartar emetic, full action Avas promoted of 490 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. that important emunctorv, the cutaneous surface. A blister Avas applied to the chest, and, in tAvelve hours after its application, the patient Avas attacked aa ith slight convulsions. It Avas under these circumstances that I Avas requested to see her. AVhen I visited her, the intensity of the pneumonia Avas broken, and so far as that affection was concerned the patient avu« making favorable progress. Put a neAV phase had developed itself in the guise of the convulsion, which, although slight, Avas still significant of portending trouble. On inquiry, I learned that there had been no indiscretion of diet, nor Avere the boAvels in any Avay constipated. Attention Avas next directed to the condition of the bladder, and the nurse, an intelli-, gent Avoman, informed us that, for about an hour before the con- vulsion, the lady had complained of much smarting about the bladder, and would call for the chamber every ten or fifteen minutes, supposing that she could pass Avater, but at each time not more than a feAV drops Avere evacuated, accompanied by the most painful scalding. Noav, gentlemen, Avhat do you call this more or less constant desire to micturate, Avith an inability to pass more than a feAV drops, accompanied by a sensation of scalding ? Is it not strangury ? Unquestionably. In the case of this patient, can any of you, from the treatment of the pneumonia already described, be at a loss to account for the strangury ? There is not one of you, I am quite confident, who is not prepared to tell me that it was produced by the absorption of the cantharides of Avhich the blister Avas composed.* As soon as we had learned the existence of this vesical irritation, an important light Avas throAvn on the cause of the convulsive movement. I had no doubt myself, and in this opinion Dr. Johnston fully concurred, that the nervous per- turbation was occasioned by the strangury, affording a tangible illustration of convulsions from irritation of the bladder. With this diagnosis of the case, I suggested the following medicine, one pill to be taken every fifteen minutes until the strangury yielded: Pulv. Doveri 1 Extract Hyoscyam. v aa. gr. xij. Pulv. Camphor. ) Ft. massa in pil. xij dividenda.f The patient J had not taken six pills before she expressed herself relieved of the strangury; there was no recurrence of" the convul- * Strangury is not a necessary consequence of the application of a blister, while at the same time, it more or less frequently results. I have seen, especially in children, who, it is well to recollect as a general rule sustain blisters badly, the most distressing suffering from strangury produced in this way. f I have repeatedly found this an admirable combination in strangury from the absorption of cantharides, and can recommend it with much confidence. X In this case, also, the urine was examined, but there was no trace of albumen. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 491 sion ; but I subsequently was informed by the doctor that she wag delivered shortly afterward of a still-born child, bearing the evi- dences of having been dead for some days. It is not of rare occurrence that the child is destroyed in utero during an attack of convulsions, and such no doubt Avas the fact in this instance. When the death of the fcetus takes place, this latter acts not unfrequently as a foreign substance, and evokes premature action of the uterus— a most fortunate provision, for the continued sojourn of a dead child in utero could not but seriously compromise the health and safety of the mother. It can scarcely be necessary to remark that if!, on examination, you ascertain the convulsions to be occasioned by the distension of the bladder, the remedy will be the prompt, but cautious intro- duction of the catheter.* I have mentioned that calculus may sometimes be the offending cause. Here, an operation for the removal of the calculus is out of the question ; for the very attempt would most certainly aggravate the irritation, and thus excite the reneAved paroxysms of convulsion. In such cases, the obvious duty Avould be, if the thing were possible, to have recourse to artificial delivery. Irritation of the Uterus and Vagina.—I shall now speak of irri- tation of the uterus and vaginaf as a cause, through eccentric action, of puerperal convulsions; and this irritation may develop itself during pregnancy, in the progress of labor, or after the birth of the child. During Pregnancy.—It is an interesting question—Under AA'hat circumstances do convulsions most frequently occur in gestation ? As far as statistics can establish the fact, and I think there is no fact better proved, they are, out of all proportion, more frequent in the primipara than in the multipara, both during pregnancy and labor, averaging over ninety per cent. Then, the inquiry neces- sarily arises, Avhy is this ? The explanation is not difficult. In a first pregnancy, the female, especially if her nervous system be deli- cately organized, is much more predisposed to nervous perturbations than one Avho has already passed through that process, and who, consequently, becomes to a certain extent accustomed to the excite- ment, Avhich more or less usually accompanies gestation. Again: it is a Avell-established practical fact, that there is much greater * It is always necessary, in the introduction of the catheter, to use caution and gentleness; but the observance of this rule is particularly called for in a case such as we are supposing, in which convulsions have ensued from vesical irritation; for the slightest injury to the urethra would be very likely to renew the paroxysm.' f It lias already been stated that, in convulsions from undigested food in the stomach, the irritation is transmitted to the spinal cord through the pneumogastric nerve; but when the source of disturbance is in the intestines, or emanates from the uterus itself, the incident excitor nerve-fibres of the spinal and sympathetic uterine nerves are the media through which the irritation is conveyed. 492 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. rigidity of the os uteri in the primipara, Avhich necessarily exposes the incident-excitor nerves of that part to increased irritation. Pesides, Avhen treating of albuminuria, its causes and effects, Ave shall tell you that congestion and other derangements of the kid- neys are far more frequently met Avith in first than in subsequent pregnancies. Another question of equal interest arises—Do convulsions mani- fest themselves, as a general rule, in middle life, or at an earlier period ? The best observation, and the most accurate details show that the particular period of life at Avhich they are most apt to occur, is betAveen the ages of seventeen and thirty-five; and it may also be stated as worthy of note, that if they develop themselves before the sixth month of gestation, it is an exception to a very general rule; for the rule, founded upon the careful observation of practical men, is that, as a complication of pregnancy, in the great majority of instances, they take place betAveen the seventh and ninth months.* This, too, is my OAvn experience, and I believe it to be perfectly in accordance Avith facts. It has been positively affirmed by some Avriters that convulsions cannot be developed during pregnancy, unless they are preceded by contractions of the uterus. This opinion, however, is at variance Avith the observation of the lying-in room. Treatment of Convulsions during Pregnancy.—Well, gentlemen, you are summoned to a lady in convulsions in the progress of her pregnancy, and labor has not commenced. What is to be done? Your action aaHI depend altogether on the surrounding circum- stances. We assume, hoAvever, that the convulsions here are due to uterine irritation simply, and are not complicated Avith uraemia, of which Ave shall speak hereafter. If you leave this university Avith the conviction, too sadly impressed upon the minds of some prac- titioners, that the reliable remedies in puerperal convulsions aref blood-letting and opium, it is reasonable to suppose that one or other of these agents Avould be immediately resorted to. Let us, for a moment, pause and examine this point; this examination may * Depaul mentions a case of convulsions in the fourth month of gestation. f There prevailed many years since a very general opinion that puerperal convul- sions were always due to one of three causes: constitutional irritability, excitability of the uterus from over-distension, or general plethora; and with this hypothesis, which has been handed down to the present day, we have the explanation why it is that one practitioner, who refers the convulsion to constitutional irritability, will employ opium: another, who can see nothing but excessive distension of the gravid womb as the cause of the nervous disturbance, will resort to immediate delivery; while the third, who always associates in his mind puerperal convulsions and ple- thora, will regard the lancet as his only hope. This, I think, will account, to a degree at least, for the routine practice, which has been adopted in the management of this serious affection; it shows also the folly of mere hypothesis, and at the same time the necessity for a rigid analysis of each case as it may present itself to tho observation of the practitioner. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 493 at some future timb serve you, and protect your patients against the fatal consequences of stereotyped—I knoAV no more emphatic term—practice. Here, then, is your patient, in gestation, and attacked with convulsions; the instant you approach her—true to the undying instincts of routinism, you call for a bandage and basin ■ the bandage is arranged, the basin all in readiness, and the lancet plunged into the vein. The blood Aoavs, the patient faints; and soon after reaction comes on, there ensues another convulsion more marked than the preceding. You have not taken aAvay blood enough, whispers that fatal delusion—routinism ! The ligature is again applied, the orifice opened, and slowly runs the current! Syncope folloAvs; the spark of life is again rekindled by a feeble read ion; another convulsion, and speedily death closes the scene, thus preventing further depletion! The practitioner, Avho has an abiding faith in blood-letting, as the only element of hope in puer- peral convulsions, Avould, if consistent, say to the disconsolate friends, " Oh! if I had seen the case at the commencement, I should undoubtedly have saved that life!" To the ignorant and uninitiated such language may, perhaps, prove a mantle for the con- cealment of reckless and unjustifiable practice; but it will fail to appease the severe exactions of science. So far, gentlemen, from depiction being indicated in the case just cited, it may peradventure be that the resort to the lancet is the true cause of death ; and I will explain why this might probably be so. Suppose, for instance, the patient, from antecedent disease, hemorrhage, or from any other cause, should exhibit an example of an ami a ; in such an event, this very anaemic condition may be one of the essential exciting sources of the convulsion. What, then, becomes of the potency of blood-letting in a case like this? Its only potency consists in the prompt extinction of life, through an aggravation of the anaemia. There is no fact more essential to be borne constantly in mind than the direct connexion AA'hich exists betAveen excessive losses of blood, no matter how produced, and convulsions. When an animal is bled to death, in the case of the calf or sheep, for example, the prelude to the death struggle AA'ill be convulsive paroxysms. Hoav often do children succumb from convulsions induced by the large abstraction of blood, either by the lancet or leeches; and in these cases of convulsion from exsanguification of the system, the result is almost always fatal.* Pe careful, there- fore, Iioav, Avithout due consideration, you employ this remedy in early childhood, for its abuse Avill readily lead to serious conse- quences. BroAvn-Sequard, I have told you, has shoAvn that the cause of the convulsion following excessive loss of blood is the same * Convulsions from ana?mia, whether the anaemia arise from blood-letting, hemor- rhage, or any other cause are to be noted as of centric origin. 494 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. as in asphyxia—there is in fact an insufficient respiration, and, there- fore, the amount of carbonic acid increases in the blood. The spinal cord and medulla oblongata become extremely sensitive to the irrita- tion of blood containing a notable quantity of carbonic acid, and hence the convulsive movcrnent* I have, I think, said sufficient to show you that the indiscriminate or routine practice of resorting to the lancet in the treatment of convulsions, is not only unsound, both in its physiology and patho- logy, but must, of necessity, sometimes pnrve a fatal practice. Therefore, gentlemen, when, in these cases, you place your hope in blood-letting, let it be a hope for which you can exhibit some sub- stantial basis. I shall presently speak of the indications for the use of this heroic, but much abused, remedy. Let us now, for an instant, turn to opium, the other routine agent. It is a habit with some practitioners to regard convulsions as exclu- sively traceable to a disquietude of the nervous system, Avithout at all taking into account the collateral and accompanying circum- stances ; and, with this limited vieAV of the pathology of the affec- tion, they administer opium for the purpose of soothing the system, and producing sleep. In order that you may fairly comprehend the point, and fully appreciate the inevitable hazard of this limited and one-sided vieAV, allow me, for the instant, to remind you of the true therapeutic properties of that important, and also much abused, agent—opium. In a plethoric condition of system, the direct ten- dency of this drug is to produce congestion of the two great nervous centres—the brain and spinal cord; and it is a AA'ell-established fact, that congestion of either of these important organs Avill, through centric influence, proAre a fruitful cause of commlsions. With this proposition before you, the truth of Avhich is universally conceded in theory, but too frequently forgotten in practice, do you not at once perceive the extent of the peril to which, of necessity, youAvill expose your patient, in the use of this medicine as a remedy in puerperal convulsions, unless it be administered Avith judgment, and with a due regard to its special therapeutic action ? Again: if the system be greatly prostrated by preA'ious losses ; if, in a word, the patient be in an anaemic state, then opium conjoined with brandy, ammonia, or coffee, is a valuable remedy ; it is, indeed, in these cases, oftentimes the means of saving human life. You see, therefore, that this medicine, in the affection of which Ave are now speaking, can be regarded as appropriate only Avhen given with due discrimination ; and the same remark apphes Avith equal force to all remedial agents. * The admirable researches of Kussmaul and A. Tenner on the convulsions caused by losses of blood, would lead to the opinion that it is chiefly irritation of the medulla oblongata and pons varolii, which induce these convulsions. [Journal de la Physiologie de 1'Homme et des Animaux. Tome 1, p. 201.J THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 495 In the treatment of convulsions during pregnancy or labor, you are to look beyond the mere paroxysm; you should, as far as may be, endeavor to ascertain the cause of the nervous disturbance, and not blindly have recourse to remedies, which, too often, have nothing to recommend them in given cases but mere custom. Just discrimination is a very necessary and essential element in the cha- racter of a medical practitioner; he should school himself to close observation, so that, through rigid analysis, he may be enabled to deduce truthful conclusions. Therefore, instead of having your minds fettered by preconceived opinion in regard to any particular form of treatment, you should be careful to subject opinion to cir- cumstances as they may develop themselves in the sick-room. If you do this, your therapeutics AviU not only be in keeping with the philosophy of science, but the results Avill be likely to be satis- factory. In illustration of this remark, I shall now endeavor to show you under Avhat circumstances blood-letting will be indicated in con- vulsions during gestation. Suppose, for instance, the patient should be plethoric, with a bounding pulse, and flushed countenance. Would any man, in his senses, hesitate, Avith these premonitions of danger, as to the course to be pursued ? I think not. Here, prompt and full depletion by the lancet is urgently demanded for tAvo substantial reasons: 1. The A-ascular fulness may be the cause of the convulsive paroxysm, in consequence of congestion of the spinal cord, or of" the brain, indirectly affecting the cord* 2. During the convulsion, the patient Avill incur the hazard of death from apoplexy, if the plethora continue undiminished. The bleed- ing, however, to be of value, must be sufficiently copious, the quantity abstracted being regulated by the peculiar circumstances of the case, of Avhich the practitioner is to be the proper judge. Should it be necessary, let the operation be repeated until a decided impression is made on the system; what I mean by a decided im- pression is the evidence afforded that the plethora has yielded to the depletion. In all cases of convulsions Avith vascular fulness, it is highly im- portant that there should be a prompt and free action of the bowels. * It has been shown by the pathologist, in the autopsies of women who have died during gestation or labor, that either of these latter conditions is usually accom- panied by what is termed a passive engorgement of the inferior portion of the spinal cord. This fact evidently demonstrates a peculiar predisposition, both during pregnancy and labor, to congestion of the cord, and, consequently, to convulsions from this centric influence. Yet, notwithstanding this predisposition, it is not true, as some writers have attempted to show, that plethoric women are more commonly attacked with convulsions than those of a debUitated and broken-down condition. On the contrary, women who, from certain pathological influences, have suffered from change in their blood constituents, as denoted by their cachectic and hydropic states, are the very women most likely to suffer from convulsions. 496 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. This may be accomplished Avith medicine by the mouth, or, in the event of the patient not being able to swallow, by means of a purgative enema. A very good cathartic, under the circumstances, is the folloAving draught: ri Infus. Senna* f. 3 iv Sulphat. Magnesiae 3 ij Mannae 5 i Tinct. Jalapae f. 3 ij- M. Put, gentlemen, I must apprise you of one fact never to be lost sight of Avhen treating convulsions: it is this—delay is oftentimes the cause of death ; and I regard it so essential, in connexion Avith the abstraction of blood, to have a prompt movement of the bowels, that I am in the habit of resorting to Avhat I have found not only a prompt but an efficient remedy—croton oil. There is, I think, an unfounded prejudice against this medicine. I have heard practitioners object to its use because of the apprehension that it would produce hypercatharsis, or excessive purging. I have em- ployed it repeatedly Avith children and adults, and I believe it to be, under discreet administration, a safe and invaluable agent. I have on several occasions resorted to it in convulsions, and Avith decidedly good effect: Olei Tiglii gtt. iv Sacchar. Alb. 3 ij Mucil. Acaciae f. § i. M. a tea-spoonful every fifteen minutes, until the boAvels are moved. Here, Ave have an important auxiliary in connexion Avith the lancet and croton oil—I mean cold applications to the head ; they will prove of very material service, and should not be omitted. As an adjuvant, also, in these cases, Ave have an admirable remedy, Avhich I think Avas first introduced to the attention of the profession, in the treatment of convulsions, by Dr. Collin.s, of Dublin. I allude to tartarized antimony in small or tolerant doses, the object being, under its administration, to keep up a relaxed condition of the system. Put the remedy of all others, after the circulation has been brought under proper control by the due abstraction of blood, etc., is the inhalation of ether, not administered so as to destroy consciousness, but merely to produce a soothing influence on the nervous system. I can speak of this agent—Avhich is another of the abused articles of the materia medica—Avith great confidence in this emergency, for I have tested it in the most satisfactory manner. Its chief efficacy, in these instances, is, I think, to be ascribed to its power of diminishing reflex sensibility. Never, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 497 however, have recourse to it in cases of plethora until, by the judicious use of the lancet, the circulation has been duly equalized. In cases, also, in Avhich there is no vascular fulness, and the convul- sion can be traced simply to nervous irritability, ether will prove invaluable from the first. If the convulsions, as will sometimes happen, continue in defiance of these remedies, then the question presents itself, can nothing more be done ? This brings us to the consideration of exciting premature action of the uterus, so that its contents may be expelled. If, in your judgment, after weighing Avith due care all the circum- stances of the case, you should be confirmed in the opinion that delivery is the only alternative, in order to save either mother or child, then I need not assure you that the course to be pursued is a very plain one, and Avithout delay you should proceed to evoke uterine contractions. The mode of doing this, and the various plans suggested by authors, Avill be stated Avhen treating of prema- ture artificial delivery. It may be mentioned in connexion with this topic that if the child should be ascertained, through ausculta- tion or other means, to be dead, and the convulsions still continue, then the expediency of bringing on labor is the more urgent, in order that the life of the mother may not also be sacrificed; and, moreover, the death of the child removes the only valid plea against the operation. During Labor.—When convulsions occur during labor, they may do so at the commencement of the parturient effort, during the process of dilatation, or, as I believe most frequently takes place, they may manifest themselves after the head has left the uterus, and is pressing upon the vaginal Avails, and especially during the last struggles just as the head * is about to make its exit. The treatment of convulsions at the time of parturition will generally vary according to the particular stage of labor at which they mani- fest themselves. In all cases, hoAvever, Avhere there is an evident plethora of system, the free use of the lancet must immediately be resorted to for reasons already explained ; the therapeutic principle, which is to guide you, is precisely the same in convulsions Avith plethora, Avhether they occur during gestation or at any stage of labor. It may, hoAvever, be that the convulsive paroxysm commences soon after the inception of labor in a patient, Avho does not ex- hibit vascular fulness, but Avhose throes of parturition are severe * It is an interesting fact to note that when convulsions occur during labor, they do so in the great majority of cases in head presentations; and strange as it may appear to those who have not examined the subject, they are extremely rare in malpositions of the foetus. It is stated as the result of the combined observation of Drs. Clarke, Labatt. and Collins, in the Dublin Lying-in Hospital, that there was but one case of convulsions coincident with malposition in 48,397 labors. 32 498 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and in quick succession. It may then become a question whether, under the circumstances, the convulsions are not a together due to the unusually rapid succession of the pains. If so, I know of no remedy equal to the belladonna,* for I am quite satisl.ed that it possesses two important attributes, one of which, at least, has, perhaps not been sufficiently appreciated in the practice ot midw.iery : these attributes are the lulling of uterine contraction, and the promotion of dilatation of the mouth of the organ. Therefore, in the case Ave are now speaking of, I should recommend you to lubricate the os uteri freely Avith the belladonna ointment 3j of the extract to = j of adeps. If this should prove as efficacious in your hands as it has in mine in subduing inordinate contractions, then I am sure you will unite with me in regarding it, under the circumstances, a most valuable remedy. In cases, too, in which, from antecedent disease or other conditions, the health of the parturient female has become much disturbed, leaving her in a state of more or less exhaustion, it mav become desirable to check, for the time, the action of the uterus, more especially when it is severe and in such quick succession as to exhaust the strength of the patient; in such in- stances, you possess in the belladonna an efficient means of fulfilling the indication. Much has been said about the propriety of rupturing the mem- branes in cases of convulsions, for the purpose of evacuating the liquor amnii; and the suggestion is advanced by many practitioners on the ground that, on the escape of the amniotic fluid, the uterus becomes diminished in size, the tension is removed, and conse- quently the uterine irritation being thus sensibly lessened, the * It is well understood that the contractility of the uterus can either be excited or depressed through the action of certain agents; and it is a knowledge of this fact, which oftentimes enables the practitioner to render essential service to his patient. For example, we know that cold, nervous excitement, ergot, titillation of the os uteri, electricity, etc., are so many influences capable of inciting contractions of the organ; on the other hand, anodynes, depression of mind, and more especially belladonna, exhibit very sensibly their power in quieting this contractile force. Some very interesting experiments have been made by Mr. T. Wharton Jones and others to show the effects of belladonna on the circulation. Mr. Jones found that an artery in the web of a frog exhibited, under the microscope, a constriction amounting almost to obliteration on the application of belladonna; while, at the same time, the blood in the corresponding capillaries and venous radicules was in a state bordering on stagnation. It would seem, therefore, that this remedy does not act directly on the muscular fibres of the uterus, but exerts its influence on the walls of the blood- vessels distributed throughout the organ; and this influence on the vessels has been explained as follows: the belladonna, it is said, excites the great sympathetic nerve or the small nervous filaments accompanying the vessels; under this excitement, the vessels contract, and consequently the quantity of blood they receive being greatly lessened, the uterus occupies a smaller space, and its tissues become dimi- nished in general volume. But it must be remarked that the reason wh.y the uterus relaxes when belladonna is applied is—that the blood-vessels contract, and the tissuo of the organ not receiving blood enough necessarily becomes softened. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 499 convulsions Avill cease. I can see no force in this argument, and 1 am convinced that the rupture of the sac before the proper dilata- tion of the os uteri is bad practice, and oftentimes will be followed by increased paroxysms of convulsions, for the reason that, as a very general rule, the contractions of the uterus are marked as soon as the liquor amnii has passed away* If, however, the dilatation have been accomplished, there can be no objection to affording the escape of the Avaters by rupture of the membranous bag. It must be recollected that ether is an important resource in the convulsions of labor, as we have shown you it is in pregnancy where parturition has not commenced, and, with the restrictions previously mentioned, you will find its employment most satis- factory. When it is practicable, there can be no doubt that the impor- tant indication—indeed, the very best practice in convulsions at the time of labor, is to deliver the patient. Some authors recom- mend version when the head is at the superior strait, and the mouth of the womb in a condition to justify this operation. With this view, under certain restrictions, I coincide. If you will permit me to express a positive and emphatic opinion on this point, it is, that under no circumstances should version be attempted in puer- peral convulsions, unless the patient be previously placed under tlie full influence, of anaesthesia, and for the following reasons : 1. The very introduction of the hand into the uterus constitutes an excit- ing cause, Avhich would almost certainly evoke the convulsive paroxysm; 2. The manipulations necessary to accomplish the delivery Avould so irritate the organ as to subject, through a repe- tition of the convulsion, the life of the mother to the most serious peril. The two next alternatives are the forceps and crotchet. If the head be Avell (Ioavu in the pelvic cavity, there should be no hesita- tion in using the forceps ; f if, on the contrary, it still be at the * This is readily accounted for. When the amniotic fluid is evacuated, the uterus then comes more or less in direct contact with the surface of the foetal body • this contact, through reflex action, tends to stimulate the muscular fibres of the oro-an to increased effort, and hence the marked or expulsive force which follows. f A short time since, I was requested by one of our most eminent surgeons to visit his daughter, who was then in labor with her first child, in consultation with Dr. Sands, Dr. John Watson, and Professor Carnochan. The lady was in delicate health, and she had been in labor some twelve hours; she had three convulsions before I saw her. On reaching the house I was requested by the medical gentle- men to make an examination, and found the head descending in the pelvic cavity. The convulsions, they informed me, had not developed themselves until the head had begun to make severe pressure on the os uteri. There was a general concur- rence of opinion among us as to two points: 1. That the convulsions proceeded from irritation of the uterus ; 2. That the indication was to place the patient under the influence of ether, and deliver by the forceps. They kindly requested me to apply the instrument, and in a few minutes I succeeded in delivering the lady of a 500 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. upper strait, I should advise you not to apply them, version 1 eing preferable. I should be unwilling, as a general principle, to have recourse to the crotchet. If the child be living, the use of the instrument Avould be without justification, and if it be dead, it could be much more speedily removed by the forceps.* No matter how skilfully the crotchet may be employed, there is always more or less delay in the delivery by this means, and the irritation to Avhich the parts are exposed during the operation, is an exciting cause to a return of the convulsion. After Delivery.—You will occasionally meet with cases in Avhich, after an auspicious delivery of the child, conA'ulsions will occur; and it is right that you should understand the contingencies which may produce them. I believe they may be enumerated as follows : 1. Hemorrhage; 2. The detached placenta, partially through the mouth of the uterus, inducing irritation; 3. The presence of coagula of blood causing distension, and consequent irritation of the os uteri; 4. The rude introduction of the hand of the accou- cheur into the vagina or uterus, for the purpose of extracting the placenta; 5. Inversion of the uterus. These may be regarded as the chief causes of convulsions occurring subsequently to the birth of the child; it is, however, to be recollected that post-partum con- vulsions will sometimes be but the continuation of the attack prior to the delivery. I have already called your attention to the relation which sub- sists between excessive losses of blood and convulsions, whether in the puerperal female, or in the young child ; and, therefore, it is not necessary for me again to allude to it. When the convulsion is clearly traceable to hemorrhage, the broad indication is, to endeavor promptly, after the arrest of the bleeding, to rally the dilapidated forces, and for this purpose I know of no remedy so certain in its efficacy as laudanum, in union Avith stimulants ; a tea- spoonful each of laudanum and brandy, in a wine-glass of water, repeated every ten or fifteen minutes, according to the emergency; or a spoonful of laudanum in a wine-glass of coffee ; the strength afterwards to be guarded by animal broths, etc. What connexion is there between a detached after-birth partially through the mouth of the uterus, and convulsions ? This is an important question, and its solution easy. The presence of the placenta induces irritation of the incident-excitor or sensitive nerves, and hence the convulsive paroxysm, through eccentric influence, as has been already explained to you. The remedy in this case is to remove the placenta without delay; and, if there living child. There was no recurrence of the convulsive paroxysm, and she had an auspicious convalescence. * If, however, decomposition had commenced, so that the forceps could not get a proper purchase, then the crotchet, as a matter of necessity, must be resorted to. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 501 be no contra-indication, let the system be quieted by a full dose of laudanum and brandy; or the inhalation of ether, not so as to destroy consciousness, may be practised Avith decidedly good effect. The same remark is applicable to the presence of coagula; they should be instantly removed, and repose of the nervous system induced. In case of inversion of the uterus, every care should be taken, as speedily as possible, to reduce the displacement; should this fail, and the convulsions continue, I would advise the free use of the belladonna ointment, both on account of its composing and relaxing effects. When convulsions occur after delivery, they are usually less violent, and also less fatal. Put, as you must plainly see, it is most material that the accoucheur should early compre- hend the true cause of the paroxysm, in order that he may at once proceed to remove it. Symptoms.—Puerperal convulsions may be said to present, as a general rule, two orders of symptoms: 1. The precursory; 2. Those which accompany or characterize the attack. The former, or precursory, consist in more or less uneasiness, and an undue degree of nervous irritability, great restlessness, severe cephalalgia, confusion of ideas, loss of memory, tAvitching of the muscles of the face and extremities. Put it may happen that, Avithout any of these premonitories, the convulsive movement displays itself by a sudden exhibition of the symptoms, Avhich are really pathognomonic or characteristic of the paroxysm. It is only necessary to Avitness one case of convulsions, Avith all its frightful cortege of phenomena, to have the impression indelibly stamped upon memory. It is one of those truthful yet terrible portraits, which the medical man, even if he would, will find it difficult to obliterate from recol- lection. Imagine, for instance, that you are at the bedside of your patient, administering Avith kindness and skill to her Avants; the labor is progressing favorably, everything looks bright and promising, and, Avithout the slightest premonition, a convulsion commences, ushered in by the following symptoms: The face becomes, as it Avere, sud- denly fixed, Avith twitchings of its muscles; the Avhole expression is altered; the eyes at first roll, and then become stationary, usu- ally turned upAvard; the pupils are dilated, and make no response to the light; the lips are draAA'n in various directions, and exhibit rapid movements ; general distortion of countenance, Avith tume- faction and a livid hue ; foaming of the mouth ; protrusion of the tongue ; violent pulsation of the carotid and temporal arteries, Avith marked engorgement of the jugulars; the head, in consequence of irregular action of the muscles of the neck, is usually drawn to one side. These changes are also accompanied by more or less spasmodic 502 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. contraction of the muscles of the arms, while the hands are firmly closed; the lower extremities, on the contrary, are more or less free from movement; as a general rule, there is not much jactita- tion, so that it does not become necessary to hold the patient to prevent her falling from the bed; the respiration is short and irregular, and sometimes, through contraction of the glottis, mo- mentarily suspended Avith intermittence of the heart's action. During all this time, there is complete loss of consciousness ; occa- sionally there will be involuntary discharges of urine and I'a-ces; the attack is folloAved by stertorous breathing, the patient present- ing the general condition of an apoplectic; after a certain time, the stertor ceases, and consciousness usually returns. There is no fixed rule as to the recurrence of the attacks ; they may come on every ten, twenty, forty minutes, and hours may sometimes inter- vene betAveen the paroxysms. Such, gentlemen, is a brief sum- mary of the principal features Avhich ordinarily accompany an attack of puerperal convulsions, and, as I have told you, once wit- nessed, they cannot readily be forgotten. Diagnosis.—It is proper to remember that the nervous system may be variously disturbed during pregnancy, at the time of labor, and subsequently to delivery, and these disturbances may assume one of several phases; for instance, either hysteria,* catalepsy, epilepsy, tetanus, chorea, or the puerperal convulsion of Avhich we have been speaking, may originate at either of these periods; it is needful, therefore, that a just distinction be made in reference to these different grades of nervous perturbation. In hysteria, consciousness is not lost, nor does either coma or stertorous respiration succeed the paroxysm ; there is great rest- lessness, amounting to violent jactitation, so that, unless the patient be well guarded, she Avill throw herself from the bed ; oftentimes, there is laughing alternating Avith shrieking; and what is almost ahvays a prelude to the attack, is a sense of constriction of the oesophagus, occasioned by Avhat is known as the globus hystericus. Catalepsy is characterized by one striking peculiarity, viz. the uniform persistence of position of the limbs during the paroxysm, corresponding with the position in which they were at the time of the invasion. I must confess I am unable to present any essential characteristic differences which will enable you to distinguish Avith positive cer- tainty epilepsy from puerperal convulsions; for I am disposed to regard eclampsia in the puerperal woman as bordering so closely on the true epileptic convulsion as to render a distinction, to say the least, extremely difficult. If there be a difference, it may be said to exist in the coma, AA'hich uniformly folloAvs eclampsia, and * Hysteria, although, as a rare exception, it may occur at the time of labor, much more usually develops itself in the first three months of pregnancy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. which, also, occasionally, but not universally, is a sequela of epi- lepsy. The continued rigidity of the limbs is the characteristic feature of tetanus, and leads readily to an accurate diagnosis. In chorea, the mind is undisturbed, and the affection consists principally in an inability to control muscular movement. Without some judgment, the practitioner might possibly, if he saAV the patient during the stage of coma, confound this condition of things with apoplexy. Put all error will be removed by a history of the case; for example, the coma of puerperal convulsions is pre- ceded by the spasmodic and convulsed action of the muscular system ; not so apoplexy ; and, besides, in this latter affection there would most probably be hemiplegia—the result of the cerebral extravasation. Again : it is Avell to bear in recollection that, even in convulsions, death Avill sometimes ensue from effusion of blood in the brain, constituting a veritable apoplexy, and, in such case, there Avill of course be hemiplegia more or less developed. Prognosis.—So far as the mother is concerned, the prognosis can- not be said, according to the best observation, to be favorable ; and yet I cannot agree Avith some avliters, Avho maintain that more than one half die. It is, I think, more in keeping Avith facts to say that, under prompt and judicious treatment, at least 70 per cent, of the mothers are saved. Pr. Churchill states that, in 214,663 cases of labor, convulsions occurred 34V times, or 1 in about 618f. In 328 cases, 70 mothers Avere lost, or about 1 in 4£. The mortality is much greater among the children ; some of these die in utero during the paroxysm, and many of course are sacrificed by the operations, Avhich may be judged necessary for the safety of the mother, such as premature delivery, version, the forceps, and the crotchet. It should, however, not be forgotten that our prognosis, in reference to the safety of either mother or child, is to be graduated by the time at AA'hich the convulsion becomes developed, its duration, the frequency of its recurrence, the character of the convulsion itself, and the condition of the patient. Occasionally, although death does not ensue, there are some serious consequences resulting from convulsions, such as loss of memory, positive mania,* imbecility; and these may continue for a longer or shorter period. Cases are recorded in Avhich permanent amaurosis and deafness Avere the results. It is stated by some authors that the great majority of women Avho survive the invasion of convulsions are attacked Avith puerperal fever. This certainly does not accord AA'ith my experience, nor can I see any other than simply a coincident relation betAveen these two pathological phenomena. * Mania and other forms of insanity may occur after parturition, even when the labor has not been complicated with convulsions. Esquirol, perhaps the best authority on insanity, says: " The number of women who have become insane after LECTURE XXXIII. Puerperal Convulsions continued—Their Centric Causes; divided into Psychical and Physical; how distinguished. Toxaemia, or Blood-poisoning—Albuminuria, its Re- lations to Convulsions—Causes of Albuminuria—Ed. Robin's Theory not sustained —A Change in the Composition of the Blood a Cause—Illustrations and Proofs— Secretion, its Objects—A Change in the Kidney, Structural or Dynamic, a Cause of Albuminuria; Proofs—Pressure on the Renal Veins a Cause—Illustration—Albu- minuria more frequent in the Primipara; why ?—Is Albuminuria a necessary Result of Diseased Kidney ?—Does it always exist in Pregnancy ?—Uraemia, what is it?—Dr. CarlBraun and Uraemic Intoxication—Is Albuminuria always followed by Uraemia?—Is Urea a Poison?—Carbonate of Ammonia and Urea—Frerichs's Theory—Orfila's Experiments with Carbonate of Ammonia on Animals; Besult— Treatment of Uraemia, on what it should be based—Therapeutic Indications— Colchicum Autumnale and Guaiacum as Remedial Agents—Dr. Imbert Goubeyre and Bright's Disease in connexion with Albuminuria—Anaesthetics in Uraemia. Gentlemen—In the preceding lecture Ave have been occupied Avith a consideration of the eccentric causes of convulsions; I propose to-day to speak of those influences AA'hich, through centric action, are capable so far of disturbing the nervous equilibrium as to occasion the convulsive spasm. The centric causes of convulsions are di- vided into psychical and physical. Under the former head are in- cluded all operations on the mind, knoAvn as emotions, so that the depressing passions, such as grief, or the more exciting emotions, such as joy, are to be regarded as among the psychical causes of this affection. The physical consist in various pathological condi- tions of one or other of the two great nervous centres, the brain and spinal cord ; for example, plethora, by inducing congestion of these centres, may proA'oke convulsions ; an anaemic state of the sy>tem, as has been already explained, may do the same thing; disease of the brain or spinal cord, Avhether of the substance or coverings, is also a centric cause. Put, gentlemen, there is yet another centric agent capable of evoking convulsions, to which I desire especially, and someAvhat in detail, to direct your attention. I allude to an impure or poisoned condition of the blood. Until Avithin comparatively a short period, authors Avere silent on the subject of certain poisonous properties contained in the urinary secretion, or, at least, they did not attach their confinement is much greater than generally supposed. At the llopital Sal- petriere nearly one twelfth of the insane women we received here became bo after their delivery." (Traite des Maladies Mentales, vol 1, p. 230.) THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 505 to it that specific interest, which late discussions have excited ; and hence the term toxaemia, or blood-poisoning, was not employed, as it noAv is, to denote a very peculiar and important state of the eco- nomy. While toxaemia is the genetic term, there are various species or grades of blood-poisoning. This question is well deserving of attention, particularly at this time, for it has recently received prominent consideration.* In September, 1853, I published a paper entitled, " Thoughts on Uramla," Avhich Avas generally distributed among my medical friends in this city, and Avhich is incorporated in my Avork on the diseases of Avomen and children.! In that paper AA'ill be found the folloAving language in reference to one class of puerperal convul- sions, and I trust I may be pardoned for quoting it here : " Recently much has been written, and questions proposed by learned acade- mies, respecting the connexion between albuminuria and puerperal convulsions; and the Avriters are almost unanimous in the opinion that albuminuria is the cause of these convulsions. Now, I con- tend that puerperal convulsions are frequently nothing more than uraemic phenomena, as is proved by their causes, symptoms, dia- gnosis, and pathology. If, then, puerperal convulsions be the result of uraemic intoxication, they are not necessarily produced by albuminuria. There is often a coexistence of puerperal convul- sions, albuminuria, and oedema, general or local; but each one of these conditions may, and has existed irrespectively of the other." Causes of Albuminuria.—I propose now, as briefly as is consis- tent Avith the interest and importance of the subject, to examine the true relation of albuminuria to eclampsia, and also the points of relation betAveen this latter and Blight's disease of the kidney. With this vieAV I shall commence Avith the consideration of the causes of albuminuria. Here Ave find A'arious opinions : Edouard Pobin maintains that the passage of albumen into the urine is the result of imperfect combustion ; that urea is produced by the oxy- genation of the albumen in the blood, and if the oxygenation do not take place the result Avill be albuminuria. This hypothesis possesses the attribute of ingenuity, but its demonstration seems to me difficult, for the obvious reason that Avhen albumen passes into the urinary secre- tion the quantity of urea, as a necessary consequence, should not be increased in the blood. It is, I believe, conceded that, although * The Uraemic Convulsions of Pregnancy, Parturition, and Childbed. By Dr. Carl R. Braujj, etc, etc. Translated from the German by J. Matthews Duncan, F.R.C.P.S., etc., LS.-iS. De l'Albuminurie Puerperale et de ses Rapports avec l'Eclampsie. Par M. LE D'ICI'ecr A. Imbert Goubeyre. Memoire Couronne, dans la Seance Publique Annuelle. December, 1854. f See page 522. 506 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. albumen does occasionally exist in the urine Avithout a diminu- tion in the fluid of urea, yet the converse of this is very often observed, viz. an increase of urea in the blood coexisting with albu- minuria. This, therefore, is in direct conflict AA'ith the explanation of Robin. It is stated by Dr. C. I. P. Williams that, per se, " albu- minuria indicates nothing more than congested kidney." I shall, on the contrary, attempt to shoAv that other causes than simple congestion of the kidney Avill occasion albuminuria; and, in doing this, it will folloAv that Dr. Williams's opinion is far too exclusive. It is quite certain that the presence of albumen in the urine is not traceable to any one influence, for it is recognised under a great variety of circumstances, and I shall endeavor to prove that it is due to one of the folloAving causes : 1. A change in the com- position of the blood ; 2. A change in the kidney, either structural or dynamic ; 3. Pressure on the renal veins. 1. Change in the Composition of the Blood.—It Avas a favorite doctrine of the old-school-men that the blood contained certain deleterious elements, which could not continue in the system Avith- out generating disease. This, too, Avas the opinion of Sydenham, Pitcairn, Cullen, and others ; and the master-minds of the present day, with all their supposed progress, are compelled to admit that there is something more than mere conjecture in Avhat Avas formerly termed the "peccant humors." The organs through which these humors or poisons pass from the economy are called glands; and each gland has its specific office assigned to it—that is, one of these glands furnishes an outlet for one character of material in the blood, and another gland for a different substance. Thus, Avhile the liver is engaged in the secretion of bile, etc., and the kidney water, urea, etc., Ave find the intestines the media through AA'hich effete matters are throAvn off. These various offices are performed through Avhat is called secretion, the true nature of Avhich is still involved in mystery. It is true, Ave understand certain general principles respecting the secreting processes, but it cannot be denied that Ave are unable to explain many of the phenomena con- nected Avith this fundamental law of the physical mechanism. Al- though, therefore, Ave are ignorant of some of the processes con- nected Avith glandular elaboration in a state of health, yet it does not follow that Ave cannot explain many of the causes Avhich, inter- fering Avith healthy secretion, result in morbid action. In order to apply this reasoning to the question before us, Ave will suppose—Avhat will not be controverted—that in a variety of diseases occasionally accompanied by albuminuria, such as cholera, scarlatina, diabetes, etc., the constituents of the blood become changed by the introduction either of a poison or some other sub- stance. If this occur, it is quite manifest that the blood is no THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 507 longer normal, and because of its altered condition its elaboration in the kidney Avill also be modified; so that in lieu of the ordinary elements contained in the urine, Ave shall sometimes recognise albu- men, an absence of urea and other pathological phenomena. May this not be satisfactorily explained on the principle that the product of endosmosis will be modified in proportion to the changes in the fluid on Avhich it acts? Again : the blood is changed in pregnancy, various circumstances tending to this modification, viz. the forma- tion of kiesteine, the secretion of milk, the quantity of blood mate- rials passing through the circulation of the foetus, together with the diseases of the embryo itself, not to speak of its excretions, some of Avhich Ave know enter the blood of the mother. These, then, being so many influences capable of altering the constituents of the blood, Avill they not explain, at least in some instances, the occasional presence of albuminuria in the pregnant female ? 2. A Change in the Kidney, either Structural or Dynamic.— Every structural change in the kidney may result in albuminuria, but we do not yet comprehend in Avhat essentially these various changes consist. For example, though it may be true that the presence of albumen in Pright's disease, in scarlatina, etc., may be due to a desquamation of Bellini's tubes, yet this cannot be said of many other affections of the kidney in Avhich albuminuria exists, but in Avhich no desquamation takes place. Several interesting experiments have been made to prove that the urinary secretion is not absolutely dependent upon the nervous system by Scgalas,* and some of a more decisive character by Dr. Prown-Sequard ;f Avhile, on the other hand, it has been satisfactorily shown that the nervous system may, under certain circumstances, exercise a marked influ- ence over this secretion, as is demonstrated by the researches of Bracliet, J. Muller,J and Marchand. The latter has pointed out a very important fact connected Avith this subject. He produced in a dog not only all the symptoms of uraemia, after placing a ligature on the renal nerves, but also discovered urea in the blood, and in the matter vomited by the dog. Kramer is said to have detected albumen in the urine of animals, after dividing the sympathetic nerve in the neck. This, hoAvever, seems to need confirmation, as the same result has not fohWed the experiments of others. Dr. Sequard, after repeated trials, has failed in establishing the fact mentioned by Kramer. Budge found albuminuria after a puncture of the cerebellum; and CI. Pernard§ * Bulletin des Seances de l'Acad. de Med. de Paris. (Seances des 27 Aout et 23 Septembre, 1844.) f Experimental Researches applied to Physiology and Pathology, Philadelphia. 1852-3. P. 13. X Manuel de Physiol. Edite' par E. Littre. Paris, 1851. P. 391. § Comptes Rendus de l'Acad. des Seances de Paris, t. xxviii., p. 393. 508 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. occasionally obtained the same result from a puncture of the medulla oblongata. In addition, hoAvever, to these demonstrations, Ave haAre numerous instances occurring in practice illustrating the influ- ence of the nervous centres—when laboring under disease or trau- matic injury—over the urinary secretion ; and it is quite possible that the irritation of the uterine nerves during pregnancy, and in many of the diseases, both organic and functional, of the uterus itself, may, through reflex action of the medulla spinalis, produce various morbid changes in the urine. Again : it docs appear to me that, if it can be proved that sudden emotions, shocks, etc., have an influence on the peculiar processes by Avhich the blood is continu- ally ridding itself of its deleterious materials, Ave shall, in this Avay, haA'e opened to us a iicav field in our investigation of disease ; Ave shall be enabled to elucidate many morbid phenomena Avhich have heretofore been obscure, and, as a necessary consequence, deduce rational therapeutic principles. 3. Pressure on the Renal Veins.—Whatever may be the other causes Avhich operate in the production of albuminuria, there is a mass of irresistible testimony to demonstrate the positive influence of an obstructed renal circulation. G. Robinson,* Meyer,f and Frerichs, have abundantly proved that a ligature tied more or less completely around the renal veins Avill cause albumen to pass from the blood into the urinary secretion ; and again Avhen the renal veins haA'e become obliterated, in every instance in which the urine was examined, albuminuria Avas detected. Cases of this nature have been observed by Dance, Rayer, Duges, Velpeau, R. Lee, Cruveilhier, Stokes, Plot, Leudet, and others. In gestation, and especially in primiparae, albuminuria is often caused by pressure of the impregnated uterus on the renal vessels. Dr. Rose Cormack, ['think, Avas the first to call attention to this subject. Dr. ProAvn- Sequard has positively ascertained the influence of pressure upon the renal vessels, in a lady Avho had albumen in her urine during the ninth month of pregnancy. He placed her in such a position that the pressure Avas much diminished, and after a certain time the urine ceased to contain albumen. When the ordinary attitude was resumed, there AA'as soon a reappearance of albumen in the urine. In 106 multiparae, Plot detected albuminuria in eleven instances onlv, Avhile in ninety-nine primiparae thirty exhibited it. The pro- portion, therefore, for the former is as one to ten, the latter as one to three. This is a remarkable difference, and must be due to some special cause.;]' It is quite evident that albuminuria is of fre- * Medico-Chirurg. Transac. of the Royal Med. Chirurg. Soc. of London. 1843. Vol. viii., p. 51. f Gaz. Med. de Paris. 1844. P. 419. j Women in their first pregnancy present a very different condition of the abao- minal walls from those who have already borne children. In the former, these walla THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 509 quent occurrence in pregnancy, and oftentimes results in death. Imbert Goubeyre* states that of sixty-five pregnant Avomen attacked with albuminuria, twenty-seven died, five remained albu- minuric, and thirty-three were restored from tAvo to fourteen days after delivery. The frequency of puerperal convulsions in albu- minuric women is very great. According to the same author, of 159 Avomen laboring under albuminuria, ninety-four were attacked with convulsions. Calient and others have endeavored to show that albumen in the urine is caused by disease of the kidney. It cannot be denied that disease of this organ may coexist Avith gestation, and in such case the albuminuria may be traced to a morbid condition of"the gland; but to say that albuminuria cannot exist in pregnancy other than as a result of disease of the kidney is in direct opposition to Avell- established observation.J As a point of diagnosis, it may be incidentally mentioned that when albuminuria in pregnant Avomen is caused by Plight's disease, there is frequently some degree of amblyopia§ and even amaurosis, while in simple albuminuria produced by pressure of the womb on blood-vessels, the retina preserves its functions. M. Lecorche, a are firm and resisting; in the latter, on the contrary, they are relaxed, and have lost much of their original tension. For this reason, in primiparje the impregnated uterus is more perfectly in the line of the axis of the superior strait of the pelvic canal; while in multipara, the organ is disposed to fall forward, constituting ante-version, more or less, of the fundus. Precisely in proportion, therefore, to the inclination of the uterus forward from the direct line of ascent will be the probability of diminished pressure on tho renal circulation. I believe, also, there is another reason why albuminuria is observed less frequently in multiparae than in primiparae. It is a well-known fact that women are much more disposed to miscarry in a first than in subsequent preg- nancies ; and, cateris paribus, this is no doubt owing in a measure to the greater irritation of the uterine nerves consequent upon a first gestation. May not, there. fore, this excess of irritation, by modiiying the urinary secretion, be occasionally a" cause of the more frequent presence of albuminuria ? I think so; and again, when, under these circumstances, the passage of albumen into the urine is followed by urea in the blood, as is often the case, even admitting that full uraemia does not take place, may not the nervous system become so much disturbed by the presence of urea as to induce premature action of the uterus, and consequently miscarriage? If there be any force in this reasoning, the preventive treatment of miscarriage in this con- dition of system may prove far more successful than it has heretofore been. * Memoires de l'Academie Imperiale de Medecine. Tome xx. 1856. f De la Nephrite Albumineuse chez. les Femmes Enceintes. These Paris 1847 1 Blot demonstrates the fact as follows: 1. The rapidity with which albuminuria d.sappears after dehvery in almost every case, very often in two or three hours, some- times ... one, after the expulsion of the child. 2. Absence of the symptoms of dis- eased kidney. 3. Certain characters of the urine entirely different from those of- fing^ s .hsease, as for instance, increase in its density, and the presence of more salts, and particularly urates. 4. In seven women who died, and in whom albumi- nuria had been detected, only three had slight pathological alterations in the kidney. [De 1 Albuminurie chez les Femmes Enceintes. These, Paris, 1849.] § From u///?A«r dull, and uif, the eye. 510 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. pupil of Rayer, gives a table, shoAving that in H32 cases of Plight's disease, there was either amblyopia or amaurosis in 02 instances. The coexistence, therefore, of this symptom Avith albuminuria in the pregnant female should be regarded as grave. The opinion is noAV Avell settled, and concurred in by a great majority of Avriters, that albuminuria is, in many cases, simply the result of an active or passive congestion of the kidney. Anything, therefore, capable of obstructing the renal circulation, Avhether it be an enlarged uterus from pregnancy or disease, an ovarian tumor, or enlargement of the abdomen of any kind, may be enumerated among the causes of albuminuria. Christison, Rayer, and others maintain that the diminution of urea in the urine, and consequently its accumulation in the blood, is in proportion to the quantity of albumen, but this does not appear to be invariably the case ; for Pence Jones has recorded an instance of moUities ossium, in Avhich he presents an analysis of the urine, showing that albuminous matter may exist in great quantity, while the amount of urea remains per- fectly natural. Is Albuminuria always followed by Uramia?*—Th at the pre- sence of albumen in the urine is not necessarily followed by uramiiais amply proved by observation ; and it is important that this fact should be Avell understood, for the reason that much error has arisen from the opinion entertained by certain writers, that there is a direct connexion betAveen uraemia and albuminuria. This error is not so much OAA'ing to any inherent difficulty of the subject, as it is to that loose appreciation of facts, or, more properly speaking, to that want of healthy digestion of well-settled principles which, unfortu- nately, too often characterizes the Avritings of professional authors. I might cite a long list of observers to show that albumen very frequently exists in the urine Avithout any development of uraemic intoxication, but I apprehend this would be unnecessary. I shall, therefore, limit myself to two or three undoubted references. Franz Simon, for example, says he has frequently detected albuminuria in * It is important, in connexion with the subject under consideration, that tne cerm uraemia should be clearly understood. Uraemia consists in disturbed action of the two nervoQs centres—the brain and spinal cord—producing either coma, partial, or complete convulsive paroxysms; the disturbances being directly traceable to the action of a peculiar poison on these nervous centres. They may be affected separately or together; and hence, according to Carpenter, there may be three forms of uraemic poisoning: 1. A state of stupor supervenes rather suddenly, from which the patient is Avith difficulty aroused, soon followed by complete coma, with stertorous breathing, etc., as in ordinary narcotic poisoning; 2. Convulsions of an epileptic character, often affecting the entire muscular system, suddenly occur, but without loss of con- sciousness ; 3. Coma and convulsions may be combined. The existence of uraemia has been differently explained by authors; for example, some contend that it is due to albumen in the urine, others that it is caused by urea in the blood, while again both of these opinions have been rejected, and a new one advanced by Frerichs, viz. that uraemia results from the transformation of urea into the carbonate of ammonia THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 511 persons apparently in the enjoyment of good health; also others have observed it "in articular rheumatism, in inflammation of the thora-ic organs, intermittent and typhus fevers, in measles, cholera, and in chronic affections of the liver. In transitory renal catarrh, such, lor instance, as occurs in erysipelas nearly as often as in scarla- tina, albumen, together with the Avell-known epithelial cylinders of Pellini's ducts, is found as constantly in the urine as in inflamma- tory affections of the kidneys, Avhere it exists in connexion with the fibrinous plugs from the same ducts, as in true Pright's disease.* ^ Kdouard Robin says " the urine becomes albuminous in croup, in ascites, and in cases of capillary bronchitis, with emphysema, accom- panied by dyspnoea; in pulmonary phthisis, in gestation when suffi- ciently advanced to occasion a habitual congestion of the kidneys; in cyanosis, diabetes, etc., etc."f In order to prove that albumen may exist in the urine indepen- dently of any disease of the kidney, and without any of those nervous disturbances characteristic of uraemic intoxication, Dr. M. T. Tegart mentions the folioAving interesting and conclusive expe- riment upon himself, and also confirmed in the person of one of his friends: He made for some time a portion of his ordinary nourishment to consist of half a dozen eggs, and albumen, as a consequence, Avas soon detected in the urine.;"; Similar experiments have been made with similar results, by ParesAvil, CI.Bernard, BroAvn-Sequard, and Dr. Hammond of Baltimore. There are few practitioners of careful observation, Avho Avill not endorse these statements. Indeed, I consider the principle to be so well established that the existence of albuminuria is not necessarily connected Avith uraemia, that further citations can scarcely be neces- sary to demonstrate the fact. Is Urea a Poison/—Vrea was, I believe, first discovered in 1771, by Rouelle, Avho detected it in the urine. It OAves its present name, hoAvever, to Fourcroy and Vauquelin. It Avas obtained pure for the first time by Dr. Prout in 1817. There is an interesting circumstance connected Avith this production—it is the first instance knoAvn of an organic compound being artificially produced, and this Avas accomplished by Woler from cyanic acid and ammonia. The true action of urea is variously described by authors, the general opinion being that it is a poison. Todd,§ Williams,|| Cor- mack,-! Simon,*2 and others regard it in this light, and contend that * Physiological Chemistry. By Lehmann. T. i., p. 345. f Ed. Robin, London Lancet, January 24, 1852, p. 96. X "These sur la Maladie de Bright." Paris, 1845. Gazette Medicale, Paris, 1846. p. 39. § Lumleian Lectures, in London Med. Gaz. 1849-50 ] Principles of General Pathology. *f London Journal of Medicine. 1849. Pp. 690-699. *a Lectures on General Pathology, Amer. Edit., p. 151. 512 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. its presence in the blood Avill occasion coma, convulsions, and other nervous phenomena. Indeed, it may be said that this has been the general opinion; it is proper, therefore, that this opinion be examined. If urea be a poison capable of producing convulsions, etc., the numerous experiments made on living animals in no Avay establish the fact. Among others, Provost and Dumas,* Segalas, Tiedeman, Gnielin, Alitseheiiich, CI. Pernard, Pareswil, Stannius.f and Frerichs, have extirpated the kidneys, and have never knoAvn convulsions to ensue. This, it may be urged, is only negative proof. Negative, hoAvever, as it is, it must be admitted that it is testimony not Avithout value; and to it may be added the interesting experi- ments of Pichat, Courten, Gaspard, Yauquelin, Segalas, Stannius, Pernard, ProAvn-Sequard, Frerichs,;J; and others, Avho, after inject- ing into the veins urea and urine, never in a single instance observed a case of convulsions. Again: Plight, Christison, Rees, and Frerichs have cited cases in Avhich a large quantity of urea existed in the blood of man unaccompanied by any of the symptoms of uraemia; and Frerichs says, in one instance, in whicli he detected the greatest amount he had ever observed, there Avas no approach to uraemic disturbance. Yauquelin and Segalas, so far from regard- ing urea as a poison, have proposed to administer it as a diuretic. Some recent experimenters, hoAvever, especially Dr. Hammond and Mr. Gallois, affirm that they have observed convulsions in rabbits after the injection of urea into the veins. Put there is no proof that it was the urea itself Avhich caused the convulsions, and not some other principle resulting from decomposition of the injected substance. The conclusions, therefore, from these facts appear irresistible that urea, to say the least, is not a virulent poison ; its excess in the blood will not per se produce uraemic intoxication, nor will it explain the numerous phenomena Avhich are so frequently found to accompany its presence in the circulation. It Avas in view of all these circumstances that Frerichs attempted to demonstrate that uraemia depended neither upon a diminished quantity of urea in the urine, nor upon an excess of the substance in the blood, nor upon albuminuria; but that it is traceable solely to carbonate of ammo- nia in the system, which, he says, is formed through the agency of a ferment from the urea itself. In other words, Frerichs's doctrine is, that uraemia is exedusively due to the transformation of urea into the carbonate of ammonia. The modus in quo, hoAvever, of this transformation is not clear; there is no proof as to the manner in Avhich it is accomplished; but the major point, viz. dependence * Annates de Chimie et de Physique. f Gaz. Med. de Paris. 1841. p. 168. X Die Bright'sche Nierenkrankeit, 1851. Analysed in Braithwaite's Retrospect, 1852. Part xxv., p. 135. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 513 of uraemia on the presence of the carbonate of ammonia, seems to rest on strong and cumulative testimony. .Many years ago, Orfila produced convulsions in an animal by giving it, internally, the carbonate of ammonia; the animal, after becoming convulsed, died. Prown-Sequard has published the fol- loAving facts in Tessier's dissertation Sur V Uremic, Paris, 1856: Carbonate of ammonia injected into the stomach does not poison ; it is absorbed sloAvly and passes off through the lungs with carbonic acid. If, on the contrary, it be injected in a certain amount into the blood, it has time to act on the nervous system, and to cause convulsions before it is expired.* CI. Pernard and BaresAvil have detected carbonate of ammonia in the stomach and intestines of animals after the removal of the kidneys; and Lehmann has also observed it in the matter vomited by patients affected Avith cholera. Christison, Jakehs, and others, have recognised, under certain cir- cumstances, an ammoniacal odor in the blood. Until, hoAvever, the exposition of the peculiar views entertained by Frerichs as to the true cause of uraemic intoxication, no signifi- cant value was attached by authors to the presence of the carbonate of ammonia in the exhalations. Frerichs states that he has ascer tained, through chemical analysis, the existence of this salt in the blood in all cases in which the symptoms of uraemia are developed ; but its true quantity is subjected to considerable variation. He further remarks that the tAvo folloAving propositions he has proved beyond a doubt: 1. That in every case of uraemic intoxication, a change of urea into carbonate of ammonia takes place ; 2. That the symptoms which characterize uram ia can all be produced by the injection of carbonate of ammonia into the blood. After china- many experiments to fortify his opinion, he says he has frequently detected the alkaline salt in the expired air of animals deprived of their kidneys, and into the veins of Avhich he had injected urea- these animals remained quiet and awake as long as the expired air Avas not impregnated with the ammonia; but the moment the lat- ter Avas observed, the various disorders of the nervous system characteristic of uraemic poisoning developed themselves. These views of Frerichs will necessarily tend to the settlement of a vexed question, Avhich has called forth the ingenuity of both the physiolo- gist and chemist. It may, however, be that the future will reveal the existence of other poisonous materials in the blood Avhich, to the present time, have eluded observation; and, in their recoo-ni- tion, we may find additional causes for the production of toxaemia. It has, indeed, been suggested that, in Plight's disease, the accu- * Many facts have recently been developed in France, proving that the phe- nomena of uraemia must he due to some kind of poisoning. It has been shown by Piberet, Tessier, Picard, Rilliet, and Barthez, that in patients who have died from urrerma, there is no organic lesion of the nervous centres. aa 514: THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mulation of oxalic acid in the blood will develop the symptoms of uraemic intoxication. I may here remark that Praun attributes the death of children to the same cause as that of the mothers in cases of puerperal con- vulsions from uraemia, viz. to poisoning by carbonate of ammonia, which poison is found in the fcetal blood. Treatment of Uraemia-*—This necessarily involves tAvo objects: 1. The immediate restoration of the principal eliminators of the system, such as those of the kidney, skin, and bowels, with a view of diminishing, through these outlets, the quantity of urea and noxious elements, which may exist in the blood ; 2. The protection of the nervous centres, as far as may be, against the injurious effects of the carbonate of ammonia. In our therapeutic management of uraemia, it is important to remember that the skin contains an immense number of glands which, anatomically speaking, are similar to the corpuscles of Malpighi in the kidney, and which glands secrete Avater, urea, and salts. The various remedies, therefore, knoAvn to increase the cutaneous secretion should be employed in cases of uraemic poison- ing. With a vieAV of neutralizing the carbonate of ammonia in the blood, Frerichs has strong faith in benzoic acid, in doses of five or ten grains, together with iced acidulated drinks. Anaesthetics in Uraemia.—Chloroform and sulphuric ether have been repeatedly employed in these cases Avith very favorable results • and I believe the credit is due to Prof. Simpson of an ingenious explanation of the mode of action of these agents in uraemic poison- ing. Availing himself of an important fact pointed out by the chemists, that chloroform produces a temporary diabetes mellitus, causing, of course, the appearance of sugar in the urine, and, per- haps, also in the blood ; and that the addition of a little sugar to urine out of the body, prevents for a time the decomposition of its urea into carbonate of ammonia, the distinguished Professor sug- gests that the efficacy of anaesthesia in restraining and arresting the convulsions may be upon the ground of its preventing this decom- position.!; * Dr. Maelagan, of Edinburgh, has drawn attention to the value of the colchicum autumnale in uraemic poisoning. The excellence of this remedy consists in its power of increasing the amount of urea in the urine. This fact, I believe, was first dis- covered by Chelius, of Heidelberg. Professor Krahmer, of Halle, has made some very interesting experiments on the subject of diuretic medicines. According to him, the average of urea secreted during the day in healthy urine is 19 64 grammes, while the tables of Becquerel give 16 grammes. Krahmer has shown that, under the influence of colchicum, the urea is increased to 22.34 grammes, and under the administration of guaiacum to 22.74 grammes. From the experiments of Krahmer, therefore, it appears that colchicum and guaiacum produce a greater secretion of urea than any known remedies. Dr. Hammond (American Journal of Med. Sciences, 1859, p. 275) has also tested the superiority of colchicum over several other diuretic*. f Simpson's Obstetric Works, vol. vi. p. 827. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 515 Conclusions.—From what has been said, it appears to me the following conclusions may be fairly deduced: 1. Disease of the kidney will often produce albuminuria, but in a large number of cases albuminuria exists without true disease of the gland, as a consequence of an active or a merely passive con- gestion, and it will also result from a variety of nervous disturb- ances.* 2. Albuminuria is often connected with uraemia, but is not the cause of it. 3. Uraemia is a nervous disturbance arising from a peculiar blood- poisoning. 4. If urea be a poison, the quantity of it which accumulates in the blood in cases of extirpation of the kidneys in animals, or in sup- pression of urine in man, is not sufficient to produce any manifest deleterious effect. 5. According to Frerichs, uraemia is merely a poisoning by the carbonate of ammonia, which is a product from the decomposition of urea. 6. The treatment of uraemia must consist in the free use of diuretics, sudorifics, and purgatives; the most suitable diuretics for this purpose being colchicum and guaiacum. * Dr. Imbert Goubeyre (Memoires de l'Acade'mie Imperiale de M6decine. tome xx.) maintains that there is a puerperal albuminuria, and that it is symptomatic of, and nothing other than Bright's disease of the kidney; that there is a puerperal Bright's disease, as there is a puerperal peritonitis, etc. He also contends that puerperal eclampsia is actually puerperal Bright's disease, in which convulsions occur; in other words, that the eclampsia is but a symptom of albuminous nephritis or Bright's disease. Dr. Carl R. Braun (Uraemic Convulsions of Pregnancy, Parturi- tion, and Childbed) defines uraemic eclampsia as follows: "Eclampsia puerperalis is an acute affection of the motor functions of the nervous system (an acute neurosis of motility), characterized by insensibility, tonic and clonic spasms, and occurs only as an accessory phenomenon of another disease, generally of Bright's disease in an acute form (diabetes albuminosus, nephritis diffusa seu albuminosa), which, under certain circumstances, spreading its toxaemic effects on the nutrition of the brain and whole nervous system, produces those fearful accidents." If, then, we are to be guided by tho statements of these two distinguished writers, and accept their opinions on this question, we must believe that when puerperal eclampsia occurs it does so as the effect of Bright's disease of the kidney. From this hypothesis, too, it should follow that there will be a constant relation between Bright's disease and albuminuria and also between that affection and eclampsia. But such is not the fact; for it has been shown that albuminuria may exist without structural alteration in the kidney and also that tho various forms of Bright's disease may be present without the detection of albumen in the urine. (See Begbie, Brit. For. Med. Chirurg, vol xii p 46 ) Again: acute Bright's disease is not always accompanied by uremia and eclampsia • in 100 cases of Bright's malady, only from 60 to 70 were affected with uraemic eclampsia; and another extremely important fact is this-Bright's disease is not uniformly recognised in instances of fatal eclampsia. This latter circumstance is to my mind a very decided negative to the necessary relation between Bright's disease and uraemic convulsions. LECTURE XXXIV. Manual Labor—Version, divided into Cephalic, Podalic, Pelvic, and Version by Ex- ternal Manipulation—Diagnosis of Manual Labor; important that it should be made early—Prognosis, how it varies—Indications of Manual Delivery; in what they consist—Time most suitable for Termination of Manual Delivery—Undilated Os Uteri, means of overcoming—Mode of Terminating Manual Delivery; the various Rules to be observed—Divisions of Manual Delivery—Rules for correcting Malpositions of the Head—What are these Malpositions, and how do they Ob- struct the Mechanism of Labor ? Gentlemen—Your attention having been directed to the various causes of manual interference for the termination of delivery, you are noAv prepared for the discussion of the question—in what way is manual labor to be accomplished? Pefore, however, entering upon the particulars of this interesting subject, it will be proper to make one or tAvo preliminary observations touching version, or, as it is sometimes termed—turning. This operation consists in bring- ing doAAm to the superior strait one or other of the obstetric extremities of the fcetus, and hence it is divided into cephalic, pelvic, and podalic version ; in addition, there is version by external mani- pulation. In the former case, the head is brought to the strait; in pelvic version, the nates or breech; in podalic, the feet; while in external cephalic version, of Avhich Ave shall more particularly speak hereafter, an attempt is also made to bring the head doAvn. Cephalic Version.—In the earliest periods of our science this Avas the only kind of version adopted; indeed, Hippocrates and his contemporaries speak of no other, turning by the feet being in no Avay alluded to by them, and consequently it must not only not have been practised, but altogether unknown. It was not until the sixteenth century that version by the feet Avas commended to the attention of the profession, as a substitute for version by the head ; and although writers generally refer the credit of the suggestion to Pare and his pupil Guillemeau, yet it is but just to say that Franco preceded them both in the suggestion.* Guillemeau Avas the instrument in the seventeenth century of spreading the neAV view, and it Avas soon adopted by Mauriceau, the great obstetric authority of that age. From that period to the present, podalic version has been very generally adopted, while, at the same time, it must be * Franco was the first to describe and recommend version by the feet, which ho did in his Traite des Hernies, in 1561. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 517 admitted that version by the head has found its advocates even in our OAvn times.* Let us now proceed to discuss the general question of manual labor under the following heads; and, in doing so, I shall endeavor to present the Avhole subject in the most practical manner : 1. The Diagnosis; 2. The Prognosis; 3. The Indications; 4. The time most suitable for its termination; 5. The mode of termi- nating manual labor; 6. Its various divisions. 1. Diagnosis of Manual Delivery—It has already been stated —and it is important to recollect the fact—that the introduction of the hand into the uterus, or, in other words, manual interference, can only be useful either in cases of malposition of the fcetus, or in the event of the supervention during labor of certain accidents, such as hemorrhage, convulsions, etc., all of which accidents AAe have fully discussed. It, therefore, is manifest that the duty of the accoucheur, Avhen at the bedside of his patient, is to ascertain whether the relation of the foetus to the pelvis be such as to enable nature, through her OAvn resources, to accomplish delivery; or Avhether, in consequence of malposition, it will devolve upon him to render assistance. For example, if he should find the head at the superior strait, the question for him to determine is, does it present naturally ? If, on the contrary, one of the pelvic extremi- ties, either the breech, knees, or feet, should be there, is the posi- tion in accordance Avith the requirements of nature ? And again, should it be a cross-presentation of some portion of the trunk, necessarily involving the propriety of version, its exact position should be ascertained Avith a vieAV of proceeding to delivery. It may, however, be that, so far as the presentation and position of the foetus are concerned, everything is perfectly natural, yet the occurrence of hemorrhage, convulsions, or some other complication, may render necessary manual delivery. As to the propriety and time of having recourse to this alternative, the peculiar nature of the case and its exigencies must determine. Is there any special period more favorable than another for the vaginal exploration necessary to ascertain the true position of the foetus ? There is undoubtedly—and that period is as soon as possible after the rup- ture of the membranous sac, for then the parts are more or less relaxed, and fitted to facilitate the object in view. It may be con- sidered, as a very general rule, that the difficulty of arriving at a correct diagnosis with regard to the presentation, position, etc., and more particularly the difficulty of either changing a malposition * A late writer, Dr. A. Mattei, is quite enthusiastic on the subject of cephalic version; he says he invariably adopts it in preference to podalie. unless there should be some insuperable obstacle; and he expresses his belief that cephalic will soon entirely supersede podalic version. [Essai sur Accouchement Physiologique. Par A. Mattel Paris, 1S53. P. 183.] 518 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. into a natural one, or of accomplishing version, Avill be enheinced in proportion to the period which has elapsed since the escape of the liquor amnii; for when this takes place, the fcetus is embraced more closely by the uterine Avails; the contractions as a consccpience become more energetic, and the presenting part undergoes such intense pressure as oftentimes to render its recognition extremely difficult. Therefore, gentlemen, I cannot too emphatically impress upon you that there is a period of election for this kind of explo- ration, and if you will treasure the fact in memory, it will frequently aid you in rendering signal service to both mother and child. 2. Prognosis of Manned Delivery.—When AA'e consider the con- summate skill displayed by nature—if not contravened—in the expulsion of the child from the cavity of the uterus, and the safety with Avhich it is accomplished, Ave cannot be surprised that this safety is necessarily greatly diminished Avhen manual delivery is had recourse to; for science, however matured and complete, cannot equal the triumphs of nature, Avhen undisturbed by adventitious influences. And again, in a case of fearful hemorrhage, Avhere the poAvers of the system are near exhaustion, or in convulsions, Avhen it becomes necessary, as the only alternative, to proceed to artificial delivery, the chances of life either to mother or child, from all these circumstances, are evidently diminished if compared Avith a natural parturition. Even the adjustment of a malposition, AA'ith a view afterward of submitting the termination of the delivery to the resources of nature, will, to a certain extent, compromise more or less the safety of the mother and child, and the operation of version itself is by no means Avithout its dangers, as I shall more particularly mention when speaking of the manner of performing it. Therefore, in all cases of manual interference, it is a duty you OAve your patient, yourselves, and science, to exercise a frankness worthy of the noble profession you are pursuing, and to acquaint, not the patient herself, but the husband and friends more immedi- ately interested in her Avelfare, that Avhat you propose doing, although it is an alternative fully justified by the circumstances, will involve in a certain degree of hazard both mother and child. In this honorable and high-toned course you lose nothing, but will gain much ; for, besides the approbation of your OAvn con- science, you will establish a reputation for candor and honesty—tAvo essential attributes in the character of a physician, and Avhich will ahvays yield a handsome interest, so far as public patronage is concerned; and, after all, it is public patronage Avhich a medical man most needs ; but never let it be purchased at the cost of truth. 3. Indications of Manual Delivery.—The indications of manual delivery are not ahvays identical; for example, in one case there may be simply a malposition of the head, such as the presentation of the occipital or parietal regions ; this malposition may oftentimes THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 519 be corrected by the timely and skilful manipulations of the accou- cheur, and the termination of the labor left to nature; again, it may be that flexion of the head has not taken place, rendering its descent into the pelvic cavity physically impossible; here, the accoucheur by opportune interference may cause the necessary flexion, and thus remove the obstacle; should the occiput remain at one of the sacro-iliac symphyses, it should be brought to either one or other of the acetabula, Avith a view of curtailing the dura- tion of the labor, thus shielding both parent and child from the dangers of a protracted parturition. In a presentation of the breech, knees, or feet, it may also become necessary to have recourse to manual interference under either of the following circumstances: 1. In case the labor should be com- plicated Avith any of the accidents to which Ave have alluded, placing in peril the life of the mother or child, and, therefore, rendering immediate delivery essential. 2. If either of these extremities of the foetus should present at the superior strait irregularly; for example, in the presentation of the feet, or knees, if one foot or knee should be so situated at the strait as to resist the contractile efforts of the uterus. Again : in a head presenta- tion it may become necessary to terminate the delivery by bringing doAvn the feet, thus accomplishing the version of the fcetus; and, also, when any portion of the trunk presents, the alternative, under ordinary circumstances, will be version. I am thus particular, gentlemen, in the details of the indications of manual delivery, in order that you may at once appreciate the necessity of sound judgment and just discrimination in the management of these various forms of preternatural labor. 4. Thnemost Suitable for the Termination of Manual Delivery. —One of the fundamental principles in midAvifery, which should be constantly borne in recollection, is—that nothing will justify a forcible entrance into the cavity of the uterus; therefore, if the mouth of the organ be not so dilated or dilatable as to permit the introduction of the hand without violence, the operation should, under no circumstances, be attempted. So you perceive, the most suitable time for the accomplishment of manual delivery is as soon after the rupture of the membranous sac as possible ; or before the rupture, provided the os uteri be sufficiently dilated or dilatable, for at either of these periods the organ will be in a condition more or less favorable to the artificial termination of the labor. Suppose, hoAA'ever, that manual delivery be indicated, and, either from the length of time Avhich has elapsed since the escape of the liquor amnii, or from other causes, the mouth of the organ should be so firmly contracted and rigid as to preclude the possibility of intro- ducing the hand, Avhat, under these circumstances, is to be done? Are you to allow the patient to sink, or the child to be sacrificed, 520 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Avithout an eftbrt to saA-e them ? Here, you will have recourse to those agents best calculated to promote relaxation. If the patient be plethoric, your great remedy will be the lancet; should blood-letting be inadmissible, tolerant doses of tartar eme- tic or ipecacuanha—the former is preferable because more reliable —Avill be found essentially serviceable. Warm emollient injections into the vagina Avill also, in these cases, oftentimes have the hap- piest effect; and if it can be resorted to Avithout too much incon- venience to the patient, the warm hip-bath, or merely sitting over the vapor of hot Avater, may result most beneficially. I have on several occasions found this latter very efficient. Here, too, you will have an important auxiliary in the belladonna ointment 3j. of the extract to "5 j. of adeps. Let it be freely applied to the mouth of the uterus.* It is Avell to remember that, as exceptions to the general rule, cases Avill occasionally be met with in Avhich the os uteri Avill be in a state of complete relaxation, although the rupture of the sac and escape of the Avaters have occurred several hours previously. 5. The Mode of terminating Manual Delivery.—The rules to be observed in all cases in Avhich manual interference is called for are feAV and simple, and should be faithfully carried out. It is, I am quite sure, to the neglect of these rules that Ave are to refer many of the unfortunate results too frequently succeeding manual labor. The rules are as folloAvs: (a) As soon as the accoucheur has decided upon the necessity of interference, he should acquaint his patient Avith the fact; and, in doing so, care should be taken not to alarm her by the slightest intimation of any danger involved in the operation. The probabi- lities of the result should, on the contrary, as has already been remarked, be stated frankly to the husband and friends.f * It will sometimes happen that the os uteri resists all the means just indicated, and it will, therefore, in cases of urgent necessity, be proper to have recourse to what is known as artificial dilatation; this is to be effected in one of two ways, either through the agency of the fingers or an instrument. For the former purpose, one or two fingers may be cautiously introduced into the os, which will act both mechanically and physiologically in the accomplishment of the object. But when the safety of the mother or child depends upon a prompt dilatation, I should, in such an emergency, prefer incising the os uteri; the operation is without danger, and usually followed by rapid dilatation. In saying this, however, I would caution you against having recourse to it except in instances of full justification. The operation is performed as follows: the patient, on her back, is brought to the edge of the bed, one or two fingers are then introduced into the vagina, as far as the os. to serve as a guide for the probe-pointed bistoury, with which four or five small incisions are to be made in the anterior and posterior lips. Should hemorrhage follow—a very rare circumstance—injections of cold water or small pledgets of lint will readily arrest it. \ Some excellent authorities recommend, when it becomes necessary to have recourse to artificial delivery, whether manual or instrumental, to do so without communicaliug the fact to the patient. In my opinion this is bad advice, and should THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 521 (6) The patient should be placed crosswise, the bladder and rec- tum having been previously emptied, with her hips brought to the edge of the bed. I much prefer her to be on her back,* although many recommend that she should rest on her left side. If on the back, a fold of blanket to be placed under the hips, to prevent their sinking into the bed. The legs flexed at a right angle with the thighs, and held by two assistants as follows: let the left hand of the assistant on the right side be placed on the knee of the patient, and with the right hand in a state of supination placed on his lap, the assUtant should take hold of the foot of the patient, holding it steadily during the operation. Precisely the same thing Bhould be done by the assistant on the other side, with the excep- tion that he should place the right instead of the left hand on the knee, and grasp the foot Avith the left. The accoucheur is to be seated between the assistants. (c) The choice of the hand. This is important, for it Avill have mucli to do Avith the success of the operation. In all cases in which the feet present, the hand should be introduced correspond- ing with the heels of the foetus; Avhen the knees present, the hand corresponding Avith the tibiae; and in a breech presentation, the hand which corresponds Avith the posterior surface of the thighs. In a head presentation, the hand corresponding Avith the face, for the purpose of giving the natural curve or flexion to the body dur- ing the operation of version. In all other presentations, the hand corresponding AA'ith the point of the uterus at Avhich the feet are situated. (el) The hand not introduced into the uterus should be applied to the abdomen, Avith a vieAV of steadying the organ during the manipulation. (e) The hand to be Avell lubricated Avith oil, fresh lard, or some mucilaginous material; and, in case of version, the coat should be removed and the shirt sleeve rolled high up on the arm, care being taken also to anoint the latter. The accoucheur should be provided with an old sheet or apron for the purpose of protecting his dress. never be followed. The adroit practitioner, who possesses the confidence of his patient, can always obtain her consent to submit to whatever his judgment may deem proper. Besides, see in what a painful position he might possibly place him- Belf by attempting the operation without having previously admonished her of its necessity. In his attempt to act clandestinely, there would be more or less risk of rupturing the uterus, to say nothing of injury to the child, through the movements of the mother as soon as she became cognizant of what was going on. * I have on two occasions been obliged to deliver patients by version in a posi- tion not altogether convenient to them, but which greatly facilitated the operation- allowing them to rest on their elbows and knees. In both of these instances I had recourse to this position for the reason that the feet of the foetus corresponded with the anterior wall of the uterus. It will be at once seen how efficiently the position of the patients removed the embarrassment of the version. 522 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. (/) The hand to be introduced with fingers and thumb gathered in a conoidal form, and the time of a pain to be selected in carry- ing the hand into the vagina; it should at first be introduced from before backAA'ard, then the elboAv should be gently depressed, and the fingers given an upAA'ard direction parallel to the axis of the superior strait; but the hand should not be made to enter the ute- rus except during an interval of pain. (g) When the hand is introduced, it should pursue that portion of the fcetus corresponding Avith the posterior plane of the uterus, and in this way the difficulty AA'ill be avoided of confounding the shoulder AA'ith the hip, the elboAv Avith the knee, or the fingers Avith the toes. (h) As soon as the hand has reached the feet, one or both should be gently seized, and, in the absence of contraction, brought down to the superior strait. (i) The version of the foetus should be made during freedom from uterine contraction, and the patient desired not to bear doAvn or employ any effort until the feet are beyond the vulva. The opera- tion to be performed Avith great caution, " Tarde et secure"—sloAvly and securely being the governing principle in these cases. 6. Divisions of Manned Delivery.—It seems to me that the mul- tiplied divisions made by most authors of manual delivery can have no other effect than that of confusing the mind of the stu- dent, and Avearying the patience of the practitioner. The great object in teaching, I maintain, is to simplify as far as it may com- port Avith the nature of the subject discussed, so that the chief end of all instruction may be accomplished, viz. to be useful. With this view, therefore, I shall present to you the folloAving classifica- tion or divisions of manual labor, Avhich, Avhile they will embrace every practical indication that may arise in the lying-in room, Avill, I trust, commend themselves to your appreciation because of their liberation from unnecessary and complicated details. I am quite sure that the numerous refinements, if I may so term them, into which Avriters enter in their varied divisions not only lead to con- fusion, but so perplex the reader as to cause him to despair of understanding them. To obviate, therefore, this difficulty, and Avith a vieAV of exhibiting this important subject in a manner so simple and tangible that all may appreciate and comprehend it, I submit the folloAving classification of the circumstances in Avhich it may become necessary to have recourse to manual interference -.* First Division, embracing head presentations, and exhibiting two varieties; in the first variety, simple adjustment of the head from a malposition becomes necessary; or Avhen this cannot be accomplished, Aersion must be had recourse to; in the second vari- * The classification I propose is somewhat kindred to the one adopted by my old master, Capuron, but I think is more simplified. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 523 ety, version is indicated, in consequence of the occurrence of hemorrhage, convulsions, or other complications. Second Division, embracing pelvic presentations, viz., the breech, knees, and feet; this division also exhibits tAvo varieties ; in the first variety it may be necessary to interpose because of malposi- tion ; in the second, interference is called for because of the com- plication of some accident, rendering immediate delivery necessary. Tldrel Division, embracing trunk presentations, including those of the shoulder and arm. We shall noAv proceed to indicate in what Avay adjustment is to be effected in the folloAving positions of the head, embraced in the first division of our classification, viz., 1. Occipital region at the superior strait; 2. Either the left or right lateral region ; 3. When the head is not flexed ; 4. In occipitoanterior positions, Avhere rotation is not effected; 5. In occipito-sacro-iliac or posterior posi- tions, where rotation is not effected. First Division.—1. Manual Delivery when the Occipital Region presents.—The occipital region may present at the superior strait as follows—and, in either case, it will be physically impossible for the head to descend into the pelvic cavity Avithout a change of posi- tion: 1. The neck of the fcetus corresponds Avith the left acetabu- lum, Avhile the vertex is in apposition Avith the opposite sacro-iliac symphysis; 2. The neck regards the right acetabulum, and the vertex the opposite sacro-iliac symphysis. 3. The neck is at the right sacro-iliac symphysis, the vertex at the left acetabulum; 4. The neck at the left sacro-iliac symphysis, the vertex at the right acetabulum. With a little reflexion, and bearing in memory what we have said respecting the fundamental conditions on Avhich is based the mechanism of natural delivery, it must be quite manifest that, in either of these positions of the occipital region, there is an uro-ent necessity for prompt interference on the part of the accoucheur. It is in cases like these, in Avhich the proper time for action being per- mitted to pass unimproved, that Ave find so much of disaster in the lying-in room. Here, for example, the contractions of the uterus— no matter hoAV vigorous—could prove of no possible avail in accom- plishing the delivery, for the reason of the physical disproportion, caused altogether by the malposition, between the head and mater- nal pelvis. Therefore, Avith a continuance of the uterine effort, and no adjustment of the abnormal presentation, the death of the child Avould be certain; and fortunate Avould it be for the mother, if she too avcre not sacrificed, from either exhaustion or rupture of the uterus! Let me then, in connexion with the case under considera- tion, again enjoin upon you the necessity of early acquainting your- selves Avith the true condition of things, so that your interposition may be opportune. Delay in arriving at an accurate diagnosis is 524 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. oftentimes, in these and kindred instances of disproportion betAA'een the organs of the mother and the presenting portion of the foetus, the cause of embryotomy or other operations, Avhich Avould not have been called for if a proper degree of vigilance had been exer- cised. Supposing, then, that a careful vaginal examination should dis- close the fact that the occipital region of the child's head presented at the superior strait, the accoucheur Avill be compelled to do one of tAvo things : either to adjust the head by placing it in a normal position, or, if this cannot be done, he must resort to version. The proper time for adjusting the head AA'ill be when the parts are soft and relaxed, and the head consequently more or less movable ; for this purpose the hand should be introduced, as already indi- cated, and the vertex brought in proper position AA'ith the strait; this being accomplished, should no accident intervene to render immediate delh'ery necessary, the termination of the labor may be committed to the efforts of nature. If, hoAvever, it become impos- sible to right the head, either by the hand or lever, the course to be pursued is to proceed at once to turn and deliver. 2. Manual Delivery, when either of the Lateral Regions of the Head Presents.—If the head should present so that one of its lateral regions rests across the superior strait, there will be a physi- cal impossibility for it to pass without change of position ; for, in such case, the largest diameter of the head—the occipito-mental— measuring 5^- inches, is in apposition Avith one or other of the oblique diameters of the strait, Avhich, you will recollect, is only 4£ inches; rendering it, therefore, out of the question for a body of 5i inches to make its exit through a space of 4^ inches. Here, too, there is a palpable necessity for early ascertaining this character of presentation, for, if it be permitted to remain unchanged under the influence of strong uterine contraction, serious consequences may ensue both to mother and child ; the former incurring the hazard and consequences of exhaustion and rupture of the uterus; the latter the serious, if not fatal, effects of undue pressure. Re- member, also, that under these circumstances, if there be unneces- sary delay, the dreaded alternative of embryotomy may become the last resource! The lateral regions of the head may present as folloAvs: First Position.—The vertex is in apposition with the left aceta- bulum, and the base of the cranium regards the opposite sacro- iliac symphysis. (Fig. 65.) Second Position.—The vertex is at the right acetabulum, and the base of the cranium at the opposite sacro-iliac symphysis. Third Position.—This is the reverse of the first, and eonse. quently the vertex is at the right sacro-iliac symphysis, and the base of the cranium in correspondence Avith the left acetabulum. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 525 Fourth Position.—This is the reverse of the second, the vertex being in apposition with the left sacro-iliac symphysis, while the base of the cranium is at the right acetabulum. Hoav can these four positions be distinguished in a vaginal examination, so that you may be able to recognise them individually? This is very readily accomplished by sim- ply ascertaining the exact po- sition of the ear of the child; for example, in the first posi- tion, if it be the right side of the head, the concave border of the ear regards the left iliac fossa; and the right iliac fossa (Fig. 65) if it be the left side of the head. In the second position, the relation of the ear Avith the points of the pelvis is the same as in the first position for each side of the head. In the third position of the right lateral region, the concave border of the ear is turned tOAvard the right iliac fossa, Avhereas the convex border corres- ponds Avith the fossa, if it be the left lateral region. In the fourth position, the concave border of the ear corresponds Avith the right iliac fossa, if it be the right lateral region ; if, on the contrary, it be a presentation of the left lateral region, the convex portion of the ear regards this same fossa. Let us noAV suppose that you are in the lying-in chamber; your patient is in labor, and you have ascertained that one of the lateral surfaces of the child's head presents at the superior strait. The very knoAvledge of this fact admonishes you that nature is at fault; she needs assistance, and the result of the labor AA'ill depend very much on the kind of assistance rendered—whether, for example, it be opportune and efficient, or tardy and unskilful. The indications in a ease like this are tAvo-fold, either to right the head by bringing the vertex to the strait, and then committing the achievement of the delivery to the natural efforts; or, if the adjustment of the maljiosition cannot be accomplished, then the necessity will be to terminate the labor by version. With a vieAV of righting or adjust- ing the head, the hand should be cautiously introduced, and the attempt made, if in the first position, to raise the base of the cra- nium from the right sacro-iliac symphysis (Fig. 65), Avhile with the Fio. 65. 526 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. other hand applied to the abdomen, gentle pressure should be directed on the left iliac region, for the purpose, if possible, of depressing the vertex in proper position. Hut if all attempts to right the head fail, then the indication is at once, if the parts be in proper condition, to proceed Avith the version of the foetus, the details of Avhich operation Ave shall discuss in a subsequent lecture. Manual Delivery, Nature being unable to accomplish Flexion.— In describing the mechanism of natural labor, it Avas stated that the head, AA'hen nature is not interrupted in her resources, under- goes three movements previous to its expulsion, viz. 1. Flexion; 2. Rotation; 3. Extension. The object and mode of production of these movements Avere fully explained at that time. Well, you are again in the lying-in room; the head presents in the most natural position, the posterior fontanelle regarding the left aceta- bulum, and the anterior the opposite sacro-iliac symphysis; the contractions of the uterus have commenced, and increase in energy; the os uteri, under their influence, dilates, but there is no change in the head; time passes on, the contractions lose nothing of their vigor, but rather increase in poAver. On a vaginal examination, you ascertain that the head is still unchanged from its primitive relations with the superior strait; there is unusual heat in the vagina, the scalp is corrugated or in ridges, and the patient's strength is giving way. Koav, gentlemen, permit me to ask you, what do these symptoms disclose ? Do they not, in the most emphatic manner, portend trouble, and inculcate that nature is oppressed by some obstacle, which she is vainly struggling to overcome ; and do they not urgently call upon you for prompt and efficient succor? Do not misinterpret this silent but eloquent appeal of nature, in the hour of her tribulation! Decision and promptness here will enable you to save human life, and draw from grateful hearts the im-ocation of the blessings of heaven upon you. The well-educated accoucheur will perceive at a glance the true nature of the difficulty; he will recognise the important fact that, with all the efforts of the uterus, the flexion of the head has not been accomplished, and, as a consequence of the failure to bring about this movement, the first link in the mecha- nism of labor is wanting; under these circumstances, the vigorous uterine contractions have been lost in the abortive attempt to accomplish the physical impossibility of causing a body of four inches and a half to pass through a space of only four inches and a half; for you AA'ill remember that the occipito-frontal diameter, which measures in the clear four inches and a quarter, receives the addition of a quarter of an inch by the thickness of the scalp, hair, and sides of the uterus, thus making the aggregate of four inches and a half to make its exit through the oblique diameter of the superior strait, which presents these same dimensions ! Here, then, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 527 is an opportunity for the exhibition of true science, Avhich is ever in striking contrast with ignorance and empiricism. One of two contingencies will present itself in the case such as we have just described ; the suffering patient will have by her side a medical man, whose previous education entirely unfits him to appreciate the nature of the difficulty, and who consequently will be in the clouds as to what should be done to overcome the obsta- cle ; or it will be her good fortune to be attended by an accoucheur who has studied in the school of nature, is thoroughly imbued with the principles which ordinarily guide her in the parturient struggle, and who, therefore, is prepared promptly and efficiently to become her substitute in the hour of need. In the former case, ignorant of the true cause of the delay, the medical man Avill content him- self with assurances to the patient that "all is right; " he Avill tell her to make the " most of her pains," and soon all Avill be over. These stereotyped expressions, the language of ignorance, may serve for a short time to cheer and infuse hope into the mind of the patient, and appease the anxiety of friends; a very few hours, however, will elapse before the predictions, so confidently made, will be proved to be false; the strength of the patient has entirely given way in consequence of the unavailing effort of nature to cause the flexion of the head—the severe pressure to which this latter has been subjected has resulted in the death of the fcetus ; and the head, from the long-continued contractions of the uterus, has become so firmly wedged at the superior strait as to render any effort to move it impossible. This is a sad picture; under the cir- cumstances, the alternative may, perhaps, be craniotomy, which Avill, in the existing condition of things, most probably compro- mise the life of the mother. Let us iioav reverse the scene. Science takes the place of igno- rance ; the Avell-instructed accoucheur, knoAving that an important part of his duty, in the lying-in room, is opportunely to ascertain when nature is defeated in her plans, so that he may at once be prepared to interpose, will not remain a passive spectator of her unavailing struggles, but AA'ill proceed by a proper examination to inform himself of the true cause of the delay in the descent of the head. He soon becomes aware that the efforts to produce flexion have proved abortive; and in lieu of waiting until the work of death has been accomplished, so far as regards the fcetus, and the life of the mother subjected to the most serious peril, he proceeds to do for nature Avhat she has vainly labored to accom- plish for herself—in one Avord, he produces the flexion of the head in the following manner: placing the patient on her back—or, if she prefer it, on the side—the accoucheur gently introduces his hand into the vagina, steadying the uterus with the other hand placed on the abdomen, and with the middle and index fingers 528 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. applied to one os parietale, and the thumb to the other, he cau- tiously, during the absence of a pain, elevates the face and depress- es the occiput, Avhich necessarily results in the desired movement, A'iz. flexion. This timely interference—founded on a knowledge of the principles on Avhich rests the mechanism of labor—over- comes the obstacle, securing safety to both mother and child, and ensures to the medical man the enjoyment of a consciousness that he has performed his duty. 4. Manual Delivery in the Occipitoanterior Positions when Rotation is not effected.—The contractions of the uterus, avc will suppose, have, as they ordinarily will, sufficed to cause the flexion of the head ; after this movement, you will recollect that the head rests diagonally in the pelvic cavity, and continues to do so until it has undergone rotation, the effect of Avhich is, in the occipito- anterior positions, to bring the occiput under the symphysis pubis, and the face into the hollow of the sacrum.* But it will sometimes happen that nature cannot effect this rotary movement—under these circumstances, the same phenomena will present themselves as in the case of non-flexion—undue pressure upon the head, corru- gated scalp, exhaustion of the mother, and serious hazard to the child. What is to be done ? Introduce your hand, and rotate the head ; if the hand be not sufficient, then recourse must be had to the forceps; the instrument to be applied in the manner I shall point out Avhen treating of operative midwifery. As soon as it has properly grasped the head, the movement of rotation can be accom- plished Avithout difficulty. This being effected, the instrument may be AvithdraAvn, and the termination of the delivery confided to nature; should it, however, be found necessary, from the condition of the mother or other circumstances, promptly to achieve the labor, this may be done by the forceps. 5. Manual Delivery in the Occipito-sacro-iliac Positions when Rotation is not effected.—We have, in speaking of vertex presenta- tions and their relative frequency, directed particular attention to the discrepancy of opinion as to Avhich is the second most frequent position of the vertex; and Ave have endeavored to account for this discrepancy by showing that authors have arrived at conflicting results for the reason that the basis of their calculations depended upon the circumstance—that their examination Avas made at different periods of labor. Before the time of Naegele the very general, indeed the universal opinion obtained that the second position of the vertex, in the order of frequency, was when the occiput corre- sponded with the right acetabulum. Naegele, however, established the fact that, although it is true the occiput is in correspondence with the right lateral portion of the pelvis, as the second most * Lecture IV, p. 48. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 529 common position of the head, it is only so after a certain progress has been made in the labor. He maintains that, primitively, the vertex is found to present second in frequency when the occiput is at the right sacro-iliac symphysis, and the forehead at the left acetabulum ; but at the same time admits that the tendency of the head, in either of the occipito-posterior positions, is to disengage itself by turning the occiput toward one or other of the anterior lateral portions of the pelvis. Indeed, so generally does this spon- taneous conversion take place, that Naegele himself states, in 1244 occipito-posterior positions, in seventeen instances only did he observe the labor to terminate Avith the occiput traversing the posterior Avail of the pelvis. So you perceive that, Avhen in these positions the change into anterior ones does not take place, the circumstance is entitled to be regarded as an exception to an almost universal rule. If, however, you should meet Avith one of these exceptional cases, my advice would be to do what nature has been unable to accom- plish, viz. bring the occiput toward one or other of the anterior and lateral points of the pelvis, depending upon, the particular posterior occipital position, which the head may have originally assumed ; for instance, the right posterior occipital is to be brought to the right anterior point, and the left posterior occipital to the left anterior point. There are two motives for doing this: in the first place, it is following the course of nature Avhen she is not interrupted ; and secondly, it will render the duration of the labor much shorter, for the reason that, in the occipitoanterior positions, the occiput will have to traverse only the length of the symphysis pubis, Avhile in the reverse positions it must pursue the entire length of the sacrum and coccyx. This increase in the ordinary duration of labor Avould necessarily expose the infant to the danger of protracted pressure, and the mother to the evils of exhaustion and other serious contingencies. This embraces the first variety of the First Division of our classification of head presentations in manual delivery ; and it will be found, I hope, both simple and practical. The second variety of the First Division Avill be discussed in the succeeding lecture. 34 LECTURE XXXV. Manual Labor continued—Certain Complications of Labor rendering Manual Inter- ference necessary—What are these Complications?—Podalic Version, or Turning by the Feet—Rules for Podalic Version—Should one or both Feet be seized ?__ Manner of Delivering the Child after the Feet have been brought to the Superior Strait—Rules for Extracting the Shoulders—Rules for Extracting the Mead__ Appalling Consequences of Ignorance—Case in Illustration—Pelvic Version- Cephalic Version by Internal Manipulation—Cephalic Version by External Manipulation—Prerequisites for its Performance—Mattei and his Views; Objec- tions to—Version in Cases of Pelvic Deformity, recommended by Denman—Prof. Simpson's advocacy of Version in Deformed Pelvis—Examination of his Opinion- Objections to Version in these Cases. Gentlemen—In the second variety of our classification of head presentations, in manual delivery, are to be included those cases in AA'hich the termination of the labor is effected by version; not because of any malposition of the head, but because of the occur- rence of some accident rendering prompt delivery absolutely necessary, either for the safety of the mother or child. We \\ ill imagine, for instance, everything is proceeding most auspiciously— the head presents in a natural position, the pains are normal, and there is a proper correspondence betAveen the maternal organs and foetus. Under these favorable circumstances, hoAvever, the sky may become suddenly clouded, indicating a storm, and the severity of the storm, if you Avill permit me to carry out the figure, may be imagined by the character of the cloud. Let us illustrate. Sup pose any of the accidents, in this favorable condition of things, capable of complicating natural labor should occur—such as hemor- rhage or convulsions. Here, the safety of the parent and child will necessarily be involved in more or less peril, and the degree of peril Avill depend very much on the gravity of the convulsions, hemor- rhage, or whatever else may represent the complication. It is to be borne in mind that artificial delivery will be indicated, not simply because the parturition is complicated with some accident, but because that accident—whatever it may be—has assumed a phase Avhich, without an immediate termination of the labor, will compromise the lives of mother and child. We will now imagine that such a case presents itself, and you have determined, as the most rational alternative, to resort to version. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 531 Podalic Version.—llow is this operation to be performed? In the preceding lecture, some general rules were given, necessary to be observed in version; in addition to Avhat Avas then said, Ave shall noAv call your attention to a feAV details essential to be recollected Avhen the operation of podalic turning is indicated. In the first place, I hold it to be a fundamental principle—one not to be for- gotten—that version should never be attempted after the head has escaped through the mouth of the uterus; and for tAvo important reasons: 1. After this es- cape, it will be impossible to return the head ; 2. The attempts to do so AA'ill incur the serious hazard of rup- turing the organ, or the vagina itself, or inflicting injury on the head of the foetus. Again : should the head have descended into the pelvic cavity, although still Avithin the uterus—and this Avill sometimes occur—the indication, as in the former case, AviU be to resort to forceps deliveiy, in prefer- ence to version. The hand, it has already been stated, should be in- troduced into the vagina in a conoidal shape during a pain, but not carried into the uterus except in the absence of pain ; the other hand to be applied to the abdomen for the purpose of steadying the Avomb. As soon as the hand has entered the cavity of the organ, before attempting to reach the feet, the first thing to do is cautiously to spread its palmar surface over the face of the child, and endeavor to place the occipital region in the opposite iliac fossa, by gently elevating and pressing with the hand thus expanded over the face. (Fig. 66.) This is a very material rule, and you cannot but appre- ciate the great advantage it affords in the successful performance of the operation. By placing the head in one or other of the iliac fossae, you at once provide sufficient space for the easy introduction of the hand and arm into the uterine cavity. 532 THE PRINCIPLES AND PRAt'TICK OF OBSTETRICS. As a general rule, when the hand has entered the mouth of the organ, this latter is throAvn into more or less violent contraction ; AA'hen this oc- curs, the hand must remain quiet until the contraction has expended itself. As soon as the uterus is freed from the contrac- tile effort, then the hand, Avith its palmar surface spread out on the surface of the child, is to be carried upward (Fig. 67), Avith a vieAV of searching for tho knees or feet. It is a mis- take to suppose that it is necessary always to seize the feet in podalic version (Fig. 68); if you can grasp the knees, either one or both, then by gentle trac- tion on them you Avill rea- dily succeed in bringing the feet doAvn to the su- perior strait. Is it essential to seize both knees, or both feet ? If both of either of these extremities can be conve- niently grasped, then it is well; but it is by no means essential, for Avhether one foot or one knee be seized, it should be brought doAvn, and the other will soon folloAv; should it not, the hand can readily be carried up again ; but this is rarely necessary. When the extremities are grasped, traction is not to be made except dur- ing the absence of pain, while these extremities are Fig. ea Avithin the uterine cavity Fig. 67. THE PRINCIPLES AND PB.ACTICE OF OBSTETRICS. 533 Fig. 69. (Fig. 69.) One of the principal dangers to the child, in the operation of version, is from undue pressure of the umbilical cord; therefore, great caution is necessary in your manipulations to avoid compressing the cord, for fear of interrupt- ing the circulation be- tAveen the placenta and fcetus ; and be careful, too, not to detach the cord from the umbilicus, Avhich might possibly happen, through Avant of proper caution, especially if it should be curtailed of its ordinary length, by being coiled around the neck or limbs of the child. Delivery of the Lower E'"re/nltles and Trunk.— Well, you have succeeded in bringing down the feet to the upper strait (Fig. 70), or Avithin {he vagina, Avhat next ? If the indications for immediate delivery be not urgent, the termination of the labor may be submitted to the resour- ces of nature; on the con- trary, if the life of mother or child be in peril, admitting of no delay, then you are to proceed as folloAvs: employ- ing the hand corresponding Avith the heels of the child, and gently seizing the loAver limbs above the ankle, trac- tion during a pain, is to be made downward and back- ward in a line parallel to the axis of the superior strait; as soon as the limbs have passed beyond the vulva, they should be enveloped in soft linen in order to Fia. tol 534 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. protect them against injury from pressure of the hand ; then the tAvo limbs should be seized, respectively, taking care to extend the thumbs lenorthwise on the posterior or anterior surface of each, as the case may be, in order that every precaution may be observed to avoid bruising Fig. 71. Fig. 72. them (Fig. 71); the tractions are to be continued, combining with them a movement of slight elevation and depression; when the hips reach the vulva, the hands are to be placed transversely across them, and the same moA'ement of alternate elevation and depression continued (Fig. 72) ; as soon as the hips have escaped, the child should be supported by the pal- mar surface of one hand, Avhile with the index and middle fingers of the other carefully introduced along the abdomen, the accouch- eur should bring doAvn a loop of the cord, in order to prevent the possibility of lacerating it at the umbilicus during the progress of the delivery ; in making this loop, traction should be used on the pla- cental extremity of the cord (Fig. 73). This being accomplished, the combined movement of traction Fig. 73. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 535 is to be continued until the entire body of the child is delivered except the shoulders. Delivery of the Arms— When the shoulders reach the external or-ans it will be necessary to attend to the delivery of the arms; the one which is below is to "be extracted first, and for this purpose the child being supported on the forearm of the accoucheur, he glides the index°and middle fingers of the right hand (if it be the first position of the vertex) along the arm of the child as far as the humero-cubital articulation, and Avith the thumb in the holloAV of the axilla, the arm is brought successively over the side of the head, the face and the neck; when delivered it will be on the right of the vulva. The child is then placed on the right arm of the accoucheur, and the two fingers of the left hand are introduced for the purpose of extracting the other arm, which is above, the mechanism of which is precisely the same as in the other instance (Fie.'. 74). Extraction of the Had.— You may, perhaps, suppose that after the entire trunk has been liberated, the difficulty is at an end, and the successful termination of the delivery at hand. But such is not always the case—indeed, the most im- portant, and oftentimes diffi- cult part of the operation is yet to be accomplished—I mean the extraction of the head; and here, permit me emphati- cally to admonish you that it is not to be delivered by brute force, but in accordance with the laws goArerning the mecha- nism of labor. Unfortunately, the recollection of this fact is too often unheeded, and the most disastrous results ensue. Ihave witnessed someappalling examples of mismanagement in these cases, avcII calculated to make the medical man pause, and reflect on the measure of his obligations in the sick-room. In order that you may fully appreciate the importance of this question, and with a vieAV of animating you to a just consideration Fig. 74. 536 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of your duties Avhen science is needed to take the place of natural effort, Ave Avill suppose that the operation of Aversion has been per- formed, and the entire child delivered Avith the exception of the head. After the shoulders and arms have been extracted, you find some obstruction to the descent of the head ; you make traction on the body of the child, hoping in this Avay to overcome the difficulty ; there is, hoAvever, no response to these efforts; you desist for a time from all further action; the mother becomes impatient, the friends are anxious, and you are importuned to do something to achieve the delivery. Tractions are again resorted to, but Avithout any avail except to augment the impatience of the mother, and the anxiety of her friends. You are questioned as to the cause of the delay; you make some excuse, as unsatisfactory to yourselves as to those aa'Iio seek the information ; time still rolls on, and still no delivery. All confidence is lost in you; silent but Avithering evi- dences of rebuke take the place of smiles and pleasant Avords; a consultation is demanded ; some medical man, versed in his science and adequate to the emergencies of the lying-in chamber, is requested to meet you. He receives from you a history of the case ; he examines the patient, discovers at once the real cause of the obstruction, and proceeds, Avith your concurrence, to remove it. In a very feAV moments, he accomplishes Avhat you have vainly endeavored for hours to do, simply because, in the first place, he possesses the requisite knoAvledge, and, secondly, brings it to bear on the case in point. What is it he does? He supports the child on the anterior surface of his arm, and Avith the index finger of the corresponding hand introduced into the vagina very soon ascertains the true nature of the obstacle to the descent of the head—this latter is resting obliquely at the superior strait with its great diameter—the occipito-mental, measuring five and a quarter inches—over the oblique diameter of the strait, Avhich you AA'ill recollect gives but four ana a half inches. Your tractions, therefore, haAre been unavailing for the reason that they Avere exhausted in the futile attempt to OA'ercome the physical impossibility of causing a body of five and a quarter inches to traA'erse a space of only four and a half inches! But, as I shall presently tell you, these tractions are occasionally more than futile ; they sometimes result in the de- struction of the child, a spectacle almost too shocking to dAvell upon! The nature of the obstacle being clearly ascertained, the accou- cheur proceeds to overcome it as folloAvs : he places the index and middle fingers of the hand already in-the vagina just beloAv the orbits, or it AA'ill suffice to introduce the index finger into the mouth ; and while he gently makes traction doAvnward, with the corres- ponding fingers of the other hand applied to the occiput, he elevates THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 537 this latter so that the combined movement results in approximating the chin to the.sternum, or, in other Avords, producing the movement of flexion (Fig. 75); this being accom- plished, he then rotates the bead bringing the occiput under the symphysis pubis, and the face into the hollow of the sacrum; as soon as the perineum is pressed upon, he has it supported by an assistant, and with a com- bined lateral and extractive force delivers the head. The entire operation can oftentimes be performed by the accomplished accou- cheur in the brief time I have taken to describe it. The simple question noAV arises—Avhy has he suc- ceeded, and why have you failed? His success is the direct offspring of know- ledge; while your failure is the result of ignorance. He has stu- died and comprehends the mechanism of labor; he knoAvs that the head, Avhether it be at the superior strait, first or last, must undergo three movements: flexion, rotation, and extension; and he also understands it to be his duty, Avhen nature is contravened, to per- form these movements for her. Let us noA\', for a moment, look at the relative position of the two medical men so far as the judgment of the patient and her friends is concerned. You, Avho have been inadequate to the exigencies of the case, AA'ill be scorned as utterly unfit for the requirements of your profession; and scathing, indeed, will be the censure, should the patient exclaim—Doctor, you could have saved my child if you had understood your business, for I felt it move for several minutes after its little body was in the world! Would not such language to a medical man, whose dereliction of duty has righteously called it forth, be the very cup of bitterness itself! Hoav different with him, Avho has so promptly exhibited the proof of both knowledge and skill. He has vindicated science, and imposed upon the patient and friends an obligation, AA'hich, if their hearts be in the right place, they never will believe can be cancelled. Case in Illustration.—I could cite several melancholy examples 538 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. of barbarous practice in these cases, to which I have been called, merely, as it were, to bear testimony to the merciless destruction of human life; but I prefer, Avith the hope of impressing upon you the sacred responsibilities of duty, to bring before you a most heart- rending instance, mentioned to me by my friend and colleague, Prof. Valentine Mott, as having occurred in his practice some years since : An unfortunate Avoman, a prostitute, Avas taken in labor with her first child. A physician Avas summoned to attend her; finding it to be a case of shoulder presentation, he requested a con- sultation ; after much delay and great suffering, version Avas effected. The child Avas delivered Avith the exception of the head; to overcome the obstacle, simple brute force Avas resorted to ; the child's body constituted a lever upon Avhich the most violent trac- tions Avere made, but all Avithout avail; a napkin Avas then attached to the body, and Avith this double lever the force Avas reneAved—the two medical men straining every effort to bring, under this increased pressure, the head into the Avorld. Nature could not long resist this combination of poAver, and the result was—the body Avas torn from the head, the latter still remaining undelivered ! Under these circumstances, Prof. Mott was sent for ; he found the patient in almost a moribund state ; in making an examination per vaginam, an extensive laceration of the neck of the uterus Avas discovered, through Avhich the detruncated head had escaped into the abdo- minal cavity! Here was a case in which science was paralysed, for the dying state of the unhappy sufferer rendered any effort to rescue her out of the question. This woman, prostitute as she Avas, and, as might be supposed, lost to every sense of refined feeling, exhibited a few moments before her death the strongest evidence of a philanthropic heart; evidence which, while it developed sym- pathy for the Avoes of others, was a telling rebuke to those Avho had participated in the act of her destruction. Her last words Avere these: " For God's sake, doctors, after I am dead examine my body, so that you may know how to relieve any one who may here- after suffer as I have done !" What a lesson do these words inculcate, and how graphically do they portray professional respon- sibility. Statistics of Podalic Version: Frequency.—Dr. Churchill has collected a total of 505,691 cases in Avhich version was performed 4,133 times, or about one in 122^. These cases are tabulated as follows: English Practice.—71,483, version 247 times, or 1 in 247.* * Mr. E. Garland Figg has recently published some papers on the subject of ver- sion which, to say the least, are startling in the views they inculcate. It would really seem that this gentleman has discovered in the operation of Turning an ele- ment of safety for the parturient woman far more reliable than anything in the resources of nature. He tells us that since writing the papers alluded to he has THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 539 French Practice.—40,376, version 451 times, or about 1 in 89£. German Practice.—393,823, version 3,393 times, or 1 in 116. Mortality to the Mother—-In 2,939 cases, in which the result to the mother is specially mentioned, 211 died, or nearly 1 in 14 ; it must be remembered, however, that this result is merely approx- imative so far as the operation itself is concerned, for the influence of the complications of labor, such as convulsions and hemorrhage, as also the duration of labor, are to be taken into the account of the mortality. Mortality of the Infant.—In 3,347 cases, in which the result to the child is detailed, 1,472 were lost, or rather more than 1 in 3.* It is unfortunate that in the results of the statistics just presented, no statement of the duration of the labors has been given; for with a knowledge of this circumstance we could the more readily appre- ciate the true mortality of turning, both to mother and child. It cannot be denied that the mortality of child-birth, in natural as well as artificial parturition, is materially affected by the duration of the labor. This Ave shall prove under the head of instrumental delivery. Prof. Simpson has tabulated twenty-four cases in which version was performed as reported by Dr. Collins of the Dublin Lying-in Hospital, with the folloAving important results, showing the influ- ence exercised by the length of the labor on the death of the mothers. Although the cases are comparatively few, they are quite significant as to conclusions: Duration of Labor. Proportion of Deaths of Mothers. Below 24 hours. Above 24 hours. 1 in 21 died. 1 in 3 died. Pelvic Version.—Some authors recommend, in lieu of seeking for one or both feet, to introduce the hand and bring down the breech, attended sixty labors, fifty-five of which he terminated by turning! He has had but one maternal death, and that " occurred five days after the operation by inflamma- tion of the peritoneum of a patient who, with contracted pelvis, had submitted to the ordeal to produce her sixth full-timed dead child." Mr. Figg says in four instances he has broken the arms of the children; but this is of very little importance, for he advises not to be " too candid to the relatives, but at once by your own dictum transub- stantiate the injury into a slight sprain received by the infant striking its shoulder against the backbone of the mother while actively prosecuting its uterine gambols.'" Really I cannot approve either of Mr. Figg's practice or his morality. [See London Med. Times and Gazette, Nov. 13 and 20, and Dec. 25, 1858.] * Ricker reports that, in the Duchy of Nassau, podalic version was resorted to 2,473 times in 304,150 cases of labor, or 1 in 123. The result to the mother was 176 deaths, or 1 in 14, corresponding very closely with the general mortality given by Dr. Churchill. Nearly 1 in 2 of the children was lost. According to the sta- tistical record of Prof. Schwerer, version was performed 182 times in 21,804 cases, or 1 in 119; 14 mothers were lost, or 1 in 13; 93 children lost, or 1 in 2. 540 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. when the child occupies a position in Avhich the breech is nearer the superior strait than the head. In my opinion, however, this prac- tice, when version is really indicated, Avill be found more difficult, and attended by more hazard than podalic version ; therefore, I should advise you to give preference to the latter operation. Cephalic Version by Internal Manipulation.—As has already been remarked, version by the head a\ as ahvays practised by the ancients; noAvhere can I find podalic version even alluded to by them. Their preference for cephalic turning Avas undoubtedly due to the doctrine they inculcated, viz. that the only natural and favorable position of the foetus, Avas Avhen the head presented at the superior strait. Hence the counsel of Hippocrates, in all cases in Avhich any other portion than the head presented, AA'as to displace it, and substitute the cephalic extremity. He relied much on changing the position of the Avoman, for the purpose of bringing the head doAvn, and gives particular directions as to this point. For instance, he recommends to place something under the hips during the labor, and also under the feet of the bed, so that the patient may be raised higher toward the feet. The hips are to be more elevated than the head, nor should the latter have any bolster. He further says that after the presentation of the foetus has become changed, the patient is no longer to be elevated as just described, and a pilloAV should be placed under her head.* Cephalic A'ersion had„for a long time fallen into neglect, so that it Avas rarely resorted to; I believe it is generally conceded that the credit of again introducing it to the attention of the profession is due to M. Flamant of Strasburgh, Avho, in 1795, became its earnest advocate. Since that period, many successful cases have been recorded. M. Busch, of Berlin, reports that, in 15 cases under his care, he delivered 14 living children ; Riecke lost 1 child in 16; while Ricker, of the Duchy of Nassau, reports 10 cases, of Avhich 9 terminated favorably for both mother and child. Other results might be cited, Avhich demonstrate the important fact that all things being equal, cephalic version is infinitely more favorable to the child than podalic, for in the 41 cases just quoted only 3 children Avere lost, or about 1 in 14. In podalic version, on the contrary, the loss is rather more than 1 in 3. The conditions justifying a resort to cephalic version may be enumerated as follows: 1st. The pelvis must possess its natural dimensions, for a con- tracted pelvis would present positive objections, unless it were ascertained that the head is unusually small. * Supinae reclinatae molle quiddam eoxis substernere oportet, atque etiam lecti pedibus aliquid supponere, quo altiores a pedibus decumbentes, esse queant. Sed et coxae capite sint altiores; nullum vero capiti cervical subsit [De Mulier. Morb lib 1 cap. p. 8.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 541 2d. The head must not be very remote from the superior strait.* 3d. The foetus should enjoy a certain degree of mobility, other- wise the hazard to mother and child would be greatly enhanced. The operation, therefore, should be undertaken before the rupture of the membranous sac, or as soon after as possible. 4th. Cephalic version is indicated when the child is situated trans- versely, or, for example, in a shoulder presentation. Mode of Performing Cephalic Version.—Having previously ascertained the true position of the head, that hand is to be intro- duced Avhich corresponds Avith the portion of the uterus at Avhich the head is situated; the other hand should steady the uterus through the abdominal parietes. If the membranes be still intact care should be exercised not to rupture them by cautiously gliding the hand between them and the internal surface of the uterus. As soon as the hand reaches the head, it should be grasped by the palmar surface, the accoucheur at the same time affording escape to the liquor amnii: an effort is then to be made to bring the head to the superior strait, Avhile Avith the hand applied to the abdomen the pelvic extremity of the fcetus should be elevated tOAvard the central line. Dr. Wright,f of Cincinnati, in a paper on cephalic version to which Avas awarded a gold medal by tlie Ohio State Medical Society, suggests the following operation: The fingers are to be applied to the top of the shoulders, and the thumb t« the axilla, or to such part as Avill give command of the chest, and thus afford lateral force. With the other hand upon the abdomen, pressure is to be made so as to dislodge the breech, and cause it to ascend tOAvard the centre of the cavity. Hence, without applying direct force to the head, it is thus brought to the superior strait; if, hoAvever this fail, the head may then be grasped. Dr. Wright states that, in all the cases treated by him from the commencement, the children were born alive. Cplndlc Version by External Manipulation.—It has been pro- posed, in certain malpositions of the fcetus, to correct them by turning the child and bringing the head to the superior strait through manipulations made on the abdominal walls of the mother. That this species of version may, under some circumstances, be accom- plished, I have no doubt. But it involves certain prerequisites- such as an accurate knoAvledge of the exact position of the foetus, * The following is the language of Van Swieten on this point, and embodies, I think, very judicious counsel: "For while the fcetus is disadvantageously situated in the womb, it cannot always be reduced to such a position as to come out by the head; this can be effected only when the head is not very distant from the orifice of the womb, so that it can be easily touched by the fingers of the midwife, and moved out of its position." [Van Svvieten's Commentaries, vol. xiv., p. 14.J f American Journal of Medical Sciences July, 1855. 542 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sufficient laxity of the abdominal Avails, and a ripe experience in this mode of manipulation. In order to ascertain the position of the foetus, recourse must be had to abdominal palpation, ausculta- tion, and the " toucher." One of the latest and most uncompro mising advocates of external version, Dr. A. Mattei,* in addition to transverse positions, recommends it in all cases of presentation of the breech, Avhich he considers unnatural and dangerous, and contrary to the physiology of parturition. He advises that, as soon as it is ascertained the breech is at the superior strait, efforts should be made to carry it up to the fundus of the Avomb, and bring the head doAvn, by means of external manipulation; and this he says is his general practice, in Avhich he claims to have been remarkably successful. The time at Avhich this conversion is to be made is from the sixth to the ninth month of pregnancy, for at this period the foetus enjoys a greater degree of mobility in utero, and hence the greater facility of the operation. There are, I think, some cardinal objections to the practice recommended by Dr. Mattei in breech cases: 1. The difficulty of its execution. 2. The danger of provoking the uterus to premature action. 3. Nature, under ordinary circumstances, is quite capable of achieving the delivery Avhen the breech presents, although it must be recollected that the child incurs more hazard than in a head presentation. 4. The possibility that the foetus may right itself before the com- pletion of the term. For these reasons, therefore, I should advise you not to adopt the practice in the presentation of the nates. External manipulation, Avith a view of changing the position of the fcetus, may be said to be a revival of an ancient practice. It, however, met Avith but little favor until Avithin the present century. It is, I think, conceded that the credit is due to Dr. Wigand, of Hamburg, for the impulse which this operation has received in our OAA'n times, and more especially in Germany. His views, decidedly in full approbation of the measure, have the endorsement of some of the ablest German obstetricians, among Avhom may be mentioned Busch, Xaegele, Kilian, Scanzoni, Arneth, Hohl, and others. In- deed, there is no doubt about the very general adoption of the practice by the leading men of the German school. In France, too, Velpeau and Cazeaux recognise external manipulation as a proper resource; Avhile, as Ihave already stated, tlie Corsican physi- cian, Dr. Mattei, is more than enthusiastic on the subject. In Great Britain, on the contrary, it has failed of approbation. In our own country, it may, I think, be said that the question is still sub judice.\ * Essai sur TAccoucheraent Physiologique. Par A. Mattei. P. 1S5. ■j- An interesting case of cephalic version during labor, by external manipulation, VIIE PRINCIPLES AND PRACTICE OF OBSTETRICS. 543 Let us, for a moment, inquire what it is that the accoucheur pro- poses to accomplish by external manipulation ? The object is tAvo- fold: 1. To change an abnormal position of the foetus into one whicli is natural; 2. To avoid the necessity of introducing the hand Avithin the cavity of the uterus for the purpose of bringing to the upper strait, through internal manipulation, either the head or the feet. This is undoubtedly the true analysis of the motive ; and if the object be carried out consistently Avith the safety of the mother and child, the operation is entitled to be hailed as one of the greatest benefactions to Avoman. It can scarcely be necessary to remark that a fundamental condition, before attempting external version, is an accurate knoAvledge of the position of the foetus in utero ; it is this knowledge Avhich constitutes the entire justification of the procedure. The next question is, how is the position of the child to be ascertained? I think the most reliable means is through ausculta- tion and abdominal palpation; but an important auxiliary will be found in the " toucher" or vaginal exploration. Auscultation, hoAvever, may sometimes lead to erroneous judgment, as in the case of a tAvin gestation. Well, Ave will suppose that the diagnosis of position has been satisfactorily determined, the next question is, at Avhat time should the operation be had recourse to ? Some Avriters, in agreement Avith Mattei, recommend its adoption during the latter months of pregnancy, say from the sixth to the ninth months. Without entering into any special argument on the subject, my advice to you is, not to attempt any interference until labor has commenced; and, as a general rule, the manipulation should be made before the rupture of the "bag of Avaters," for, it is to be recollected, in pro- portion to the escape of the liquor amnii will be the diminished mobility of the fcetus, and the consequent difficulty of the evo- lution. Mode of Performing the Operation.—The patient should rest on her back; the accoucheur then places one hand flatwise on that portion of the abdomen corresponding with the head of the foetus, Avhile the other hand is directed to the opposite point at which the breech will be found ; these two portions of the foetal surface being thus embraced, the one hand should gently depress the head toward the pelvis, and a movement of elevation imparted with the other to the breech. The tendency of this counter-movement aa ill be to bring the head of the child to the superior strait, thus converting it from a transverse or oblique position to a cephalic presentation. As a comparative laxity of the abdominal and uterine Avails is essential to the success of the operation, it is needless to remind with safety to mother and child by Prof B. Fordyce Barker, is recorded in the American Medical Times, June 2, 1860. 544 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. you that these manipulations are to be restricted to the intervals of the labor pains. It is recommended while the pain continues, to place the patient on the side corresponding Avith the head, and at the same time to make uniform and guarded pressure on this latter by means of a small pillow or cushion. As soon as the pain ceases, the position on the back is to be again assumed, and the same character of manipulation continued. When the head has been made to descend, it Avill be disposed, should it enjoy much mobility, to resume more or less its former position; to obviate this, the membranous sac should be ruptured, so that, Avith the escape of the amniotic fluid, the head may become fixed. It has been suggested by Kilian and others, and Avith good reason I think, that the rectifi- cation of the child's position is not exclusively due to the exhernal pressure of the hands; but that in connexion AA'ith this pressure must be taken into account the influence Avhich it exercises in the correction of certain obliquities of the uterus, to which these mal- positions of the fcetus are oftentimes due. If, as sometimes will occur, the operation should prove unsuc- cessful, the alternative will be version of the child by the introduc- tion of the hand into the uterus ; or the plan proposed by Dr. Wright may be attempted. If the head be brought doAvn to the superior strait or not, and any complication present itself calling for immediate delivery, podalic version AA'ill be the resource. Version, in Pelvic Deformity.—It noAv remains for me to call attention to the subject of version in certain cases of" pelvic deformity, as recently revived by Prof. Simpson, avIio gives it the weight and authority of his name, and urges it as a substitute for craniotomy. I say revived, for it is Avell known that this practice Avas advocated by Denman and some of his contemporaries, but had fallen into almost utter oblivion until again introduced to the attention of the profession by the distinguished Avriter just named. The tAvo chief arguments in favor of version in pelvic deformity offered by Dr. Simpson, are: 1. That the transverse diameter at the base of the foetal skull (the bi-mastoid) is less than the corresponding diameter at the arch of the cranium (the bi-parietal). 2. That the head may be extracted consistently Avith the life of the child, after the body has been delivered, through a smaller space than is needed for its passage in a vertex presentation, and impelled simply by the contractile efforts of the uterus. In addition to these two main propositions, he says that version, Avhen deformity of the pelvis exists, contrasting it Avith craniotomy, gives the chid a chance of life; it is more safe to the mother, because it can be performed earlier in labor, and more speedily; it enables us to adjust and extract the head through the imperfect pelvic brim in the most advantageous form and direction; lastly, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 545 it is a practice that can be followed when proper obstetric instru- ments are not at hand, and the avoidance of instruments is generally advisable Avhen it is possible.* The importance of the question, and the high authority of the gentleman who commends its adoption to the profession, AA'ill justify an examination of the arguments adduced in its favor. It is undoubt- 4 edly true, as Prof. Simpson alleges, that there is a difference in the respective transverse diameters of the foetal skull at its base and arch ; for the former measures three inches, Avhile the latter gives three inches and a half. When describing to you the foetal head in connexion AA'ith child-birth,f you will remember I told you the characteristic difference betAveen the base and arch of the cranium is, that the base at the completion of utero-gestation is ossified, and cannot be made to yield to pressure; and, moreover, I pointed out to you that this is a most essential provision, for the exercise of pressure on the loAver portion of the brain and medulla oblongata Avould most likely result in the destruction of the child's life. The arch, on the contrary, from the peculiar construction of the sutures, overlapping each other, AA'ill yield occasionally half an inch in its transverse diameter, and the temporary pressure, consequent upon such diminution, could be sustained Avith impunity for the reason that the upper portion of the brain is not essential to life. It would, therefore, folloAv that if the contraction in the antero-posterior diameter at the superior strait were less than three and one-eighth inches, the delivery of the head by version would, I think, be physically impracticable; for admitting, for argument's sake, the opinion of Prof. Simpson, that the head can be made to traverse a smaller space, after the delivery of the body, than in an original , vertex presentation, yet, as the transverse diameter of the base measures three inches,"!; and undergoes no diminution, it will need a space of at least three inches and an eighth to enable it to pass. But again: if there be a space of three inches and an eighth, it is possible that the head may descend in a vertex presentation, for the reason that the transverse diameter of the arch will occasionally, through the overlapping of the bones, yield to the extent of half an inch. Therefore, Avith such a pelvic deformity—such as Ave haA'e described, it is far better to trust, all things being equal, to the resources of nature than attempt delivery by version. Although it is undoubtedly true, as a general principle in mechanics, that a body may be more easily drawn through a space when its apex pre- sents than impelled through the same space by a vis a tergo force * Provincial Medical and Surgical Journal, December, 1857. P. 647. f Lecture III. X It is prosper to state that in the six cases of measurement of foetal heads given by Prof. Simpson, the bi-mastoid diameter (transverse of the base) varied ii'oni 2£ inches to 3] inches. 35 546 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. directed against the base, yet I do not think this principle Avill always apply in the case of child-birth. I have much more confi- dence in the ability of nature Avhen not interfered Avith, than I have in the most consummate skill of man. What I mean is this—Sup- posing an instance of pelvic curtailment to the extent of three and an eio-hth inches, I should have more faith in the efforts of nature so to diminish the transverse diameter of the arch as to enable it to descend, than in the manipulations of the accoucheur, no matter what dexterity he might possess, after the body of the foetus had been delivered. But, gentlemen, there are, in my judgment, other serious objec- tions to version in these cases. You haA'e been told—and the fact is perfectly patent—that turning, under the most fiworable circum- stances, is au operation of peril both for mother and child ; and just in proportion as the natural dimensions of the pelvic canal are abridged, the peril will be enhanced. Again: another solid argu- ment, it seems to me, against version in pelvic deformity is, the very probable contingency, after having subjected parent and child to the dangers of the alternative, that the delivery will be required to be terminated by craniotomy. My advice to you is this—if the antero-posterior diameter do not measure more than three and an eighth inches, trust, as long as circumstances will justify it, to the resources of nature;* if these be found inadequate, and there should be indications of peril either to mother or child, then, in lieu of Aversion, have recourse to the forceps, for although, as a general rule, when the head is still at the superior strait, I prefer turning to forceps delivery, yet, in the event of a pelvic deformity, such as Ave have been considering, my choice would be the instrument. The safest practice, hoAvever, Avould unquestionably be the induc- tion of premature delivery, but this would, of course, involve the necessity of ascertaining the existence of the deformity at some time prior to the completion of utero-gestation.f * The resources of nature are occasionally most extraordinary in overcoming a disproportion between the head and pelvis. This fact is well known to accoucheurs, who have observed well; and it would be more frequently recognised in practice, were it not for that too general sin—"meddlesome midwifery." \ When discussing the subject of premature artificial delivery, we shall mention the various grades of pelvic abridgment in which this alternative will be justifiable. LECTURE XXXVI. Manual Delivery continued—Presentation of the Breech, Knees, and Feet; Manual Delivery in—The Indications in these Pelvic Presentations—Malpositions of the Pelvic Extremities—Excessive Size of the Breech; how managed—Presentation of the Pelvic Extremities complicated with Hemorrhage, Exhaustion, Convul- sions— The Management of Pelvic Presentations in Inertia of the Womb—Iner- tia, how divided—Inertia from Constitutional and Local Causes—Importance of the Distinction in a Therapeutical Sense—Blood-letting in Inertia, when to be employed—Ergot, when indicated. Gentlemen—We noAV proceed to the consideration of our second division of manual labor, embracing the pelvic presentations, A'iz. the breech, knees, and feet, and Avhich also has tAvo A'arieties. In the first variety, you AA'ill remember, it may become necessary to interpose because of malposition of these extremities; in the second, interference is called for because of the complication of some acci- dent, rendering immediate delivery essential. It is important that you should bear these two distinctions in recollection, as they Avill be the guides for the particular kind of interference indicated. Presentation of the Breech.—I have stated that, under ordinary circumstances, natural labor may be accomplished Avhen either the breech,* feet, or knees present; but it may happen that nature is so far contravened when either of these extremities is at the supe- rior strait, either from malposition, excessive size, or from the occurrence of some accident placing in peril the life of mother or child, as to need the prompt interference of the accoucheur. Let us illustrate this interesting practical point. You are at the bed- side of your patient, labor has commenced, and a vaginal explora- tion has satisfied you that it is a case of breech presentation. You are content AA'ith the abstract fact that the breech is at the upper strait; you give yourselves no further concern, and rely upon the efforts of nature to terminate the delivery. Pain succeeds pain; time elapses, and yet, notAvithstanding strong uterine contractions, the breech does not descend into the pelvic cavity; the reiterated efforts of the uterus have made a decided impression on the strength of the mother, while they have not failed to exercise a pressure more or less injurious on the foetus itself. * For the diagnosis and positions of these various presentations, see Lecture XXIV. 548 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In this state of things—animated to duty, perhaps, by the ardent appeals of the patient—you institute another examination for the purpose of ascertaining Avhy the breech does not descend in response to the vigorous efforts of nature ; at this late hour, after the exhaustion of the mother from unavailing struggles to advance the labor, and the danger to the child from extreme pressure, you discover that the cause of the delay is due to one of tAvo condi- tions—either the breech does not present properly, or its great size preA'ents its progress into the pelvic canal. Here, you perceive, the cardinal error consists in the fact that you were careless in not hav- ing ascertained the true nature of the obstruction at an early stage of labor; so that by opportune interference the difficulty might have been overcome, thus sparing the mother the possible fatal consequences to be apprehended from exhaustion and a protracted parturition, Avhile the child would have been protected against the injurious effects of undue pressure. It is a great principle in midAA'ifery—one to be kept constantly before you—not to delay action until the mother and chilel are ' sacrificed, but to exhibit the aids which science will enable you to do opportunely, and in time to save human life. What avouM be your judgment of the navigator who, in disregard of the fearful storm, should remain perfectly passive, and aAvaken to a conscious- ness of peril only Avhen his noble vessel had fallen a wreck to the hoAA'ling tempest ? The parallel is perfect, so far as duty is con- cerned, betAveen the captain to Avhom is intrusted the safety of his ship, and the medical man, who has in custody the life of his patient. If it should be found that the obstruction consists in malposition of the breech—in other words, if, instead of presenting centre for centre at the superior strait, one of the hips, the sacrum, or poste- rior surface of the thighs should rest upon some portion of the upper contour of the strait, the indication is obviously to bring the breech, Avithout delay, in a position parallel to the long axis of the pelvis, so that it may be made to respond to the contractile efforts of the uterus. This rectifying of the position may be effected by the introduction of the hand, during the absence of pain, endea- A'oring gently to elevate the breech, and place it in proper relation Avith the strait; should the hand not be adequate, it may become necessary to resort to the lever, or one of the branches of the for- ceps. I have known instances in Avhich change of attitude in the patient has sufficed to accomplish the object. But we Avill suppose that these various expedients fail; Avhat then is to be done? The next alternative, about Avhich there should not be a moment's hesi- tation, is to introduce the hand and bring down the feet, the manner of doing Avhich we shall explain before the close of this lecture. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 549 In the case of excessive size of the breech,* the accoucheur should endeavor to place his index finger in the bend of the thigh, situated posteriorly, and make gentle traction doAvmvard and backAvard in the direction of the axis of the superior strait; in the event of failure to accomplish this, the blunt hook or fillet may be substituted for the finger, of which Ave shall speak more particu- larly under the head of Instrumental Delivery. If, hoAvever, all these prove negative, then, as in the other instance, the feet must be brought down by the introduction of the hand. It may, hoAvever, happen that the pelvic extremities present in the most natural manner; but OAving to the occurrence of some complica- tion, such as hemorrhage, convulsions, or exhaustion, by Avhich the safety of the mo- ther and child may be com- promised, it Avill become expe- dient to terminate the labor. I'nder these circumstances, you Avill proceed as follows: Supposing the breech to pre- sent in the first position Avith the sacrum regarding the left acetabulum, and the posterior portion of the thighs in cor- respondence with the opposite sacro-iliac symphysis, the left hand is to be carried up as far as the breech, Avhich, by a gen. tie effort, you will attempt to FlG- 76- elevate Avith a vieAV of enabling you to bring down the limb Avhich is behind, and afterward the one in front (Fig. 76); the delivery is then to be completed as if the feet originally presented.f If, * The breech will sometimes be found only relatively disproportionate in size, and there is a very important practical fact connected with this circumstance. For example, it will occasionally happen that the feet present at the superior strait simultaneously with the breech. Under these circumstances, in consequence of the increased volume of the presenting parts, there will necessarily be more or less delay in the delivery, and very generally interference will be called for. Some au'hors recommend to replace the feel within the cavity of the uterus in order that more space may be allowed for the descent of the breech. I cannot regard this as judi- cious practice, and would advise you. instead of returning the feet, to seize one or both, and bring them down, thus converting the case into one of foot presenta- tion. f See Lecture XXXV. 550 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. however, it should be found impracticable to succeed in this Avay5 recourse must be had to the blunt hook, by placing it in the groin of the limb, AA'hich is posterior, and making doAvmvard and backward tractions until the hips approach the vulva. The hand then can readily complete the extraction. The same rule of conduct is to govern you in either of the other three positions, remembering always to introduce the hand corresponding with the posterior surface of the thighs. Presentation of the Feet.—A presentation of the feet cannot be regarded so favorable to the safety of the child as Avhen the breech presents, and for the following reasons: The membranous sac is made to protrude, and becomes more or less elongated through the mouth of the uterus; it, therefore, is unable to reach its full development, and, in addition, it is liable to be early ruptured. Under the circumstances, the uterine orifice is but partially dilated, the consequence of Avhich Avill be compression more or less serious of the foetus, to Avhich may be added undue pressure of the umbilical cord, and not unfrequently premature detachment of the placenta, all of Avhich are so many influences adverse to the safety of the child. On the contrary, in a breech presentation, the membranous sac does not rupture as a general rule, until the full dilatation of the orifice, and consequently both the fcetus and cord are pro- tected, at least measurably, against the amount of compression to which they are exposed in a footling case. The life of the child, it should be recollected, is ahvays more endangered Avhen the pelvic extremities present in a primipara than in a multipara, for the reason that, as a general principle, the parturition in the former being more protracted, there is increased risk of pressure of the cord. In a footling, as in a breech presentation, it may become neces- sary for science to interpose, either because of malposition or of the occurrence of some accident calling for prompt delivery. In the case of malposition, before anything can be attempted, the first duty of the accoucheur will be to ascertain the special character of the obstacle; for example, the feet, in lieu of being so situated at the superior strait as to become responsive to the contractions of the uterus, may rest, one or both, on the anterior, posterior, or lateral borders of the strait, thus contravening every effort of the womb to cause their descent. Should not the source of the difficulty be early ascertained and removed, the consequence will be exhaustion of the female from fruitless efforts to overcome the physical obstruc- tion, and, perhaps, the sacrifice of the foetus from the effects of long continued pressure. The indication in such a contingency would be without delay to introduce the hand and right the feet, by bringing them in proper line AA'ith the strait. In the event of some complication, such as hemorrhage or convulsions, artificial THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 551 delivery must be accomplished remembering to introduce the hand, Avhich corresponds with the heels (Fig. 77) of the child. Allow me here to make a suggestion not to be forgot- ten, and it is this: whenever the toes are found to corres- pond Avith one of the ante- rior and lateral portions of the pelvis, as soon as the hips are passing through the pel- vis, care should be exercised to rotate the foetus in tts long axis, so as to bring the pos- terior plane of the child's body in apposition Avith one or other of the acetabula; if, for instance, the toes are toAArard the left cotyloid ca- vity, the back of the foetus should be brought to the right lateral point of the pelvis; if to the right coty- loid cavity, to the left lateral point. The object of this movement is to reduce the posterior to the anterior po- sition, and thus facilitate the delivery of the head. The same rule also applies in breech presentations, Avhen the sacrum is at either of the sacro-iliac junctions. Presentation of the Knees. —This form of presentation is extremely rare, and Avhen it does occur, the general position of the foetus is the same as in presentation of the feet. The indications are also identical as in footling eases ; if there be malposi- tion, it must be corrected ; and if the labor suffer from complication, delivery is to be accomplished. For this *'io. 78. Fig. 7T 552 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. purpose, the hand should be introduced Avhich corresponds by its palmar surface Avith the anterior surfaces of the child (Fig. 7s), and the knees being brought doAvn, the same principles are to guide you as in a foot presentation. It may, however, be that there Avill be unusual difficulty in extricating the knees Avith the hand ; in this case, the fillet may be advantageously employed, Avhich, being placed in the ham of the leg Avhich is posterior, dowiiAvard and backward tractions are to be made until the knees arc liberated. If these latter be situated so high up as to render the application of the fillet impracticable, then resort must be had to the blunt hook, Avhich, being carefully inserted into the ham of the posterior limb, AA'ill enable you by proper extractive force to bring doAvn the knees. Pelvic Presentations with Inertia of the Uterus.—I have called your attention to the management of pelvic presentations, under certain complications of labor ; and it now remains for me to speak of them in connection Avith inertia of the uterus. You will occa- sionally meet Avith cases in practice in Avhich, under breech pre- sentations—and the same thing may occur when the vertex or ahy of the other extremities of the ovoid present—the uterus, after vigorous effort, ceases for sometime to contract. This cessation of effort on the part of the organ is very apt to be regarded as the uniform result of inertia, and hence, Avith this abstract vieAV, recourse is too frequently had to certain special remedies, Avhich are knoAvn to excite uterine action. The term inertia is, I think, oftentimes misunderstood, and this very circumstance leads to bad, if not dangerous practice. The question is worthy of a moment's exami- nation, for it involves an important principle in the lying-in room. In order that you may comprehend Avhat I mean, I shall regard inertia of the womb in child-birth as due to one of two conditions: either to constitutional or local influence. Examples of the former you have in Avomen Avho have suffered from antecedent disease, or from exhausting drains; inertia may also be traced to a naturally delicate organization; in certain susceptible constitutions, mental emotions Avill occasion it. Again : excessive plethora may be ranked among its causes. If this vieAV of the subject be correct, it is very evident that one of the fundamental prerequisites for judicious treat- ment Avill be to distinguish the particular constitutional circumstance to Avhich the inaction of the organ is to be referred. In the case of inertia from previous disease, or any exhausting influences, the remedy Avill consist in the administration of stimulants together Avith generous and renoATating diet; if, on the contrary, it be due to mental influence, resort must be had to those agents best calculated to calm the mind, and infuse it with the invigorating auxiliaries of hope and confidence. If the patient labor under plethora, then the abstraction of blood is broadly indicated—the quantity to depend upon the surrounding circumstances of the case. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 553 Among the local causes of inertia may be enumerated the folloAV- ing : increase in the volume of the uterus from an excessive quantity of liquor amnii, which, by temporarily paralysing the muscular fibre of the organ, induces a state of more or less complete inacti- vity ; unavailing efforts of the uterus to rupture the membranous sac, occasioning exhaustion of its fibre; unyielding condition of the cervix in consequence of an abnormal induration of the part; departure of the uterus from its long axis, so as to render abortive any effort to expel the contents, thus, as it were, tiring out the organ ; inherent debility of the uterine muscular fibre dependent upon want of proper nervous influence. You must perceive, gentlemen, how manifestly essential it is to examine critically into the existence of these various causes capable of producing inertia iu order that the appropriate remedy may be employed. If, for example, you should be satisfied that the inactive condition of the organ is traceable to excessive distension from an unusual quantity of amniotic fluid, the indication Avill be at once to rupture the membranes, and, by the escape of the liquor amnii, liberate the uterus from the paralysis to AAhich it has been subjected by the excessive distending force. The same course, also, must be pursued Avhen, in consequence of the prolonged resistance of the membranes, nature is unable to rupture them. If the source of the trouble be found to consist in an unyielding, indurated condition of the cervix, benefit may be derived from the application of the belladonna ointment; if this fail to afford the necessary relief) I should not, under the circumstances, hesitate to incise the cervix; and, in having recourse to this expedient, I Avould advise you to make several small incisions on the anterior and posterior lips. Suppose^, however, that neither of the above conditions of the organ be present, and you should have ascertained that the inertia is due to malposition of the uterus, constituting a want of parallelism betAveen its long axis and that of its superior strait, thus preventing the uterine effort from concentrating on the centre of the pelvic canal, and consequently Avearying the organ in useless struggles to expel its contents. It can scarcely be necessary to say to you that, in such case, the indication Avould be tAvo-fold : either to restore the uterus to its parallelism, or proceed at once to terminate the labor by artificial delivery. When the inertia can be traced to inherent debility of the uterus consequent upon a Avant of nervous power, then you will find an efficient remedy in ergot. If there be nothing to contra-indicate its administration, it may be given in infusion, powder, or tincture. For this special purpose, I prefer it in the form of infusion—say, 3 ij- of the powder in 3 iv. of boiling AA'ater; let it infuse for tAventy minutes, a tablespoonful to be taken at an interval of ten 554 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. minutes, until action of the uterus is produced. If the ergot be of proper quality, it AA'ill rarely happen that it Avill not have the desired effect after a feAV doses are administered. In this latter character of inci-tia, I have found repeated drinks of ice Avater, taken in small quantity, to be of signal service in promoting uterine contraction; warm tea or gruel AviU occasionally have the same effect. LECTUPvE XXXVII. Manual Delivery continued—Trunk or Transverse Presentations, including the Abdomen, Chest, Back, and Sides of the Foetus—Presentation of the Abdomen : its Diagnosis and Treatment—Presentation of the Chest, Back, and Sides; lnw Managed—Shoulder Presentation with or without Protrusion of the Arm—Treit- ment of—Management of these Cases by the Ancients, barbarous and destructive to the Child, because founded upon Ignorance of the Mechanism of Labor—Their Management, Philosophic and Conservative in our Times—Spontaneous Evolu- tion—Meaning of the Term—Divided into Cephalic and Pelvic—Comparative Rarity of Spontaneous Evolution—Statistics by Dr. Riecke—Statistics of Dublin Lying-in Hospital—Fearful Fatality to the Child in Spontaneous Evolution—Dr. Denman's Exposition of the Manner in which the Evolution is performed, shown to be Erroneous by Dr. Douglass, of Dublin—Spontaneous Evolution not to be relied upon when Artificial Delivery is indicated. Gentlemen—Our third division of manual labor embraces trunk or transverse presentations together AA'ith those of the arm ani shoulder.* It is quite obvious that Avhen the trunk, shoulder, or arm presents, it will be physically impossible for the child to pass, except through spontaneous evolution, for the reason of the dispro- portion which must necessarily exist betAveen it and the maternal organs. Therefore, the alternative in this form of presentation will be to change the position of the child by version. I shall first speak of trunk presentations, and in doing so avoid the numerous subdivisions of authors, and present the subject to you under the folio whig heads : 1. Presentatiop of the abdomen ; 2. Presentation of the chest; 3. Presentation of the back; 4. Presentation of the sides of the fcetus, including the shoulder and hips. It is proper here to remark, that I shall recognise only two positions for each of the presentations of the trunk, and for the substantial reason that they practically embrace the various divi- sions of authors, inasmuch as the rules for their termination are identical.f Presentation of the Abdomen.—In this presentation, Avhich is extremely rare, the child is in a state, as it were, of extension, and consequently the risk it incurs is much greater than in either of the * Indeed, some clever writers comprehend transverse presentations under those of one or other shoulder, believing that the abdomen, back, and sides of the foetus are, when found at the superior strait, simply varieties of the shoulder presentation. f This is the classification suggested by Hahnagrand, and others, and I adopt it because I think it not only rational, but eminently practical in its results. 556 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. other trunk presentations. When the abdomen is at the superior strait, the fact Avill be ascertained by the presence of the umbilical cord, which sometimes will have descended into the vagina, and even protruded beyond the external parts ; the child lies so com- pletely across the pelvis that its anterior surface is in relation with the mouth of the uterus, Avhile the dorsal region looks toward the fundus of the organ. Whether the head be at the left or right side of the pelvis—or, in other words, in order to recognise the particu- lar position of the foetus, the accoucheur Avill readily discover in directing his finger from right to left, AA'ith Avhich side of the pelvis correspond the borders of the false ribs, the crests of the ilia, and the organs of generation. First Position.—Here the head is in relation with the left iliac fossa, while the feet regard the opposite point of the strait. In this position, the left hand, pro- perly prepared, should be introduced into the uterus (Fig. 79); it should then gently pass to the left side of* the child, gliding along the entire posterior surface of the body until it reaches the feet, which, being seized, are to be brought doAvn, and converted into the second position of the feet. The delivery to be terminated as if it Avere originally a footling case. Seconel Position.—This position is precisely the reverse of the preceding, the head corresponding Avith the right, and the feet with the left iliac fossa; in this case the right hand should be selected, and the delivery accomplished as in the former position ; the feet, hoAvever, in this instance will be converted into the first position. It may happen that, on introducing the hand, only one foot can be seized. Under these circumstances, let the foot which has been brought doAvn be attached by a fillet, and retained in position, while the hand is again introduced for the purpose of seeking for the other extremity Avhich, Avhen grasped, is to be placed by the side of the foot held by the fillet. Presentation of tlie Thorax.—When the thorax presents, it Avill be readily recognised by the ribs and sternum, as, in the presenta- tion of the abdomen, the anterior surface of the child's body is THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 557 doAvnward, and the dorsal plane is upward. Here the head is much nearer the superior strait than the feet, rendering it more difficult to deliver by the feet than in an abdominal presentation; for this reason, it has been recommended to bring the head instead of the feet to the strait, and then confiding the termination of the labor to the natural resources, unless there be some urgent indica- tion for the immediate extraction of the child. The objection to the practice of cephalic version in this case is tAvo-fold : 1. It is very difficult to place the head of the child in proper position at the superior strait, Avithout inflicting upon it more or less injury, and incurring at the same time the hazard of rupturing the uterus ; 2. If the head should be brought to the strait, and not placed in cor- respondence Avith the pelvis, the necessity Avill then arise of having recourse to podalic version. For these reasons, therefore, I should advise you to proceed at once, in case of thorax presentations, to seek for the feet. First Position.—The head is turned tOAvard the left, and the feet toward the right iliac fossa. The left hand is to be introduced in the same manner as indicated in the first position of the abdo- men ; and Avhen the feet are grasped, they are to be brought to the strait, and the labor is terminated as in the first position of the feet. Second Position.—The head to the right, and the feet regarding the left iliac fossa. The right hand is introduced, the feet grasped, and the delivery accomplished as in the first position of the feet. Presentation of the Back.—When the back presents, the child is not subjected to the same degree of danger as in a presentation of the abdomen, for the reason that, instead of being extended, it is flexed on itself. There is no difficulty, Avith a due degree of attention, in recognising a back presentation ; the evidences are : a broad, and more or less elastic tumor, the borders of the false ribs, together Avith. the tAvo scapulas. These various points xaill also enable you to ascertain the particular position. First Position.—-The head is in correspondence Avith the left, and the feet with the right iliac fossa. The left hand is to be introduced iu a state of supination, and the foetus being gently grasped, its position is slightly changed, so that the back is brought toward'the symphysis pubis; the hand then pursues the anterior plane of the body, and after successively passing over the abdomen and thighs, reaches the knees and feet, which, being brought to the strait,°are converted into the second position of the feet, and the labor is then terminated, as already indicated. Second Position.—Here, the situation of the child is reversed, the head being in relation with the right, and the feet with the left iliac fossa; the right hand being introduced, the same rules are to be observed as in the first position. Presentation of the Sides.—Under this head will be embraced, as 558 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. identical, the lateral surfaces and hips of the child, the recognition of the latter at the superior strait constituting the diagnosis of the presentation. The presence of one or other hip Avill be revealed by a small rounded tumor, the sacrum, crest of the ilium, and the organs of generation. First Position of the Right Hip.—In this position the head regards the left, while the feet are to the right of the pelvis ; the dorsal surface of the child is in relation Avith the symphysis pubis, and the anterior plane Avith the promontory of the sacrum. The left hand is introduced, and, after elevating the foetus, the feet are reached by pursuing the anterior surface of the child; they are then brought to the strait, and the delivery terminated. Second Position of the Right Hip.—The head to the right, the feet to the left of the pelvis; the anterior plane is in front, the posterior behind. The right hand is introduced, and manipulation the same as in the former case. First Position of the Left Hip.—The head toward the left iliac fossa, the feet to the right. With the left hand the foetus is to be elevated, and after pursuing the anterior surface of the body, Avhich is in front, the feet are grasped and brought to the strait; the pre- sentation is reduced to the second position of the feet. Second Position of the Left Hip.—The head to the right, the feet to the left. The right hand is to be introduced; the same rules observed as in the previous instance, except that the feet are reduced to the first position. Presentation of the Shoidder.—In calling attention to shoulder presentations, it AA'ill be proper to divide them into tAvo classes: 1. Where simply the shoulder presents; 2. Where, together Avith the shoulder, the arm and hand protrude. As we proceed, it will be seen that this is a very important division, and has involved con- flicting opinions in reference to the special practice to be adopted in these cases. It is a point of much moment to remember that always, in shoulder presentations, it is essential that an accurate diagnosis be made early; for, generally speaking, precisely in pro- portion to the time which has elapsed from the escape of the liquor amnii to the determination of the diagnosis, will be the difficulty of operating, and also the danger to the child. Some care Avill be needed in distinguishing the shoulder, for it may be confounded with the elbow, the breech, hips, or knee. The true distinction, the one Avhich makes it certain that it is a shoulder presentation, consists in recognising Avith the finger the scapula, clavicle, and the upper ribs, Avhich may be done Avith a proper degree of caution. First Position of the Right Shoidder.—The head is to the left, and the feet to the right side of the pelvis; the back of the child is turned slightly upward toward the pubes, while its anterior plane has a posterior aspect. The left hand being introduced, the shoul- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 559 der is gently raised, and the feet are then sought for by carrying the hand along the anterior surface of the child's body ; they are then brought to the strait of the pelvis, being converted into the second position of the feet. Second Position of the Right Shoulder.—The head to the right, the feet to the left; the back of the child is posterior, and the ante- rior plane is directed forward and upward. With the right hand, the accoucheur elevates the shoulder; and seizing the feet, in tra- versing the anterior surface of the body, brings them to the strait converting them into the first position. First Position of the Left Shoulder—The head to the left, the feet to the right; in other respects, the position of the child is the same as in the preceding example. The left hand is introduced, and the feet brought to the strait, converting them into the second position. Second Position of the Left Shoulder.—-The head to the right, the feet to the left; the posterior plane of the child above and a little in front, the anterior plane below and slightly backAvard. The left hand is carried up to the shoulder and trunk, on which a partial movement of rotation is effected in order to place the anterior plane beloAv; the feet are then brought to the pelvis, being converted into the first position. Presentation of the Shoulder with Protrusion of the Arm.—The treatment of this compound presentation by the accoucheurs of the present day forms not only a striking contrast, but exhibits in a most favorable manner the progress of obstetric science as compared Avith the practice inculcated by our predecessors. In this presen- tation, delivery AA'as deemed impossible with safety to the child, and hence the most extraordinary rules were instituted for the manage- ment of these cases. Indeed, Avhenever the arm protruded, in shoulder presentations, the accoucheur in former times regarded it as one of the most formidable complications of the lying-in room; but one thought occupied his mind—the destruction of the child as the necessary and only means of saving the life of the mother. With this vieAV, numerous expedients Avere resorted to ; one incul- cated the practice of tAvisting off the arm, and terminating the deli- very by bringing doAvn the feet; another suggested amputation ; a third recommended to diminish the volume of the arm by means of scarifications and incisions. Deventer, Avith the hope of causing the fcetus to Avithdraw the arm into the uterus, directed the hand to be pinched or pricked Avith a pin ; for the same purpose ice was employed. Xeed I tell you, also, that, ignorant of the principles on which rests the mechanism of labor, the absurd and reckless prac- tice Avas maintained by some of making tractions on the protruded arm, under the conviction that the body of the child could thus be delivered! 660 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. But all these were the suggestions of men Avho had not suffi- ciently studied in the school of nature ; they neither comprehended her resources Avhen undisturbed by contravening influences, nor did they appreciate the ability of science to aid her in the moment of Avant. Xoaa', hoAvever, through the advances Avhich obstetric medi- cine has made, these murderous alternatives have been abandoned, and a more conservative and rational practice substituted. The protrusion of the arm, in a shoulder presentation, is no longer regarded as necessarily fatal to the child ; and, under ordinary cir- cumstances, these cases, with a proper degree of care, can be managed Avith safety to both mother and foetus. There are, how- ever, it is well to remember, certain conditions connected with this form of presentation, AA'hich AA'ill very much enhance the danger to the child, and not unfrequently involve the mother in more or less peril. If, for example, much time have elapsed since the escape of the liquor amnii, causing rigidity of the os uteri, or undue mani- pulations have been practised inducing an inflamed state of the maternal organs, the difficulty of terminating the delivery and the danger Avill be greatly increased.* First Position of the Right Shoidder with Protrusion of the Arm.—The fact that the arm protrudes in a shoulder presentation, need occasion no undue alarm to the practitioner, for the circum- stance Avill neither necessarily involve the safety of the child, nor embarrass the operation essential to its delivery. Indeed, in these cases the termination of the labor by version is, all things being equal, accomplished with more facility than in head presentations, for the reason that the feet, because of their not being situated so high up, are more readily seized, and there is also, as a general principle, more room for the introduction of the hand. In the first position of the rigid shoulder, the pelvis of the foetus will be toward the right and more or less toward the upper portion of the uterus, Avhile the head regards the left iliac fossa. The first thing to be done is to attach a fillet (Avhich consists of a ribbon or piece of linen one inch in Avidth, and tweh'e inches in length) around the Avrist of the protruded arm. The fillet should at first be entrusted to an assistant, but after the feet are brought down to the strait, the accoucheur should take charge of it, the object of the fillet being not to prevent the ascent of the arm into the uterus (Avhich Avill take place as the feet are brought doAvn) but merely to keep the arm elongated on the body during the manipulation. As in the * The long-continued pressure of the contracting womb will very naturally occa- sion a livid hue of the arm, together with more or less tumefaction, giving rise to the belief that the child is dead, thus inducing the practitioner to a resort to instru- ments to dissect the fcetus for the purpose of extracting it. This will oftentimes prove a fatal error, for these physical changes may occur without necessarily com- promising the life of the child. THE PRINCIPLES AND PRACTICE OF OBSTETRICSL 561 Fig. 8tt first position of the right shoulder the feet regard more or less the right portion of the uterus, the left hand should be in- troduced, and carried as far as the axilla; it should then be directed along the ante- rior surface of the child's body, until the feet are reached; these are to be brought down to the strait, and the labor terminated as in the second position of the feet. Second Position of the Right Shoulder with Protru- sion of the Arm.—In this case, the fillet is to be at- tached as in the first posi- tion ; the right hand is then to be introduced (Fig. 80), and directed along the ante- rior surface of the child Avith a view of reaching the feet; these are brought down to the strait (Fig. 81), and the delivery is terminated as in the first po- sition of the feet. First Position of the Left Shoulder with Protrusion of the Arm.—Here, the left hand is to be introduced, and the same rules followed as in the second position of the right shoulder, except that the feet are reduced to the second instead of the first position. Second Position of the Left Shoulder u-ith Protru- sion of the Arm.—The right hand to be introduced, and the same principle pursued as in the first position of the right shoulder, the feet being re- duced to the first position. Spontaneous Evolution.-Jhixing now spoken of the general inn -iples which are to guide the practitioner in cases of shoulder 86 Fig. 81 562 THE PRINCIPLES ANI) PRACTICE OF OBSTETRICS. presentations, either Avith or Avithout protrusion of the arm, it is proper that I should allude to tAvo other questions in connexion with this subject, viz. evisceration in cases in Avhich version is found impracticable, and spontaneous evolution. Evisceration of the foetus Avill engage attention in a future lecture, Avhen treating of instrumental delivery; on the present occasion I propose to make a fenv observations in reference to the interesting point of spontaneous evolution. This term implies the ability possessed by nature of causing a voluntary change in the position of the fcetus in utero, so that a part of the foetal body originally more or less remote from the superior strait may descend into the pelvic excavation, and be delivered Avithout displacing that Avhich first presented. Spon- taneous evolution is divided into cephalic and pelvic ; in the former, the head descends to the superior strait; in the latter, the pelvis. I must confess I have never, in the course of my observation, met Avith an instance of a\ hat may be properly termed spontaneous evo lution; although I have on more than one occasion heard medical gentlemen speak of it as having repeatedly fallen under their notice. I am inclined to think, hoAvever, that AA'hile they intended no vio- lence to truth, their opinion Avas founded on a misapprehension of the real position of the foetus. There can be no doubt that this spontaneous change will sometimes take place ; for practitioners of conscience and high moral worth have testified to its having occurred in their practice. There is, hoavever, a very general con- currence of opinion on one point, viz. its extreme rarity. It is mentioned by Dr. Riecke that it Avas observed only 10 times in 220,000 labors at Wurtemberg, while Drs. Johnston and Sinclair report its occurrence twice in 13,748 deliveries in the Dublin Lying- in Hospital. In the Vienna Hospital, under Dr. Spaeth, there Avas but one instance of spontaneous pelvic version in 12,523 cases of labor. Its fatality to the child is most fearful; in thirty cases men- tioned by Denman, but one child survived. Some of the older writers Avere unquestionably impressed AA'ith the idea of the great mobility of the foetus in utero, and it Avas upon this conviction, no doubt, that was based the direction of causing the pregnant female frequently to change her position, and, indeed, to be shaken for the purpose of overcoming a malpresentation, as directed by Hippocrates himself. But it is to Dr. Denman that we are indebted for the first full account, by the natural poAvers of the system, of what he denominated " spontaneous evolution.''* In the * Although it is conceded that Dr. Denman was the first author to direct special attention to the subject of "spontaneous evolution," yet the possibility of its occur- rence had been recognised previous to his time. Dr. Ramsbotham says Anthony Everard seems to have been the first who described a case of " spontaneous evolu- tion." It happened in his own wife's third labor, and she had gone to her full term. The book in which the case is mentioned, a very scarce 12mo., is entitled Novus et THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 563 course of his extended practical observation, he had noticed the spontaneous change in the position of the foetus under a shoulder presentation, but his explanation of the phenomenon has been shoAvn by Dr. Douglass of Dublin to be erroneous. Denman maintained that, during the process of labor, in an interval of uterine repose, the shoulder and arm receded within the cavity of the organ, and Avere replaced by the breech of the child. Douglass,* on the con- trary, demonstrated the fallacy of Denman's opinion by proving that the foetus, Avithout any recession of the superior extremity, descends into the pelvis doubled on itself, and is then expelled. He showed that the strong contractions of the uterus at first press the shoulder and chest into the pelvis, when the acromion process is felt under the symphysis pubis; as the loins and nates descend into the pelvic excavation, the apex of the shoulder passes upAvard in the direction of the mons veneris, thus yielding more" space for the passage of the breech into the cavity of the sacrum ; in this way, after sub- jecting the perineum to extraordinary distension, the nates together with the shoulder are expelled. With this explanation, which is now generally admitted, it is evident that the shoulder becomes, as it were, fixed under the arch of the pubes, this latter being made a fulcrum on Avhich the foetus revolves. In order that spontaneous evolution may be accomplished, it is essential that either the foetus be relatively small, or the pelvis more than ordinarily capacious ; and it is an interesting fact to note that, in several instances in Avhich this movement has been cited by authors, the foetus had not reached its full time. I cannot divest my mind of the conviction that a too full reliance on the ability of nature to effect spontaneous evolution has often- times been followed by bad results in the lying-in chamber. This reliance, in cases of shoulder presentation, causes the accoucheur to allow the proper time for terminating the delivery to pass, thus subjecting the mother to more or less hazard, and the life of the child to almost certain sacrifice. While, therefore, you are to con- cede the occasional occurrence of the phenomenon, yet my advice to you is—never to depend upon it as an alternative in any case in which it is possible to terminate the labor by the introduction of the hand, but to proceed without delay to bring down the feet as already indicated, the instant the fit opportunity will justify your interference. My reasons for this advice are as follows: 1. Spon- taneous evolution is among the extremely rare occurrences of the parturient room. 2. The child is almost always sacrificed. 3. The risk of rupture of the uterus from the necessarily protracted and Genuinus Hominis Brutique Animalis Exortus. It was printed at Middleburgh in 1661. * An Explanation of the Process of the Spontaneous Evolution of the FaUzis, etc. By John C. Douglass, M.D., etc., Dublin, 1811. 564 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. increased contractions of the organ. 4. The great difficulty and consequent danger of terminating the delivery after the shoulder has been pressed low doAvn into the pelvic cavity, in the event of nature being unable to accomplish the movement. It may, however, happen that you Avill not be called to the case until it is too late to attempt the version of the child, and that, under these circumstances, from the length of time which has elapsed, the shoulder is so far forced into the pelvis as to render the effort to bring down the feet utterly impracticable. What, in such a contingency, is to be done ? Here you will be compelled to have recourse to evisceration, or to the decapitation of the child; of the manner in which these operations are to be performed we shall speak under the head of embryotomy.* * The following is an interesting example of podalic version, connected with mal- position of the uterus: it should more properly have been introduced when discuss- ing the displacements of the gravid womb: Some years since I was requested by Dr. Elwes, of the United States Army, to visit Mrs. B. at Fort Hamilton, Long Island, distant twelve miles from the city. I was informed by Drs. Carpenter and Elwes, the former of whom saw her at the commencement of her sickness, that she had been in labor, not, however, accompa- nied by very strong pain, for eight days, and that the liquor amnii had been passing from her, in small quantities, for the four days previous to my visiting her. Dr. Carpenter, who was the family physician, and who had attended her in two former accouchements, stated that he had been unable to reach the mouth of the womb, and that, from the commencement of her labor up to the period at which I arrived, he had been completely foiled in every attempt to effect this object. Dr. Elwes had experienced the same difficulty. At the request of these gentlemen, I proceeded to make an examination. On introducing my finger into the vagina, I discovered a large resisting tumor, which I recognised to be the head of the fcetus, the womb intervening between it and the finger. In examining very cautiouely the surface of the tumor, I was unable to discover the os tineas. It occurred to me that this was a case of retroversion of the neck of the womb, and in gently sliding my finger under the fcetal head, and carrying it towards the posterior part of the pelvis, I felt the os tinea?, Avhich was turned so entirely backward as to regard the concavity of the sacrum. It was now quite apparent why the labor had been so protracted, and t was certain that while the uterus retained its present position, delivery would be out of the question. In consequence of the malposition of the womb, the whole force of the uterine contraction was directed in such way as to render it physically impos- sible (without laceration of this viscus) for the child to pass through the pelvis. The position of the uterus, under ordinary circumstances, is parallel, or nearly so, to the axis of the superior strait, so that the whole force of the contractile effort being directed from above downward, it is evident, should there be no impediment to a natural delivery, that the child must be propelled through the maternal pelvis. In this case, however, in consequence of the malposition of the womb, the force of the contractions was centred against the posterior wall of the cervix uteri, and the point of resistance was found to be the internal surface of the sacrum. This, then, accounts at once for the difficulty of the labor, and shows most conclusively that it could not have been otherwise than protracted. As soon as I had discovered the position of the uterus, and thus assured myself of the entire cause of the delay, I withdrew my hand, and suggested to Drs. Carpenter and Elwes, in which suggestion they both coincided, that, in my opinion, this case presented two indications, viz.: LECTURE XXXVIII. Instrumental Delivery—Instruments divided into Blunt and Cutting—Blunt Instru- ments—What are they?—The Fillet and its Uses—The Blunt Hook and Vectis; their Uses— The Forceps—The Abuse of Instruments in Midwifery—Their too General and Indiscriminate Employment—The Object of the Forceps—The For- ceps an Instrument for both Mother and Child—Abuse of the Forceps—Case in Illustration—The Forceps a Precious Resource when employed with Judgment— Statistics of Forceps Delivery—What is the true Power of the Forceps ?—Is it a Tractor or Compressor?—The Forceps a Substitute for, or an Aid to, Uterine Effort—To what Part of the Child should the Instrument be applied?—The Advantages and Evils of the Forceps—How is the Head of the Child to be Grasped by the Instrument ?—Modification of the Forceps—Its Cranial and Pelvic Curves—The Author's Forceps—Indications for the Use of the Forceps—Time of Employing the Instrument—The Opinions of Denman, Merriman, aud others— Objections to—The Justification of Forceps Delivery, a Question of Evidence to be Determined by the sound Judgment of the Accoucheur. Gentlemex—We shall now consider the second branch of preter- natural labor, viz. Instrumental Delivery—and here, permit me to say, Ave enter upon a most important discussion. The instruments recognised in midwifery are embraced under two classes—blunt and cutting instruments. The former are applied to the child, and do not necessarily invoK'e its life; the latter are used either on the 1st. To rectify, as far as practicable, the malposition of the cervix uteri. 2d. To turn and deliver by the feet. I should have remarked that the mouth of the womb was quite soft and dilatable. It will, I apprehend, be unnecessary for me to enter into any argument to show the paramount necessity of the first indication ; and if it be recollected that the patient was in a state of dangerous exhaustion, the propriety of the second will be evident But why, it may be asked, not apply the forceps ? My answer to this question shall be brief. The head of the fcetus was still at the superior strait, and, without refer- ence to the opinions of others on this subject, I can aver for myself, that, where immediate delivery is indicated, I should always prefer (provided the parts were in a proper condition) turning by the feet, to the delay which must necessarily attend delivery by the forceps before the head has begun to descend into the excavation of the pelvis. The operation being agreed upon, Mrs. B. was placed on her back, with her breech on the edge of the bed, her legs flexed on her thighs, and her feet resting on the hands of Drs. C. and K, who were seated one on each side of me. I intro- duced my right hand, and, with the other applied to the abdomen, I reached the os tinea;: I then succeeded in fixing my index finger within the circle of the anterior lip, which was cautiously brought toward the centre of the pelvic excavation, at the same time gently pushing back the fundus with the hand applied to the abdo- men. In this way 1 succeeded in overcoming the malposition of the uterus; and in fulfilling the second indication I proceeded as follows: Before determining on which 566 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mother or child. When employed on the mother, her safety will, as a consequence, be placed in more or less peril; and I need scarcely remark that the destruction of the child is the inevitable result of their use upon it. Blunt Instruments.—These consist of—1. The Fiilet; 2. The Blunt Ih>ok; 3. The Lever or Vectis; 4. The Forceps. 1. The Fillet.—This is simply a piece of ribbon or linen, one inch in Avidth and tAvelve in length. It may be applied under the folloAving circumstances: (a) In a breech presentation Avhere, in con- sequence cither of the great size of the nates, or the undue slug- gishness of the labor, it becomes necessary to aid nature ; it should be passed up Avith the finger to the bend of one of the thighs, so as to encircle the groin, the tAvo ends of the fillet are then seized by the accoucheur, and, Avith Avell-directed traction, it becomes a ready means of bringing down the breech, (b) In cases in Avhich the trunk is expelled, and there is unusual delay in the descent of the shoulders, the fillet being placed under the axilla will be of essen- tial use. (c) The knees may have descended into the pelvic exca- vation, and, for Avant of proper uterine effort, remain there, thus protracting unnecessarily the delivery; here again the fillet carried to the bend of the knee becomes an important aid. (d) In version, when only one foot has been brought down, the fillet may be attached around the ankle, while the accoucheur seeks for the other foot, (e) In shoulder presentations with protrusion of the arm, the hand to employ in order to effect the version, I first acquainted myself with the pre- cise situation of the foetal head, which I found to be placed in the second position of the vertex, the posterior fontanelle corresponding to the right acetabulum, and the anterior to the left sacro-iliac symphysis; consequently I introduced the right hand for the purpose of performing the version, in order that the natural curve might be given to the child's body. The hand was carried up in the usual manner until the feet were reached; these were gently grasped and brought into the vagina. The patient, at this time, became alarmingly exhausted; she rallied under the influ- ence of a little brandy and water, and I proceeded to complete the delivery without delay. The child was alive and vigorous, and both parent and offspring recovered from their perilous position, and are, I believe, at this time in the enjoyment of good health. The above case is interesting on two accounts. In the first place, that the child should not have been sacrificed by the great length of time Mrs. B. was in labor; and, secondly, the possibility of mistaking the retroversion for an imperforate condi- tion of the os tincse. Cases are recorded in which the orifice of the womb was com- pletely obliterated in women in labor. Lauverjat's case, in this particular, is inte- resting: it is cited by Sabatier in his Medeciue Operatoire. Lauverjat not being able to detect the mouth of the womb, during labor, in a woman pregnant for the first time, made an incision into the portion of the uterus corresponding with the orifice. M. Gautier, a Parisian surgeon, had a similar case. Instances of the same kind are likewise quoted by Hammond and others. And in another part of this work I will give the particulars of two cases, in which, in consequence of injuries inflicted on the os tincae, it became necessary for me, at the time of labor, to incise the orifice, which resulted favorably to both mother and chUd. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 567 fillet should be placed around the wrist, for reasons already explained when treating of this form of presentation. 2. The Blunt Rook.—This instrument is employed for most of the purposes for which the fillet is used, viz. to bring down the breech or shoulders, and also to facilitate the delivery of the knees, when their stay in the pelvic cavity is protracted. The mode of using the instrument is as follows: The fingers of one hand being careful] v carried to the particular part of the fcetus on which the blunt hook is to be applied, the instrument, previously warmed and oiled, is made gently to glide along the hand, which acts as a direo Fio. 82. tor, and Avhcn the point is reached, either the bend of the thigh (Pig. S-2), the knee, or axilla, as the case may be, the hooked extre- mity of the instrument is to be cautiously applied to either of these 568 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. parts, and then dowinvard traction exercised. In this way, the foetus AA'ill be brought doAvn Avithout injury to it or tho parent, and the delivery promptly terminated. As soon as the part reaches the A'ulva, the instrument should be AvithdraAvn, and the delivery, if necessary, terminated by the hand. 3. The Lever or Vectis.—This instrument has been variously estimated by different Avriters on midAvifery; some claiming for it merits of a high order, Avhile others repudiate its use altogether. It has been urged that the leA'er can oftentimes become a substitute for the forceps, inasmuch as it may be made an instrument of trac- tion. It does seem to me, however, that under no circumstances should it be resorted to as a tractor; the only purpose to which it can be legitimately applied is to correct peculiar malpositions of the head. For example, when the occiput is extended backward, the lever AA'ill prove, in dexterous hands, an important auxiliary in changing the position to one of the vertex. Or, in case the head should fail to rotate in the pelvic cavity, and the hand be inade- quate to accomplish the movement, the vectis may be employed with good effect. Contrast between the Forcpps and Lever.—I do not deem it necessary to institute any special contrast betAveen the comparative advantages of the forceps and lever, as some authors have done ; for, contrary to the opinion maintained by them, among whom may be mentioned Bland, Lowder, Dennison, and others, I hold that no comparison can be justly made, for the reason that, in their opera- tion, they are entirely different instruments—the one being a trac- tor, the other a corrector of malpositions. Whatever may be said in reference to the frequent necessity for the employment of the lever, I will merely state to you that, in the Dublin Lying-in Hos- pital, during the mastership of Dr. Collins, in sixteen thousand four hundred and fourteen deliveries, the lever Avas used but three times; and in the same institution, during the mastership of Dr. Shekleton, as reported by Drs. Sinclair and Johnston, in thirteen thousand seven hundred and forty-eight deliveries, the lever was resorted to but once! How strangely do these statistics compare with what we are so much in the habit of hearing, in these latter days, of Avhat occurs in the private practice of certain medical gentlemen, Avho speak of their almost daily use of the vectis, forceps, or crotchet, precisely as if a man's skill in the lying-in room is to be measured by the fre- quency with Avhich he resorts to instruments! I believe in the converse of this proposition ; to my mind, the truly skilful accoucheur rarely (comparatively, at least) employs instruments, for the obvious reason, that, in the first place, he is thoroughly imbued with a knoAv- ledge of the laws by Avhich nature is regulated in the parturient effort; and, secondly, he is cognizant that, Avhen not interfered THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 569 with by officious meddling, this same nature is generally adequate to the proper accomplishment of her Avork. 4. The Forceps.—I shall not occupy your time Avith the early history of this instrument, nor with the various modifications it has undergone from its first introduction to the attention of the profes- sion. Suffice it to say that the obstetric arsenal, so far as the num- ber and kind of force] is are concerned, is not only a vast armory, but has really become an institution in itself; and, indeed, it may be asked, with some degree of propriety, Avhether the interests of humanity would not have been more wisely served if some of the time employed in the construction and modification of this instru- ment had been given to the proper consideration of the more important question—Under what circumstances and in what man- ner is the Forceps to be Emjtloyed? If this question, I repeat, had received more mature deliberation, we should have been spared the numerous appalling examples of injury and death consequent upon the unbounded love, Avhich some practitioners have for instrumental delivery. It is time that plain language should be spoken on this subject; the spirit of conservative midwifery seems to have been lost in sleep; the ordinances of nature have been disregarded, and the accoucheur, with instrument in hand, rampant in his desire for opportunity, rushes Avith good heart and unmeasured confidence to Avhat he deems the scene of conquest; but too often, alas! it proves a scene of harroAving agony to the unhappy pa- tient. One Avould almost think that nature had become emasculated of her power, and that Avhat Avere once considered her own admirable laws had been so changed, and she so utterly deprived of resources, as to render parturition no longer an act of hers—to be accom- plished in her own inimitable way, and by her OAvn consummate ordinances—but an act to be carried out according to the peculiar caprices of the accoucheur. Mature, gentlemen, is always the same so far as her oavu fundamental laAvs give her an identity; she is now in this particular Avhat she Avas at the commencement of the AA'oiid, Avhether as represented in the human family, in the animated tribes, or in the vegetable kingdom. I claim for her perfection of design and unequalled skill in the display of her own efforts, when not contravened either by morbid influences, or the officiousness of man. It must, hoAvever, be conceded that she sometimes needs assistance, but that assistance, in order that it may be serviceable, should be both justifiable and opportune. Motives on which Forceps Delivery should be Based.—In the use of the forceps, I cannot too emphatically impress upon your recollection the necessity of keeping constantly iu vieAV two cardinal principles: 1. A moral justification for its employment: 2. Such a use of it as shall secure, as far as may be, the maximum of good 570 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. viz. softy to both mother and child* With these maxims to guide him, the accoucheur, in the retrospect of his professional life, will find nothing for self-rebuke, but much for congratulation in the conviction that, in this particular, he has faithfully discharged his duty to those Avho, in the hour of tribulation, looked to him for assistance. You, a\'1io have attended the obstetric clinic, Avhere you enjov such abundant opportunity of Avitnessing every variety of disease incident to women and children, have on more than one occasion had arrayed before you instances of the fearful results arising from the unnecessary use of instruments; and Avith the hope of impressing you by example as Avell as by words, I shall take the liberty of refreshing your recollection Avith a brief abstract in reference to the melancholy case of a married Avoman, Avho Avas brought before you not a long time since, in Avhom there Avas com- plete occlusion of the meatus urinarius, with part'ad adhesion of the icalls of the upper fourth of the vagina, together with a vesico- vaginal fistula,\ produced by forceps delivery. The following is the case, as reported in my Avork on the Diseases of Women and Children: J Mrs. 11., aged 22 years, married, complains of inability to pass her Avater in the natural way, and says it runs from her nearly all the time through the front passage. " Hoav long, madam, have you been married?" "Just twenty-six months, sir.1' '"Were you a healthy Avoman before your marriage?" " Ves, sir ; I never had a day's sickness, thank God!" " You have had a child, have you not ?" " Yes, sir." '• When Avas it born ?" " Fifteen months ago, sir." "How long Avere you in labor?" "Three days, sir." " Was your labor severe ?" " Xo, sir, but it was lingering." •- Had you any one to attend you?" " Yes, sir, there Avere tAvo doctors Avith me." " Was your child born alive?" "Oh! no, sir; the * Prof. Meigs says: " The forceps is the child's instrument." I think the eminent Professor is disposed, in this maxim, to curtail the advantages of tho forceps iu a manuer not endorsed by the experience of the lying-in room. So far. tln-ivfi>re from circumscribing its benefits to the mere safety of the infant, I maintain that the forceps is an instrument for both mother and child, and its true benefits are fully realized only when, through opportune application, it enables the accoucheur to save the lives of both parent and offspring. \ The employment of the forceps may, without a due degree of care, give rise to vesico or urethro-vaginal fistulas, for the reason that sometimes great effort will be needed to cause the head to descend, being obstructed in its passage by the anterior wall of the pelvis; this effort necessarily falls more or less on the bladder and urethra, producing, if not fistulous openings, incontinence of urine from paralysis of the bladder, and other derangements. Still, it is well to recollect that these very difficulties may also arise from too long delay in a resort to the forceps, and may then be fairly chargeable^ to long-continued pressure on the parts, terminating in inflammation and ulceration. From these latter causes will sometimes ari.si a recto va that it may become absolutely locked; 2. There must be contractions of the uterus adequate to cause this partial descent. If Avhat I have just said be true, and I refer you for the demon- 604 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. stration to the bedside, it manifestly follows that, although dispro- portion may exist, yet, Avithout sufficient contractile force, locked- head cannot ensue; for it is, as you Avill not fail to recollect, the continued impelling action of the uterus, Avhich wedges—I knoAV no better term—the head of the fcetus into the contracted space. Therefore, the real causes of this complication may be divided into the predisposing and exciting; the former refers to the dispropor- tion between the pelvic canal and foetus; Avhile the latter, the ex- citing cause, AA'ill be the effort of the uterus. Diagnosis of Locked-head.—The head may become locked either at the superior strait, or in the excavation. In either event, it Avill be in one of tAvo positions, viz. it will present directly or transversely. In the former case, the occiput will regard the pubes, and the face the sacrum, or vice versa; in the latter, the head being in the transverse direction, one of the ossa parietalia will be in front, the other behind. Before describing the means of reme- dying this difficulty, and thus protecting the mother and child against the. dangers of the complication, it may not be unprofitable to inquire, for the moment, in Avhat the true diagnosis of locked- head consists, and Avhether it may not be likely to mistake some- thing else for it. The solution of this inquiry is essentially material, under the circumstances, to the proper duty of the accoucheur ; and here, allow me to impress upon you the necessity of a just dis- tinction between Avhat is and Avhat is not. I am quite sure that Avant of proper judgment has oftentimes induced the inexperienced practitioner to imagine that he had a case of impacted or locked-head, Avhen, in fact, this state of things had no sort of existence; the error has arisen in this Avay: he has recognised, by a digital examination, a more or less hard tumefac- tion of the scalp, a thick and sAvollen condition of the neck of the uterus, together Avith unusual engorgement of the vagina and vulva, and these phenomena, too, accompanied by strong uterine contrac- tions; noAV, the question is, do these symptoms positively indicate locked-head? By no means; for the testimony, in order to be complete and of value, needs one more circumstance, Avhich consti- tutes the essential and only positive proof of the head being locked, A'iz. its immobility notwithstanding the vigorous efforts of the uterus* Therefore, before determining that this complication exists, it must be first ascertained that the head is not apparently, but really fixed, or, in other Avords, immovable. A just diagnosis on this essential point, will be the means of preventing interference oftentimes not called for. There are few accoucheurs of extensive practice, Avho Avill not concur in the opinion that nature is frequently enabled to accomplish delivery by * It mav be mentioned in this connexion that recession of the head between the pains is decisive evidence that impaction does not exist. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 605 her own resources in cases in Avhich all the symptoms above described, except the immobility of the head, are present; and hence you will occasionally see, in the course of your observation, examples of an extremely elongated head, the result of the extra- ordinary pressure it has undergone, and yet the child born alive. This goes to sIioav the conservative care of nature, and how ade- quate she is, oftentimes under the most unfavorable circumstances, to perform her duty—if not officiously intruded upon—consist- ently Avith the safety of both mother and child.* But we AA'ill assume that all doubt as to the existence of locked- head is at an end, and the diagnosis complete; Avhat, then, is to be done? The object to be accomplished is, unquestionably, to deliA'er the child as speedily as possible, for every moment Avhich elapses from the time the head has become immovable is so much against both mother and child. The mode, however, to be adopted in the delivery Avill depend upon Avhether the child be alive or dead; and this, under the circumstances, I hold to be an important distinction. If the child be still living, recourse should be had to the forceps. On the contrary, if it be dead, I should recommend the perforator and cephalotribe as the most available means of terminating the birth. . \ppllcation of the Forceps in Locked-Head, in the Direct Posi- tion, the Occiput at the Pubes, the Face toward the Sacrum.— Before introducing the instrument, the true condition of the head must be fully comprehended; here, for example, resting as it does Avith the occipito-frontal diameter in accordance AA'ith the direct or antero-posterior of the pelvis, it is eA'ident that the lateral surfaces of the head correspond Avith the sides of this canal; consequently, the rule is to introduce the blades of the forceps, one on the left and the other on the right side, in order that the head may be pro- perly grasped laterally in the direction of its occipito-mental dia- meter. The manner of introducing the instrument is the same as has previously been described in this position of the head when it is not locked or immoA-able. The blades, Ave Avill suppose, are pro- perly applied, and the handles in juxtaposition. What is next to be done ? A moment's thought will remind you that the forceps has grasped a head, which is completely immovable in the pelvic canal. Therefore,the brain of the accoucheur must be slightly exer- * In these cases, however, of more than ordinary difficulty, it becomes the accou- cheur to exercise a constant and judicious vigilance; otherwise, serious consequences may ensue. It; for example, he should recognise a giving way of the mother's strength, or any other circumstance likely to compromise her; or should he find that the pre-vure t.i which the head is subjected, is such as to place the life of the child in peril, then, of course, it will be his duty to interpose, and terminate the delivery. However, what I desire to inculcate is this : as long as the head is known to respond in it" pro.-rets to the contractions of the uterus, all other things being equal, the labor i-h'inld be committed to nature. 606 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. cised in order that he may determine upon the course to be pur- sued. What he is to do is this—the forceps being adjusted on the head, the accoucheur should seize the handles, and endeavor to change the position to a diagonal one by bringing the occiput tOAvard the left acetabulum ; but much dexterity AA'ill be needed. If he attempt by mere force to push the head upward, he may inflict immeasur- able injury; or to endeavor by poAverful tractions to cause the head to descend into the pelvis, before it has undergone the required change of position, Avould be equally dangerous and nugatory. lie should, on the contrary, attempt in the first place, if I may so term it, to unlock or loosen the head by a cautious and continued lateral movement from right to left. This once accomplished, the occiput is to be placed in apposition AA'ith the left acetabulum, and the extraction terminated as already indicated. If the forehead be at the pubes, and the occiput tOAvard the sacrum, the same rules obtain both for the introduction of the instrument, and the delivery of the child; except that, instead of the occiput, the forehead should, in converting the direct position into a diagonal one, be brought to the left acetabulum.* In the event of the head being locked when resting either in the diagonal or transverse position, the rules for the introduction of the instrument are the same as Avhen the head occupies either of these positions, and is not locked. These rules have already been given; yet it is well to remember that, in both instances, the for- ceps should be so introduced as to seize the head on its lateral sur- faces, and not place one blade on the occiput, and the other on the face, as is recommended by some authors, Avhen the head occupies a transverse position. * It may happen that, either in an occipito-pubic or occipito-sacral position, it will be easier to turn the occiput or forehead to the right instead of the left aceta- bulum. In such case it should be done without hesitation. LECTURE XL. Forceps Delivery continued-Use of the Instrument when the Head is retained after the Expulsion of the Body-Circumstances justifying the Forceps in these Cases-Application of the Instrument, the Head at the Inferior Strait, with the Occiput at the Symphysis Pubis, the Face in the Concavity of the Sacrum- Application in a reverse Position—When the Occiput is at the Left and Front of the Pelvis—The Occiput at the Right and Front of the Pelvis-Use of the Instru- ment, the Head resting at the Superior Strait-The Forceps in Face Presenta- tions—Under what Circumstances indicated—Practice of the Old Schoolmen in Face Presentations—Objections to-When Version us to be Preferred to Forceps Delivery in Face Presentations—The Manner in which the Face usually presents at tho Superior Strait—Right Mento-iliac Position—Left Mento-iliac Position- Mode of Descent in these Positions—Manner and Difficulty of applying the For- ceps in Faco Presentations at the Superior Strait—Use of the Instrument when the Face is at the Inferior Strait—Mento-anterior Position—Mento-posterior Posi- tion—Comparative Rarity of the latter Position—The Oblique Positions of the Face at the Inferior Strait—How managed—Face Presentation and Convulsions—Case in Illustration. Genti.emex—We have now to speak of the use of the forceps after the body of the child has made its exit through the maternal organs. Although, Avhen discussing the natural presentations of the foetus iu utero, I told you the presentation of either of the obstetric extremities of the ovoid is in perfect keeping Avith the resources of nature, yet, at the same time, you Avere admonished that the child encounters more hazard Avhen either of the pelvic extremities is found at the superior strait, than in an ordinary vertex presenta- tion ; and for the double reason that, in the first place, the umbili- cal cord is much more liable, especially in footling cases, to undue and dangerous pressure; and, secondly, there is the possibility of more or less difficulty in delivering the head after the body has made its escape. The mode of overcoming this difficulty by sim- ple manipulation has been fully explained in a previous lecture. It may, hoavever, sometimes be found impracticable to bring the head into the Avorld by any manual effort, and, under these circum- stances, it aa-ill become necessary to resort to the forceps. I am inclined to believe that a dexterous accoucheur, one who not only knows Avhat to do, but Iioav the object is to be accom- plished, Avill almost ahvays succeed in delivering the head by a manual operation, unless the obstacle be in consequence of more or less disproportion between the head and pelvis, the latter being 603 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. slightly contracted, or the former slightly enlarged. In these hitter instances, it is, I think, that the use of the forceps AA'ill be more fre- quently indicated after the trunk has been expelled. With, per- haps, more than my share of pelvic presentations, either in my OAvn immediate practice or through consultation, I have met Avith but two cases in which I could not overcome difficulty in the delivery of the head by simple manipulation. In the tAvo cases alluded to, the arrest in the expulsion of the head Avas occasioned, in one instance, by a contraction of about one quarter of an inch in the antero-posterior diameter of the upper strait; in the other, the head Avas unusually large. In both cases I Avas obliged to have recourse to the forceps, and Avas fortunate in delivering the children alive. Some appalling results occasionally ensue from the rude and unskilful attempts to extract the head by manipulation. Such, for example, as the detruncation of the foetus, rupture of the uterus, breaking the neck of the child, or, what is just as fearful, disloca. tion ; serious lacerations of the soft parts of the mother, involving the vagina, rectum, or bladder. Many a tale of Avoe could be told, if the truth Avere spoken, in reference to this point. There is no necessity for these sad consequences once in ten thousand times ; and they accumulate merely because brute force is too often sub. stituted for judgment and skill. These melancholy occurrences in the lying-in chamber attract, unhappily, no special attention; sur- rounding friends are satisfied because they have had rung into their ears, and they have faith enough to believe it, that stereotyped phrase—"All Avas done that could be done!" Hoav fortunate for some men that they practise among a credulous public, and that their acts are subjected to no truth-revealing scrutiny! But is there a corresponding benefit to the public?—is that public in any way requited for its measure of faith ? I think not. Indicatiotis for Forceps Delivery after the Expulsion of the Trutde.—It may become necessary to resort to the forceps for the purpose of delivering the head after the passage of the trunk through the maternal organs, under the folloAving circumstances: 1. In version, the entire operation being completed, except the extraction of the head, this latter being arrested in consccpience of some disproportion, etc.; 2. In an original pelvic presentation, in which the natural effort has been adequate to expel the trunk, but not the head; 3. The occurrence of convulsions, exhaustion, or any other serious complication, after the exit of the trunk has been completed. When, in any event, it becomes urgent to apply the instrument, the head may be arrested either at the superior or inferior strait, in the direct, diagonal, or transverse positions. We fehall first describe the manner of using the forceps, the head having reached the inferior strait: Fm. 95.. be maintained in this position by an assistant, Avhile the application of the forceps is to be conducted as follows: The male branch, held by the left hand, is glided along the fingers of the other hand on the side of the pelvis and head, precisely as has been indicated in the corresponding position of the vertex, with the occiput toward the pubes and the face in the concavity of the sacrum. This branch adjusted, it is entrusted to an aid, and the female branch is then seized by the right hand, and carried on the other side of the pel- vis. The instrument is locked, and the extractive and lateral forces conducted upon the same principles as previously described ; the extremity of the handle of the forceps should be gradually raised toward the pubes until the forehead has passed the vulva, and care should be taken to give proper support to the perineum, in order that laceration may be preA'ented. Ajp/icatlon of the Forceps after the Escape of the Trunk, the Oceifut at the Sacrum, the Face toicard the Pubes.—Here the trunk and arms of the foetus, instead of being elevated, should be directed backAvard in the direction of the perineum, and being held by an assistant, the accoucheur proceeds to introduce the forceps on the sides of the pelvis and head in the same manner as if it Avere a vertex presentation, Avith the occiput toward the sacrum, and the face at the pubes; the extractive and lateral forces, together Avith the delivery, are also to be governed by the same rules as in this latter position of the head. Application of the Forceps after the Escape of tlie Trunk, the Occiput toward the left and front of the Pelvis, the Face at the opposite Sacro-iliac Symphysis.—Here, you perceive, the head rests in a diagonal position, and the body of the child should be 39 610 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. placed in a corresponding direction. The trunk and arms, there- fore, should be turned toward the left thigh of the mother, and confided to an assistant. The instrument is then to be introduced as if the vertex presented Avith the occiput to the lateral portion of the pelvis, and the face regarding the opposite point of the pelvic canal. The occiput in this case being to the left and front of the pelvis, the female branch of the instrument is introduced first ; it is held by the right hand, and glided on the fingers of the left along the right side of the pelvis until it reaches the chin ; it should be continued in the same direction as high as the forehead, from Avhich point it should be made to pass, by the gentle pressure of the fingers, Avithin the pelvis, under the middle of the face and upon the left temple, in order that it may be brought under the pubes; at the same time the extremity of the handle should be slightly depressed, and turned tOAvard the left thigh, with the vieAV of adjusting the blade properly to the length of the head. This branch is iioav entrusted to the aid; the accoucheur then holds the male branch with his left hand, and introduces it along the fingers of the other hand in front of the sacrum, in order to grasp the other side of the head. The forceps is then locked, and before resorting to any extractive force, a rotary movement from left to right should be imparted to the instrument, for the purpose of placing the occiput at the pubes, and the face in the concavity of the sacrum. The combination of the lateral and extractive forces is next to be employed, and the delivery completed as if it Avere an original vertex presentation with the occiput tOAvard the sym- physis pubis. Application of the Forceps after the Escape of the Tru?ik, the Oecipjut to the right and front of the Pelvis, the Fire at the oppo- site Sacro-iliac Symphysis.—Here, again, the position of the head is diagonal in the pelvis, and the same rules are to be observed in the introduction of the forceps as in the preceding example, except that the male branch is to be introduced first, because the occiput, instead of being to the left, is to the right. It is to be brought under the pubes, while the female branch should be directed along the front of the sacrum, in order that the neAV curve of the instrument may correspond Avith the occiput, or anterior portion of the pelvis. The tAA'O branches being locked, rotation from right to left is first accomplished for the purpose of changing the direction of the head from the diagonal or oblique to the direct position, by placing the occiput in correspondence Avith the sym- physis pubis, and the face toward the sacrum. The delivery is then completed in accordance Avith the principles already indicated.* * If, after the escape of the trunk, it be found that the head occupies a diago- nal position, the reverse of those we have just described, viz. the occiput at either of the sacro-iliac symphyses, and the face to the lateral anterior surfaces of the pelvis, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 611 Application of the Forceps, the Head at the Superior Strait.— Having pointed out the rules to be adopted in the use of the forceps, the head being at the inferior strait after the exit of the trunk, it remains for us to make one or tAvo observations in refer- ence to the application of the instrument when the head, from Avhat- ever cause, becomes arrested at the brim. You have been reminded that, in a vertex presentation, and the body of the child yet within the uterus, the adjustment of the forceps, the head being at the upper strait, is one of the most difficult operations in obstetric sur- gery ; for this reason you will remember, when artificial delivery is indicated, and you have the alternative of choice, I recommend version in preference to instrumental delivery. But, however em- barrassing and perilous the application of the forceps in an ordinary vertex presentation at the superior strait, the difficulties and dangers are enhanced after the trunk has made its escape and the head remains at the brim; for here, you will perceive, is the increased difficulty of conducting the forceps to the strait, in consequence of the vagina being more or less obstructed by the upper portion of the child's body, and this, too, in proportion to the elevation of the head in the pelvis. If, hoAvever, you should have a case in which forceps delivery is indicated, the head remaining at the superior strait after the escape of the trunk, the same rules are to govern in the use of the instrument as if it were originally a vertex presenta- tion, and the head arrested at the brim, the only important difference being that proper provision is to be made for supporting the body of the child, as Avas pointed out when speaking of the application of the instrument, the head being either in the excavation or at the inferior strait. Application of the Forceps in Face Presentation.—When treat- ing of face presentations,* you Avere told that, all things being equal, they are entitled to be regarded as natural, and, therefore, within the resources of nature. But here, as in the case of an ordi- nary vertex presentation, something untoward may occur render. ing it essential that artificial delivery should be resorted to. It is proper, therefore, that the rules for the use of the forceps in these cases should be indicated. It may, hoAvever, be premised that, in face presentations, if the face be at the superior strait, version should be preferred to instrumental delivery for the same reasons that this preference should obtain, under similar circumstances, Avhen the vertex presents and artificial aid becomes necessary. It the accoucheur should attempt, if possible, to turn the face toward the sacrum. In this, however, he would most likely be foiled; the alternative, under these cir- cumstances, would be to apply the forceps, remembering that the new curve of the instrument must correspond Avith the faca After the instrument is adjusted, the face is brought to tho pubes, and the labor terminated as if it were an original vertex position, with the face in front and the occiput behind. * See Lecture xxiv. 612 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. was the general practice among accoucheurs before the mechanism of a face presentation Avas understood, to have recourse to various expedients for the purpose of overcoming Avhat they supposed to bean insurmountable difficulty, when the visage came first. For example, one Avould recommend to push the face upward and reduce the pre- sentation to that of the vertex ; another, to grasp the occiput Avith the fingers or lever, and draAV it tOAvard the centre of the pelvis. Independently of* the undeniable fact that these mutations of the head are not only extremely difficult to accomplish, and the attempt to effect them oftentimes accompanied by more or less danger to the child and mother, it is iioav Avell demonstrated that they are alto- gether unnecessary for the reason that nature, Avhen the proper proportion exists betAveen the head and maternal organs, is com- petent to cause by her OAvn efforts the descent and expulsion of the child. Again: it Avas the custom of some practitioners, as soon as it Avas ascertained that the face presented, to resort at once either to version or the forceps. These abstract modes of procedure had no justification, and Avere all founded on the supposition that a face presentation Avas abnormal, and, therefore, beyond the ability of nature to remedy. But experience has proved the contrary of all this, and, in our day, Avhen either version or the instrument is em- ployed, it is not because the face presents, but because of some con- tingency or complication, which renders the interposition of science absolutely necessary. You have been told that, as a general rule, the face is found at the superior strait in one of tAvo positions, although occasionally there will be variations; the positions to Avhich I allude, are: 1. The forehead of the foetus is toward the left iliac bone, while the chin regards the opposite side. This is recognised as the right mento-iliac position ; and here the fronto-mental diameter of the face is in apposition or correspondence with the transverse or bis- iliac diameter of the brim, while, on the contrary, the transverse diameter of the face is parallel to the sacro-pubic diameter of the pelvis. 2. The forehead is toward the right iliac bone, and the chin to the opposite point. This, it will be perceived, is the reverse of the first position, and is knoAvn as the left mento-iliac. In either of these positions, the head, in its descent, undergoes tAvo move- ments—diagonal and direct. Thus, as the labor advances in the first position, it changes from the transverse to the oblique direc- tion, so that the fronto-mental diameter of the face accords Avith the right oblique diameter of the pelvis, the chin being opposite; to the riodit foramen ovale ; then the chin, through the direct move- ment, is brought behind the pubes, and the forehead turned into the holloAV of the sacrum. In the second position, the mechanism of descent is precisely the same, except that the rotary movement is from left to right instead of from right to left. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. My object in recalling to your recollection the peculiar direction of the face in these two most frequent presentations at the superior strait, is to show you the almost impossibility of applying the for- ceps, until the head has begun to assume, in the course of its descent, the oblique or diagonal position; for, until this is done, the face occupies the strait transversely, either exhibiting the right memo-lllnc or left mento-iliac position. Therefore, if, before the change from the transverse to the oblique direction, there should be imminent urgency for artificial delivery, I advise you by all means to abandon any attempt with the forceps, and proceed to terminate the labor by version. It may, however, happen that the face will so present at the brim as that the chin shall correspond Avith the pubes, and this Avould be more likely, perhaps, to occur if there Avere a slight contraction or narrowing of the transverse dia- meter ; or, instead of the chin being at the pubes, it may corre- spond Avith one or other of the acetabula constituting an example of the diagonal or oblique presentation of the face. In such an event, although I should again as a general principle prefer version to the instrument, yet it is very evident, Avith a moment's reflection, that the forceps could be applied Avith about the same facility as if the vertex were at the superior strait. To illustrate, suppose the chin were toward the pubes. In this case, the face Avould exhibit a direct position, its mento-frontal diameter corresponding Avith the sacro-pubic diameter of the brim. The forceps, under these circumstances, should be introduced along the sides of the pelvis, and would consequently grasp the head in the proper or lateral direction. If, on the contrary, the chin regard one or other of the acetabula,* the mento-frontal diameter would be in apposition Avith one or other of the oblique diameters of the * It will sometimes occur, that the chin, in face presentations, will occupy a posterior position, corresponding with one or other of the sacro-iliac symphyses, and, under such circumstances, the natural powers may suffice, during the progress of the head, to bring tho chin and anterior surface of the child's body in front, and thus the labor will be terminated without the assistance of the accoucheur. But we will suppose an example, in which this change in the position, from behind forwardi cannot be accomplished by the natural effort. In this contingency what is to be done? In the first place, it maybe remarked that the mere adjustment of tho forceps to the head would not of itself be so difficult: but it is to be remembered that, after the adjustment, the difficult thing to accomplish is to bring the chin to the front of the pelvis, a fundamental requisite in all cases of face presentation in order that the head may make its exit; and this will be found, I may safely say, impossi- ble to do, unless the pelvis be unusually capacious or the head under size. There- fore, if nature prove incompetent to direct the chin toward the anterior half of the pelvis, and this should be ascertained opportunely, the resort should be version. If, however, from rigidity or other opposing conditions of the uterus, the hand cannot be introduced, and these antagonizing influences do not yield to the appropriate remedies already pointed out, then there is no alternative but craniotomy if the child bo dead; if alive the question may arise, craniotomy or the Csesarean section— which topics will be fully discussed iu a future lecture. 61-1 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. upper strait. In such an aspect of things, the forceps could also be applied, the same rules precisely being observed as if it Avere a vertex presentation Avith the occiput to the pubes, or to the left or right. So much for the management of face presentations, through the aid of instrumental delivery, the head being at the superior strait. Let us uoav examine the modus in quo of procedure after the head has passed into the pelvic excavation. Under these latter circum- stances, the chin Avill be either in front or posteriorly, constituting the mento-anterior or mento-posterior positions. The Mento-anterior Position.—In this position, the head may rest in the pelvic cavity either directly or obliquely, depending upon Avhether the chin has completely turned tOAvard the pubes, or AA'hether its aspect is to one or other of the lateral points of the excavation. In the former case, the head occupying the direct position, Avith the chin at the pubes and the forehead tOAvard the sacrum, the forceps must be introduced in the same manner as if the occiput Avere at the pubes and the face regarding the sacrum. The blades being adjusted to the head and properly locked, the first tractions should be directed doAvmvard in order that the chin may be brought from under the pubic arcade; as soon as this is accomplished, not forgetting to protect the perineum by judicious support, the handle of the instrument is to be gradually elevated toward the abdomen for the purpose of completing the extraction of the face. In the oblique or diagonal position, Avith the chin at either the left or right of the anterior surface of the pelvis, the same rules are to be observed in the introduction of the instrument as if the occiput regarded one of these points; when the head has been properly grasped, the first thing to be done is to produce a rotary movement from left to right, or from right to left, as the case may be, with a vieAV of changing the position from the oblique to the direct. The delivery is then to be proceeded with as already described. The Mento-posterior Position.—It is most fortunate that this position of the face is comparatively of rare occurrence. You have been told that, in face presentations, the persistent tendency of the natural effort is, through a special mechanism, to bring the chin for- ward either to the pubes or to one or other of the lateral points of the anterior portion of the pelvis. Nature, hoAvever, is occasionally contravened in this effort, and then she relies entirely on the dis- creet interposition of the accoucheur. Suppose you had an example of mento-posterior position, what course would you pursue? In the first place, you are to recollect that in no case, unless as an exception, if I may be permitted to say so, to an almost universal rule, can the head be made to accomplish its exit through the maternal organs, the chin continuing to remain in a posterior posi- tion. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 615 When speaking of this position a feAV moments since, the face being at the superior strait, you Avere admonished of the difficulties attending it; these difficulties are in no Avay diminished after the face has descended into the pelvic cavity. When, therefore, you have become satisfied that nature is incompetent to bring the chin toward the anterior portion of the pelvis, and further delay AA'ould be perilous to the child, and not altogether without serious conse- quences to the mother, three indications will present themselves to the mind of the experienced accoucheur: 1. To endeavor by means of the forceps to bring doAvn the vertex, by making an extreme doAvnward and backward traction, and thus substituting a vertex for a face presentation ; 2. To endeavor, by an adroit rotary move- ment Avith the instrument, to detach the chin from one of the pos- terior to one of the anterior points of the pelvis ; 3. If the head should not have passed beyond the mouth of the uterus, and this latter be in a condition to justify the operation, version may be attempted. These, then, are the three alternatives, the tAvo first most difficult to accomplish, and, indeed, I may say the chances of failure greatly preponderating. Version, hoAvever, if the conditions premised be present, is much more feasible, and, in dexterous hands, may suc- ceed. Hypothecating that these three alternatives should fail, is there any other resort left, or is the mother to be permitted to die undelivered? This is a grave question—but yet it must be answered. The last resort, perfectly justifiable under the circum- stances, provided the child be dead, is craniotomy; should, on the contrary, there be satisfactory evidence that the child is alive, there may arise the momentous question—shall the child be sacrificed, or the chances of life betAveen it and its parent equalized by subjecting the latter to the hazards of the Cesarean section ? Before closing my remarks on the subject office presentations, I may, I hope Avithout the imputation of improper motives, be per- mitted briefly to narrate the tAvo folloAving instances in AA'hich I applied the forceps Avith safety to both mother and child ; I am induced to refer to these cases, because they have, in my judgment, a useful practical bearing, and may, under similar circumstances, serve to remind you of your duty: Dr. Oatman requested me to visit in consultation with him a lady, aged twenty-seven years, the mother of one child, three years old. She had been in active labor tAventy-four hours before I saw her; the pains from the commencement had been strong, and she suffered greatly from their more or less constant recurrence, the slight inter- mission betAveen them constituting a remarkable feature in the labor. The membranous sac had become ruptured three hours after the commencement of the parturition-, but the mouth of the uterus was previously Avell dilated. Dr. Oatman, on making a vaginal exami- 616 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. nation, ascertained that the face presented ; the head a\ as slightly responsive to the vigorous contractions, but its descent into the pelvic cavity extremely sIoav ; after the face had fully reached the excavation, it became arrested, and notAvithstanding the continued poAverful efforts of the uterus, it made no farther progress. The mother's strength was yielding under the influence of these repeated but fruitless contractions, and the child's safety in great peril from the pressure to which it Avas exposed. It Avas at this period of the labor that a messenger reached me requesting that I would promptly meet Dr. Oatman. I immediately obeyed the summons, and on my arrival found the condition of things as described above. The face exhibited an example of mento-anterior presentation, the chin being at the left of the pubes, Avith the forehead regarding the opposite sacro-iliac symphysis ; in other words, the face rested in the left- diagonal position. I soon became satisfied that nature had strug- gled long enough, but vainly, to produce on the head the rotary movement, Avhich Avould have resulted in placing the chin in appo- sition Avith the pubes, and the forehead toward the sacrum. The basis for this opinion Avas the evident exhaustion of the mother, together Avith the unusual tumefaction of the child's face, and the increased heat in the vagina ; these phenomena, remember, accompanied by poAverful but unavailing contractions of the uterus. There could be no doubt as to the course to be pursued under the circumstances; inaction on the part of the accoucheur, founded upon an abiding faith in the ability of nature to accomplish the delivery, would, Avithout a doubt, have resulted most disastrously, for the evidence AA'as abundant and unequivocal that, if this condi- tion of things had been permitted to continue, the forces of the mother Avould have given way, and the life of the child sacrificed. What, therefore, Avas the indication ? Why, evidently, to consume no time in idle expectation, but to proceed at once and render the needed assistance, so that, by opportune interference, the lives of both mother and child might be rescued from the dangers Avhich threatened them. Dr. Oatman concurred entirely in this view of the case, and at his request I applied the forceps in accordance Avith the rules already indicated. As soon as the instrument had been adjusted on the head, I brought, by a rotary inclination, the chin to the pubes, thus changing the position from the diagonal to the direct; this being accomplished through proper tractions as pre- viously described, I had no difficulty in bringing the head into the Avorld. The child, a little daughter, Avas alive, and the mother had a favorable convalescence. Hesitation, or, perhaps, an hour's delay, Avould have rendered these agreeable results impossible. On another occasion, I received a note from Dr. Jiubou to meet him under the following circumstances : He was in attendance on a lady in labor Avith her first child. She Avas twenty-one years of age, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 617 and, Avith the exception of a delicate nervous organization, enjoyed good health. Her parturition commenced at six o'clock a.m. Dr. J. saAv her at eight; the pains Avere slight, but the labor had fairly begun. After remaining for an hour Avith her, he left Avith the request that he might be notified as soon as his services Avere needed. At four o'clock p.m., just ten hours from the first indi- cation of the parturient effort, he Avas again sent for. At this time, some progress had been made, the os uteri dilated to the size of a dollar piece, Avith increasing and recurrent pains. Things continued to progress; at seven o'clock the membranes ruptured, and there escaped an unusual quantity of liquor amnii. Soon after the rup- ture of the sac, the Dr. discovered the presentation to be that of the face. The pains increased in power, assuming an expulsive cha- racter ; the head began to descend into the pelvic cavity; at ten o'clock it had passed to the loAver strait, Avith the chin to the pubes and the forehead to the sacrum. The pains now assumed a strong expulsive force, and during one of them, the patient Avas suddenly attacked AA'ith convulsions, Avithout any premonition Avhatever. In fifteen minutes there Avas a second convulsion, the pains becoming more marked and vigorous. At this time, eleven o'clock p.m., I Avas requested to meet Dr. Jndson. At half after eleven, Avhen I arrived, I found the uterus contracting Avith full force, and nature doing all she could to "ter- minate the delivery. The features of the face were excessively tumefied, and, notAvithstanding the vigor of the pains, the head did not advance in a corresponding ratio. Twenty minutes after mv arrival, the third convulsion occurred. These Avere all the facts of the ease, and hoav the question to be determined Avas this— What, under the circumstances, Avas the most rational course to be pursued ? 3ly own opinion, frankly expressed to my friend, the doctor, Avas—that the convulsions Avere of eccentric origin, due alto- gether to the irritation of the incident excitor nerves of the vagina; and this opinion Avas grounded upon the important fact that the convulsive movement did not occur until this extreme pressure had begun to exert itself on the Avails of the vagina ; there had been no previous indication of any such nervous derangement; there Avas an entire absence of any hydropic condition, etc., indicating the presence of albuminuria. Supposing this view of the case to be sound, Avhat Avas the necessary practical deduction as to our line of conduct ? It was to remove, at the earliest possible moment, the cause of the irritation, and this could only be done by prompt artificial delivery. Therefore, as every instant of time Avas pre- cious, at the doctor's request I applied the forceps, having first placed the patient under the full influence of ether. I Avas fortu- nate in extracting a living child. The mother had no recurrence of the convulsion, and AA'as soon in the enjoyment of her usual health. LECTURE XLI. Cutting Instruments—"What they Involve—Importance of the Question—"What is the Smallest Pelvic Capacity through which a Living Child can be made to pass, and Avhat the Capacity through which a Child may be extracted piecemeal ?—Dis- crepancy of Opinion on these Questions—Symphyseotomy, in what it consists— Sigault its Originator—The true claims of the Operation—The Question exa- mined—Comparison instituted between Symphyseotomy and the Cesarean Section —Statistics of each—Deduction—The Cesarean Section—The Opinions in Great Britain and on the Continent of Europe as to the Merits of the Operation—Reasons for the marked Difference of Opinion—Analysis of the Views of Authors touching • the Caesarean Section—Statistics of the Operation—How its Fatality may be Modified—Opinion of the Author as to the Advantages of the Cesarean Section over Craniotomy—What are the Dangers of the Operation ?—The Benefits of Anaesthesia in controlling the Shock to the Nervous System—Post-mortem Cesar- ean Section, when resorted to—The Case of the Princess of Schwartzenberg—The Roman Law on the Subject of the Post-mortem Operation—Method of Performing the Cesarean Section; the Vertical Incision through the Linea Alba preferred— Why?—Should the Operation be Performed before or after the Rupture of tho Membranous Sac?—How is the Child to be Extracted through the Opening in the Uterus ?—Rules for Removing the Placenta—Dressing the Wound, and sub- sequent Treatment—The Operation of Elytrotomy, as a Substitute for the Incision into the Uterus, proposed by Jorg and others—Merits of the Operation—Dr. Christoforis and the Resectio-subperiostea of the Pubic Bones. Gextt,eaikx—Having described to you the blunt instruments used in midAvifery, their object, and mode of employment, the next topic for our consideration Avill be the cutting instruments Avliich, Avhen resorted to, must of necessity either destroy the child, if alive, or subject the mother to the hazards of a perilous operation. You see, therefore, in the discussion of this question, Ave approach a point, the most important, perhaps, so far as a just decision is concerned, in the Avhole range of obstetric science—a point Avhich not only involves human life, but imposes upon the medical man the highest and most sacred obligations. In the examination of this topic, I shall, I trust, have my mind emancipated from the thraldom of bias or preconceived opinion, and shall endcrvor to reach the truth through a proper sifting of evidence; for, after all, the employment of cutting instruments, Avhether upon the child or mother, is simply a question of testimony to be developed by surrounding circum- stances, and determined by the honest judgment of the accoucheur and his associates in counsel. Prerequisites for the Use of Cutting Instruments.—It should be THE PRINCIPLES AND PRACTICE OF OBSTETRICS. G19 remembered that the fundamental prerequisite for a resort to these instruments is such a disproportion between the maternal organs and foetus as to render it physically impossible that the latter can be made to pass, either through the natural effort, version, or by the aid of the forceps, per vlas na t urates ; and this disproportion may arise from a contracted pelvis, the presence of osseous or sar- comatous tumors, a narrowing of the soft parts, an abnormally large child, or from malposition of the foetus itself. In either event, how- ever, the grave question presents itself, shall the cutting instrument be applied to the child, or to the mother? In the former case— assuming, of course, that the child is alive—it will inevitably be destroyed ; in the latter, on the contrary, although the safety of the mother is in more or less peril, yet it is not necessarily compro- mised, and the chances of fife are equalized between her and the child she carries Avithin her. The decision of this question is, I repeat, of momentous import, and cannot be regarded lightly by the medical man Avho is governed by a high morality, and feels that there is nothing incompatible betAveen the scientific physician and conscientious Christian. Amount of Pelvic Contraction consistent with the Birth of a Living Child.—As to what really constitutes a contracted pelvis, such as will not permit the transit of a living child at full term, there exists a remarkable discrepancy of opinion ; and this very circumstance, no doubt, Avill explain, in part at least, the conflicting views of authors regarding the justification for the employment of cutting instruments. For example, Buseh, of Berlin, says, for a living child to pass, the antero-posterior diameter must measure from 2£ to 3 inches; Burns 3£; Dr. Joseph Clarke :U. Dr. Os- born* places it a fraction beloAv 3 inches, Avhile Dr. Ritgen is of opinion that a contraction of 2 inches is not inconsistent AA'ith the passage of a living foetus at maturity ! Aly own opinion, arrived at not Avithout full consideration, and some share of experience, is that a diameter of 3^ inches antero-posteriorly is the smallest possible space, except under very rare exceptional circumstances, through Avhich a living fcetus at the end of gestation can make its exit,f and * " AA'henever a woman falls into labor, the small diameter of whose pelvis mea- sures only 21 inches, one or other of the following circumstances must take place: 1. The child's head must be opened; 2. For the certain preservation of the child's lite, the mother must be doomed to inevitable destruction by the Cesarean opera- tion; 3. As a mean between the two extremes, the mother must submit to the division of the symphysis pubis (symphyseotomy), an operation less dangerous to the patient than the Caesarean section, but less safe for the child; or, if none of these means will be permitted, the wretched mother, abandoned by art to the exeru kiting and unavailing anguish of labor, will probably expire undelivered." [Essays on the Practice of Midwifery in Natural and Difficult Labor. By Win. Osborn, M.D. 1792. p. 194] f See Lecture Fifth. 620 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. even Avith such capacity, more or less hazard and a protracted delivery Avill be the almost necessary result.* Amount of Pelvic Deformity through which a Fetus may be Extracted Piecemeal.—The same Avant of concurrence is noticed * An exception, perhaps, to this rale may be made in certain cases of hydroce- phalus, in which the bones of the head become so excessively yielding as to undergo an extraordinary pressure without destrojdng the life of tho child. I saw a case of this kind some years since, which occurred in the practice of Dr. Ilibbard of this city. He requested me to meet him in consultation under the following circum- stances : The lady, aged twenty-nine years, was taken in labor with her first child at 5 o'clock a.m. The doctor saw her at 8 o'clock; the pains, before he arrived, had commenced with an unusual degree of force; he found, on examination, the os uteri fully dilated, the membranous sac ruptured, and the head beginning to descend into the pelvic cavity. The pains lost nothing of their expulsive character, but con- tinued with regularity and vigor. There was, however, at 4 o'clock p.m., but a slight advance in the position of the head ; a this time I saw the patient, being just eleven hours from the commencement of the labor. After giving a history of the case as above detailed, Dr. Ilibbard requested me to examine the patient. The head rested diagonally in the pelvis, and had evidently continued to make progress under the strong contractions of the uterus, although the advance had been ex- tremely slow. During an interval of pain, I again introduced my finger into the vagina, when I very distinctly recognised a peculiar condition of the head ; it was flaccid to the touch, and the bones were movable, the one upon the other. What could this be ? Was it because of the death of the child, and its putrefaction ? This hypothesis was soon removed, because auscultation revealed the beatings of the foetal heart, and the mother, too, was conscious that her child was alive, for she very distinctly felt its movements. Here, then, was an interesting state of things, and there was much need of sound judgment. Some writers place great confidence in the flaccidity and overlapping of the bones of the head as an evidence of the death of the foetus ; and, therefore, in the case now under consideration, if this evidence had been accepted as worthy of guidance, it might possibly have happened that, under the conviction that the child had ceased to live, a resort may have been had to the perforator and crotchet for the purpose of bringing the dead foetus into the world, and thus terminating the deli- very. In these days of fondness for instruments, such an alternative is certainly not among the very improbable things of the lying-in room. From all the circumstances of the case, I had no doubt of the true cause of the flaccidity and overlapping of the bones, it was manifestly an example of hydrocephalus; in this opinion, I was happy to find Dr. Ilibbard fully concurred. With this diagnosis, the question arose—What, under the circumstances, was the course to be pursued ? It was agreed that the labor should be confided to nature, and for these obvious reasons: 1. The child was alive; 2. The strength and general condition of the mother were good. The pains continued with their wonted force, and at half-past three o'clock a.m., twenty-two hours from the commencement of the parturition, we had the satisfaction of witness- ing the propriety of the course adopted in the birth of a living child; although alive, its head exhibited a most uncomely appearance, in consequence of the extreme elongation it had undergone, the occipito-mental diameter measuring nine inches. It soon, however, recovered from this temporary malformation, and survived its birth four months and one week. The mother had an ordinary convalescence. I was anxious to ascertain the true condition of the pelvis in this case, and in carrying the finger to the upper strait, it was quite evident that there was an unusual contraction In the antero-posterior diameter, which could not have presented a fraction over three inches. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 621 among authors as to the extent of deformity through AA'hich it is possible to extract a child at full term, fragment by fragment, in the operation of embryotomy. Burns, for instance, justifies the operation, Avhen there is a space of lj inches; Hamilton 1^; Osborn \\ ; Davis 1 inch ! Dr. Dewees, on the contrary, thinks if the contraction be less than 2 inches, embryotomy should not be resorted to. I have endeavored to shoAv (Lecture V.) that if the direct or antero-posterior diameter fail to measure from 2 to 2J inches, embryotomy cannot be accomplished without the almost certain hazard of laceration of the maternal organs, Avhich may more or less involve life, or entail upon the parent sufferings to Avhich death itself would oftentimes be preferable ; and, therefore, I emphatically urge that the operation should not be attempted Avith a less space than 2j inches, AA'ith tlie single exception that the child be dead. Whether AA'ith this space, or even a greater one, it will ever be justifiable to resort to the perforator and crotchet, if the child be living, it AA'ill be our purpose to discuss as Ave proceed, Deductions.—Taking, therefore, the two extremes, Avhich, in my judgment, AA'ill be found correct, viz. a space of 3* inches for the passage of a living child,* and 2 J inches to justify embryotomy, the question naturally arises—what is the rule of conduct, when the pelvis shall ]>resent a contraction between these measureme/ds. or below 21 inches, if it should be ascertained that the child is alive, and the woman at the full period of her gestation ? In the exami- nation of this question, it must be constantly borne in mind that the alternative of choice is to rest altogether upon the simple but important issue—shall the child, knoAvn to be alive, be sacrificed, in order that the mother may be saved ? or shall the mother be sub- jected to an operation, Avhich, Avhile it Avill involve her in serious peril, AA'ill afford a reasonable, or, if I may be permitted to say so, more than a reasonable, hope for the life of the child, thus, as it were, equalizing the chances betAveen parent and offspring. If the latter course should be decided upon, the choice of operations to be performed on the mother, Avill be betAveen what is known as sym- physcotonng and the Cesarean section ; if, on the contrary, it be determined to destroy the child, then resort is to be had to cranlo- tomq, cij/halotripsy, or embryotomy, as circumstances may indi- cate. I iioav propose to review in succession these various alternative-, vielding to each, as far as I can do so, its proper place in the scales * I am aware that authors of integrity have recorded examples of living children being born, through the natural eftbrt, when the abridgement was less than 3^ inches : for example, Smellie and Baudelocque both cite cases of this kind, in which the head, natural and healthy, had undergone extraordinary pressure, and was expelled without compromising the safety of the child. But these are to be regarded as exceptional instances, and, therefore, cannot form the basis of a principle. 622 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of right, and deducing from statistical data and other sources the basis of conduct by Avhich the conscientious accoucheur is to be guided, when, from disproportion between the maternal organs and foetus, the latter cannot pass at full term, per vias naturales, excipt through the intervention of cutting instruments. 1. Symphyseotomy.—This consists in a section of the symphysis pubis, Avith the vieAV of giving such an increase of capacity, as to allow the exit of the child. The projector of this operation Avas a French medical student, named Sigault, Avho made it the topic of a memoir, Avhich was presented to the Academy of Surgery in 1768; it Avas, hoAvever, not well received by the Academy. But Sigault, still firm in his conviction that he would be able to demonstrate the great fact that symphyseotomy Avas destined to become a sub- stitute for the Caesarean section, and entirely do aAvay with the necessity of the latter operation, selected the same question -as the subject of his thesis in the school of Angers in 1773.* It is due to this enthusiastic surgeon to state that, at first, he simply proposed to experiment on living animals, and then on condemned criminals; his essays on the dead subject having satisfied him of the correct- ness of his opinion as to the feasibility and advantage of the opera- tion on the living woman in certain cases of pelvic deformity. As on most questions of science, the persevering demands of Sigault for an opinion soon gave rise to two parties, the one in favor, and the other adA'erse to the suggestion. Among the former, may be mentioned the learned Holland physician, the well-knoAvn Dr. Camper, Avho, in 1774, Avrote a letter on the subject to Van Gesscher, entitled, De Emolumentis Sectionis Synchondroseos Ossium Pubis in Partu difficili. Xothing, however, of a positively decided character developed itself in the minds of the profession, if we except the mere expres- sion of opinion as to the anticipated benefits or evils of the pro- posed operation, until 1777, when Sigault, assisted by his friend, A. Le Roy, tested the feasibility of his theory, by resorting to sym- physeotomy on a married woman, named Souchot, Avhich resulted in safety to both mother and child. This Avoman, it appears, had previously borne four dead children. The success of the operation was like the electric current, for it Avinged its flight almost with the rapidity of lightning ; for the time being, all doubts Avere at an end, and Sigault AA'as the idol of Continental Europe. His name became one of honor ; the poor student, Avho was ridiculed at first, Avas hoav the very centre of attraction ; he Avas the originator of a new epoch in obstetric science ; he had caused to be expunged from practice the " barbarous and deadly " Caesarean section, and substituted in its stead the " rational and conservative" operation of symphy- * The following is the title of the thesis: An in Partu contra Naturarn Sectio Symphyseos Ossium Pubis Sectione Caesarea promptior et tutior. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 623 seotomy. I am only quoting the words AA'hich were on every one's tongue at the period of Avhich I speak. His fame was not limited to the adulations of the body of the profession, but he became the recipient of the highest honors of learned academies—the very academies Avhich had originally nearly crushed his spirit by the unfavorable manner in which his " rational and conservative" pro- position had been received ! The Academy of Medicine of Paris voted him a medal, bearing the following inscription : " Anno 1768, Sectio/iem Symphyseos Ossium Pubis invert it, Proposuit: Anno \111, fecit feliciter M. Sigault, D. M. Ipsique, centum ccdcidos illos esse offerendos. Juvit M. Alph. Le Roy, D.M.P. Cui quinqua- ginta offcrentur calculi illi argentei." In addition to this medal, making such honorable mention of Sigault, and his assistant, Alph. Le Roy, a royal pension Avas granted to the illustrious benefactor of the age. But this Avas not all; many an eloquent pen Avas busy Avith oblations of praise, and Sigault Avas lauded as the man, of all others, who had contributed a precious floAver to the garden of science, and had conferred on womankind a blessing which Avould not fail to be appreciated in all time. Indeed, there Avas a perfect furor in public opinion, and Sigault Avas its subject. Panegyric after panegyric was issued from the press, and he must have grown giddy Avith the euiogiums of his admiring friends, one of the most enthusiastic of Avhom, Roussel de Vausesme,* supposed that nothing short of inspiration could have led the mind of Sigault to such a magnificent conception: " At tandem Sigault, D.M.P. haec alta mente diu revolvens solus divino quasi afflatus numiue quam monstrarat natura viam ingreditur."' Again : under the influence of the same unbounded enthusiasm, this writer predicts that posterity will not fail to regard symphyseotomy as among the most useful of operations: " Non longam post elapsam annorum seriem, inter operationes maxime salutiferas annumerctur." I have thus presented this brief and running sketch of the origin of symphyseotomy, and of the acclamation by Avhich its first success Avas received, in order that you may understand how oftentimes it happens that human judgment, even in grave matters of science, is premature in its decisions because of the crudeness Avith Avhich investigation is carried out. Here we find upon simple assumption, founded in the first instance on the success of a solitary case, the professional mind, as it Avere, becomes startled at Avhat it deems a great fact—learned bodies are impelled by the enthusiasm of the moment, and their imprimatur is affixed to Avhat the future proves to be the veriest phantom ! There is a moral in all this too palpable to need comment. Let us for a moment consider the objects of symphyseotomy, * De Sectionc Symphyseos Ossium Pubis Admittanda. Paris, 1778. 624: THE PRINCIPLES AND PRACTICE OF OBSTETRICS. together Avith the results of the operation, and then determine whether, in any event, it can become the substitute for the (Cesa- rean section ; or Avhether, under any circumstances, it should con- tinue to receive the sanction of the profession as a humane or justi- fiable resort in the lying-in chamber. Its Objects.—The most ardent advocates of symphyseotomy based the motiA'e for its performance upon the exclusive facts—that it would so far increase the capacity of a deformed pelvis as to permit a living child to pass, and that it is a less dangerous operation than the Cesarean section. Ample experiment has very satisfactorily shoAvn that it is not possible, by the separation of the symphysis pubis, to obtain in the direction of the antero-posterior diameter, at the utmost, an increase beyond half an inch, and in accomplishing this there AA'ill be the serious hazard of lacerating the sacro-iliac syn- chondroses. If this be true—and the fact is, I think, universally conceded—it follows that no good result can be expected to the child if the contraction of the antero-posterior space should be a fraction under 2% inches, for Ave hold that a living child cannot be made to pass if this diameter be less than 3 J inches; and even AA'ith that allotment the difficulty Avill be very great. As the chief motive for symphyseotomy is to save the child, that object Avould most certainly be defeated, if the space Avere much short of 2:] inches. Another very important circumstance to be taken into account— and about which there is a general assent among authors—is that in consequence of the posterior relations to the pelvis of the sacro- iliac synchondroses, it ensues, as a necessary physical fact, that the greatest space obtained by this operation AA'ill be : 1. In the oblique diameter of the pelvis ; 2. In the transverse ; and, 3. In the antero- posterior. Noav, if it be remembered that it is the abridgment of the antero- posterior diameter, AA'hich in the first place constitutes the obstacle to the delivery, and, secondly, the motive for a resort to the opera- tion, it would seem to folloAA', not only as an irresistible logical sequitur, but as an essential practical deduction, that unless sym- physeotomy Avill afford an additional space betAveen the pubes and sacrum, such as beyond all peradventure Avill permit the passage of a living child, it fails to secure the object for Avhich its advocates haA'e contended; and, under the circumstances, in addition to the risks of the operation itself, it Avould become necessary to superadd the dangers to the mother of embryotomy, not to speak of the consequent sacrifice of the child. But let us suppose that the antero-posterior diameter shall measure 2f or even 3 inches—is symphyseotomy, Avith this space, indicated ? Its friends—If there be any now left—Avould perhaps be shocked at such an interrogatory. I have no hesitation, hoAvever, in saying, that in any case in Avhich the division of* the pelvic bones has been THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 625 recommended, I should myself, as an alternative, prefer the Caesa- rean section, for the obvious reason that I believe its dangers to both mother and child to be less than those involved in the opera- tion of symphyseotomy. It has, I think, been shoAvn that the first argument of the symphyseotomists—the acquisition of an increased space—Avhen the contraction is less than 1\ inches, is worthless in practice; and their second argument—that the operation is more conservative to parent and child—will be proved to be equally fallacious, as Ave shall see by a glance at the statistics of the two operations. Statistics.—It would appear that, in symphyseotomy, one mother is lost in every three, and one child in every two. These, it must be remembered, are simply the aggregate results of the operation ; there is no account taken of the serious and not unfrequently remote fatal issues to the mother in consequence of the injury inflicted on the soft parts, more particularly the bladder and uterus, to say nothing of the permanently crippled condition of the unhappy parent, which has occurred in more than one instance. If Ave hoav compare this table with that of the Caesarean section, we shall find that in the latter one mother is lost in 2^, while more than two thirds of the children are saved. Here, it is true, more mothers die, but the safety to the child is greatly increased. When, how- ever, a Avoman recovers from the Caesarean section, she has not entailed on her the accidents which so commonly result from sym- physeotomy, but she enjoys good health, and is not disqualified from attending to her ordinary duties, as is proved by the fact—which has repeatedly occurred—of the same woman having been subjected to the operation several times, and Avith success to her and her child. Again: the results to the mother from the Caesarean operation just given, are not, in my opinion, to be regarded as fair exponents of its positive fatality, for they are taken from mixed cases, the great majority of Avhich Avere no doubt operated on in extremis^ Avhen the vital forces, from previous effort, had been so dilapidated as greatly to tend against recovery; and, as we proceed in the investigation of this question, I shall endeavor to demonstrate that the Caesarean section woidd be far more favorable to the safety of the mother if, as a general principle, it were resorted to earlier, and not left, as has been too often the case, until the last spark of life is near extinction. I can comprehend no difference, in this essential particular, betAveen the Caesarean section and any other capital sur- gical operation. In the latter, is not the great element of success an opportune and timely resort to the knife, Avhen the system is best prepared to resist the shock, and in condition to lead to reco- very? The truth of this no one Avill doubt, and yet, so far as the Caesarean operation is concerned, this great conservative principle 40 626 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. has been sadly neglected. Therefore, for the reasons stated, my advice to you is to repudiate, as altogether unjustifiable, because without an equivalent for the hazard it involves, a recourse to sym- physeotomy. 2. The Caesarean Section.—This operation consists in an incision through the abdominal Avails and uterus of the mother, for the pur- pose of extracting the child ; this, at least, is the generally accepted definition. The definition, however, is too circumscribed, for, in strict construction, it is still the Caesarean section, AA'hether the child be extracted by an opening through the abdominal parietes or vagina; hence it has been, I think, properly divided into abdo- minal hysterotomy and vaginal hysterotomy, depending upon whether the incision into the uterus be through the abdomen or vagina. I do not deem it necessary to enter into any special dis- cussion touching the early history of this operation; I prefer rather to direct your attention to the important question— Under what cir- cumstances is the Cesarean section justifiable, and what, as a con- servative resource, are its true relations to craniotomy ? FeAV subjects, perhaps, in midAvifery have given rise to more seri- ous discussion, and called forth more decided opinion, both for and against, than the very question which Ave are noAV to consider. Here, Ave find the controversy not limited to mere individuals, but it has, in the full sense of the term, become what may be truly called national. In Great Britain, for example, the almost univer- sal voice of the profession is in favor of craniotomy in preference to the Caesarean section ; the writers and practitioners of that com- monAvealth, as a very general principle, avow that there is no com- parison to be instituted betAveen the value of the life of the mother and that of the child; and, therefore, in cases requiring cutting instruments, the perforator and crotchet are resorted to, Avhether the child be living or dead. On the Continent, on the contrary, the reverse of this obtains ; and craniotomy is, comparatively, much less frequently practised than the Caesarean section. It does really seem to me that, amid the conflict of sentiment, Avhich has and still con- tinues to exist on this vexed topic, facts have had too frequently to yield to an inflexible determination not to surrender preconceived opinion ; in this Avay, and under the influence of a false principle, the human mind is oftentimes fettered in its judgment, and, as a consequence, much harm is entailed both upon science and huma- nity. Discrepancy of Opinion touching the Caisarean Section.—I wish you distinctly to bear in memory that the controA'ersy, Avith regard to the benefit or evil of the Caesarean operation, seems to rest on the contrast which authors have, in their oavh minds, insti- tuted betAveen it and craniotomy, and also on the respective value Avhich they affix to the life of the mother and child. It is worthy THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 627 of recollection, too, that the deductions of both parties are some- times from very false premises, as I hope to demonstrate before closing this lecture. It may not be without profit to array before you the opinions of some of the leading authors on this subject, and you Avill appreciate, in perusing their conflicting notions, the maxim—Quot homines tot sentential, which may be liberally trans- lated : As men9s features differ so do their opinions. Dr. Osborn* says, " The valuable life of the mother should never be exposed to absolute destruction by the Caesarean operation for the certain safety of the child. The perforator should be had recourse to without reference to the life of the child." Mauriceauf writes, " The Caesarean section should never be per- formed on the living woman ; it is an inhuman, cruel, and barbar- ous operation." BaudelocqueJ holds, "To mutilate a living child, in order to avoid the Cesarean section, is the offspring of ignorance and inhuma- nity ; nothing can excuse the practitioner who will have recourse to the perforator or crotchet without first being certain that the child is dead?' Gardieng says, " It is with good reason that prudent accouchem^ in view of the fatal results of embryotomy, prefer the Cesarean operation.'* Dr. Weidemann|| " recommends the Caesarean section in every pelvic deformity in which a living child cannot be delivered by other means /' and he is most emphatic in his denunciation of the crotchet and perforator, for the following is his decided language, charac- terizing the destruction of a living child by these means a monstrous crime: " In fcetum vivum, uncas et perforatoria adigere, nefan- dumfacinus est." Smellie,*! England's great obstetric light, speaks thus : "When a woman cannot be delivered by any of the methods recommended in preternatural labors, on account of the narrowness or distortion of the pelvis, etc.; in such emergencies, if the woman is strong and of good habit of body, the Cesarean operation is certainly advisa- ble, and ought to be performed; because the mother and child have no other chance to be saved, and it is better to have recourse to an operation ichich hath sometimes succeeded, than leave them both to inevitable death." Sir F. Ould says, "The Caesarean operation is most certainly * Essays on the Practice of Midwifery, p. 225. f Traite des Maladies des Femmes Grosses, vol. L, p. 352. j L'Art d'Aceouchement, vol. ii., p. 220. § Traite complet d'Accouchement, p. 103. H Comparatio inter sect, tosar. et dissectionem cartilag. et ligament, pelv. in parta ob. pelv. august, impossib. " Midwifery, vol. i, p. 239. 628 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mortal, and I hope it will never be in the poAver of any one to prove it by experience." Merriman* speaks thus: " It cannot be matter of much surprise that, with so little success as has attendeel the Cesarean operation in England, the British accoucheurs should be so reluctant to per- form or adopt it; and, therefore, recourse is never had to it, except in such deplorable cases only as preclude the ptossibility of delivery by any other means.'1' Blundellf says, " It is an axiom in British midwifery, that we are never to deliver by the Cmsarean operation, provided we can, in any way, deliver by the natural passages. I feel persuaded that women might sometimes be more safely and more easily delivered by the Ccesarean section, than by the passages of the pelvis; but if, acting on this persuasion, we were once to establish the princi- ple, that the Cesarean delivery may be used as a substitute for delivery by the perforator, there would, I fear, be too many cases in which it Avould be needlessly adopted ; and men would noAv and then, not to say frequently, perform this operation in circumstances in which it ought never to have been dreamed of. Where embryo- tomic delivery is practicable, let it be preferred." Dr. MaunsellJ observes, " The truth is, that in Great Britain the Caesarean operation never did, and never will, flourish.'' Dr. Murphy§ advises, "In order to decide upon the Caesarean section, you should weigh carefully the probable result to the mother, if the operation be not performed; and if it appear to you that perforation is impracticable, or so difficult to perform that the dan- ger seems to be nearly so great to the patient as opening the uterus, you are then authorized to undertake the operation, because, if there be a probability that perforation will not ensure safety to the mother, you are certainly bound to consider the child, and give it a reasonable chance for its life." Sufficient, I apprehend, has been done in the way of quoting authorities to demonstrate the extraordinary discrepancy of opinion on the question we are now considering; and it will be well to remind you that the Avriters I haA'e cited are of no mediocre posi- tion ; on the contrary, they are men of eminent name. How is this difference of sentiment to be reconciled ? on what principle of reasoning can it be satisfactorily explained? One would imagine that, according to every principle of logic, legitimate deductions are the necessary results of a legitimate construction of well-founded data. Is it, therefore, not true that many of these authors have given less consideration to this character of data than they have to * Synopsis of Difficult Parturition, p. 166. \ Principles and Practice of Obstetric Medicine, p. 371. X Dublin Practice of Midwifery, p. 139. § Lectures on Principles and Practice of Midwifery, p. 202. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 629 their own prejudices or preconceived notions? I think so, and it is in this Avay only that I can account for the remarkable Avant of concurrence on atopic, involving so grave and sacred an interest as that of human life. When I speak of data, in connexion with this subject, I allude to certain statistical testimony, which, if properly discriminated, will oftentimes constitute, in questions such as Ave are noAV discussing, a very essential element for opinion; but do not forget that, for this testimony to become a recognised and safe substratum, it should be duly eliminated with the sole view of sus- taining a fundamental truth, and not for the purpose of affording apparent strength to individual sentiment. In one word, individual opinion should always yield to well-established facts, instead of attempting to accommodate facts to opinion. In order to illustrate what I desire most earnestly to urge, let us suppose that a certain number of you had decided in your OAvn minds that, in consequence of the far greater value Avhich you attach to the life of the mother than to that of the child, you would, under no circumstances, hesitate between the Caesarean section and embryotomy, but that, in all cases calling for cutting instruments, your choice would be a resort to the latter expedient. Such a decision, I think you Avill agree Avith me, is legitimately entitled to be considered the offspring of preconceived opinion, and, as such, it Avould, of course, ignore the testimony of well-attested facts. Decisions like these, are, I maintain, umvorthy of science; they are one-sided, and, therefore, cannot be truthful. This brings me to the reiteration of Avhat I have already stated in a pre- vious part of this lecture—that the choice between the Caesa- rean section and other modes of extracting the child, must be determined by a just balancing of evidence; and, Avith this con- viction, I shall now proceed to lay before you, as briefly as may be consistent with the import of the question, the particular kind of evidence by Avhich, according to my judgment, AA'e are to be guided. Contrast between tlie Caesarean Section and Craniotomy Sta- tistics.—You have already seen that the Caesarean operation meets with but little favor in Great Britain, while, on the other hand, craniotomy has for a long time been, and still continues to be, honored by the general endorsement of the profession of that enlightened nation. In order that you may at once appreciate the relative frequency of this alternative in Great Britain and on the continent of Europe, I Avill present you Avith the folloAving tables, Avhich I derive from Dr. Churchill: Among British practitioners, 517 crotchet cases in 150,381 deliveries, or about 1 in 291 ; among the French and Italians, 69 crotchet cases in 38,908, or 1 in 563f; and among the Germans, 386 crotchet cases in 646,645 deliveries, or 1 in 1,675; altogether, 835,934 labors in Avhich the crotchet Avas 630 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. used, or 1 in 1,1204.* The mortality for the mothers is 1 in every 5; and, of course, the very nature of the operation demonstrates that all the children are sacrificed. But, gentlemen, it is essential you should note the important fact that these tables give us only the immediate deaths, in the proportion of 1 to 5 of the Avomen Avho have been subjected to the hazards of craniotomy; not one word is said of the dreadful lacerations and destruction of the soft parts, sometimes terminating fatally, involving too frequently the unhappy sufferer in distress and anguish, Avhich Avould cause her to invoke death as a blessing ! Dr. Maunsellf says, "Dr. Joseph Clarke found it necessary in the Dublin Lying-in Hospital, to use the perforator in 1 in 208 cases. In the Wellesley Female Institution, it Avas employed during the year 1832, 1 in 21l£ cases; and during the year 1833, 1 in 137 cases." This record would seem to shoAv a striking average difference in the frequency of the operation, as exhibited by the statistics of Dr. Churchill; and AA'hat, it seems to me, must be apparent to every reflecting mind is, that these tables of Dr. Maunsell, presenting the number of craniotomy operations in Avell-conducted hospitals, super- vised by men of eminent skill, must fall greatly short of the true average frequency of this alternative among the profession in out- door or private practice, Avhere oftentimes " hot-haste" and dispatch are substituted for patience and sober judgment! Again: Dr. Joseph Clarke mentions that in the 49 craniotomy operations performed by him in the Dublin Lying-in Hospital, 16 Avomen out of the 49 died, or about 1 in 3; not 1 in 5, according to the statistics of Dr. Churchill. Thus, the sad result—16 of the mothers lost, and all the children destroyed in 4!) cases; and yet it is but fair to presume that in the hands of Dr. Clarke, a gentleman of acknoAA'ledged skill and experience, assisted as he no doubt Avas, in counsel, by other eminent practitioners, this mortality is much less than Avhen the operation is performed indiscriminately in private practice, and, alas! in instances in which there is too often a Avant, not only of proper deliberation as to the necessity of the alternative, but of ordinary dexterity in the execution of the deed. It is proper now, in the Avay of contrast, to turn to the results of the Caesarean section. It Avould seem that the mortality to the mothers in this operation is 1 in 2J, and to the children 1 in 3^. The deaths, therefore, among the mothers are much greater than in craniotomy, for, according to Dr. Churchill's tables, in this latter, the fatality is only 1 in 5. Yet, on the other hand, in 49 cases of craniotomy occurring in the Dublin Lying-in Hospital, under Dr. Joseph Clarke, 16 mothers Avere sacrificed, or 1 in 3 ! This cer- tainly reveals a melancholy picture, and it needs no argument to * Theory and Practice of Midwifery. London, .1860: p. 371. ■J- Dublin Practice of Midwifery, p. 138. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 631 show, according to this latter table, hoAV much more destructive to human life, if we embrace the fatality to both mothers and children, is craniotomy than the Caesarean section ; for, in the practice of Dr. Clarke, a practitioner of sound judgment and ripe experience, in 49 cases there was the dreadful sacrifice of 65 lives, supposing the children to have been alive at the time of the operation ! Nor does history record the condition of the 33 mothers who survived, AA'he- ther they Avere with or without lacerations. Thus, if Ave adopt Dr. Maunsell's record, as a proximate basis for opinion in reference to the relative mortality of the tAvo operations, the Caesarean section and craniotomy, the evidence aa ill be greatly in favor of the former expedient; for Avhile in craniotomy 1 in 3 of every mother is sacrificed, to say nothing of the contingent injuries, which, if they do not ultimately lead to death, will oftentimes impose upon the surviving mother a life of more or less suffering, every child is necessarily sacrificed. In the Caesarean operation, on the contrary, one child only is lost in every 3£, and one mother in every 2£. If, then, we suppose the Caesarean operation to be per- formed in 49 instances, Ave shall have, in contrast with 65 deaths, as in craniotomy, a very different result; 1 death in 2^ of the mothers, and 1 in 3^ of the children. But, gentlemen, I Avish to direct your attention very emphatically to another point in connexion with the statistics of the Caesarean section as furnished by Dr. Churchill; and in doing so, I shall endeavor to prove to you that they are not substantial data for a just comparison between the relative fatality of the tAvo operations. In the first place, the number of Caesarean operations cited-by him are Avhat may be termed mixed cases, including those of Great Bri- tain, the continent of Europe, and some in our OAvn country. It is very Avell knoAvn that, more especially in Great Britain, in conse- quence of the very decided prejudice against the Caesarean operation, it has not been resorted to, in the great majority of instances, until the life of the mother Avas nearly extinct from previous effort, and her forces so prostrate as to deprive her of the elements essential to recuperation. Again : I think this objection is true, also, but not to the same extent, as regards the cases derived from the conti- nents of Europe and America, for it cannot be denied that, Avhat- ever may be the individual preference for the Caesarean operation over craniotomy, there is more or less repugnance to commence it, and hence the general delay. If, in addition, Ave consider the effect on the mind of the patient AA'hen told that, in the best judgment of her medical advisers, the alternative for her life and that of her offspring is—to cut the child out of her womb through an incision of her abdomen, it is not difficult to appreciate Avhy, under the combination of protracted delay, and prostration, through fright, of the nervous force, one mother in every tAvo and one third should 032 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be sacrificed. I am free to confess I am not a little surprised that the mortality is not far greater in view of the circumstances just alluded to. It is a fact highly commendatory to their sagacity, and which, at the same time exhibits, I think, ample evidence of sound thought, that, as early as the sixteenth century, some of the Avriters on the question hoav before us gave very significant counsel, all other things being equal, as to the particular time during the labor of performing the Caesarean operation ; and I am strongly impressed with the conviction that, had their counsel been hearkened to, great Avould have been the gain to the parturient Avoman. Rousset and Ituleau (the former Avrote in 1581, the latter in 1704) recommended in the most decided manner that " the Cesarean operation should be per- formed before the rude manipulations of the accoucheur had injured and more or less exhausted the woman." Levret,* the great obstetric authority of his times in France (1750), says, "As soon as the labor has fairly commenced it is proper to proceed Avith the operation, in order that the most favorable time may be selected for the operation itself, as Avell as for its consequences." With the sound advance Avhich surgery has made in the present century, it is strange that more attention has not been given practically to these fundamental precepts, for no really experienced surgeon, I appre- hend, will attempt either to controvert their Avisdom, or the influ- ence they must necessarily exercise on the final issue of the Caesa- rean section. Therefore, I am quite confident, if the alternative were more opportunely resorted to ; if, in a word, the same principle of gui- dance should obtain in reference to it, Avhich we find to constitute the rule of action in all capital operations, the result would be vastly different; and I have no hesitation in saying that, under these favorable circumstances, the Caesarean operation Avould not only prove to be infinitely less destructive to human life than craniotomy, but that it Avould soon take its rightful place as a just expedient in the lying-in chamber. The evidence in demonstration of the sound- ness of this opinion seems to me to be entirely satisfactory ; for, in addition to other proofs, we have the strong corroborative testi- mony furnished by those examples in Avhich the Caesarean operation has been performed several times on the same woman, with success to both mother and child; and in Avhich cases, it is fairly to be pre- sumed that, at least, if not the first operation, the subsequent ones were undertaken opportunely before the strength of the mothers had become exhausted by antecedent and protracted effort. As a matter of statistical information, it is proper that I should refer to the following data furnished by Keyset- of Copenhagen, although * Levret, Suite des Observations sur les Causes des Accouchements Laborieux, p. 244, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 633 they are someAvhat adverse to the position I have just assumed. I cannot but think there is some error in the details of the cases he cites. Kcyser, taking the time of the operation from the com- mencement of labor, reports as follows : first 24 hours, mortality to mothers 0.67, infants 0.28 ; between 25 and 72 hours, 0.55 to mothers, infants 0.33 ; more than 72 hours after labor commenced, mortality to mothers 0.72, to infants 0.60; so that betAveen 25 and 72 hours it was most successful to mothers.* M. Simonf (1749) presented to the Academy of Surgery a col- lection of sixty-four cases of the Caesarean section, in more than one half of which the operation occurred in thirteen Avomen, some of these having been operated on tAvo, three, five, six, and even seven times, and all were successful; singular enough, most of these ope- rations Avere Avithout good cause, for, of the sixty-four Avomen, thirteen had borne children naturally either before or subsequent to the section. Stoltz, of Strasbourg, mentions fourteen undoubted cases in which the Caesarean section was resorted to Avith complete success tAvice on the same patient. Michaelis reports a case of a female, named AdaAvetz, born in 1795 ; she was four feet high, affected Avith rickets, and the antero-posterior diameter at the upper strait measured tAvo and a fourth inches. In 1826, Dr. Zwanck delivered her by the Caesarean section ; the child had been dead for some time previously to the operation, but the Avoman recovered. In 1830, this patient was again delivered through the same means by Prof. Weidemann, mother and child both saved. In 1832, the Cesarean section Avas resorted to for the third time, and the result Avas equally fortunate to parent and infant. Klein has gathered Avith much care 116 Caesarean sections, of Avhich 90 Avere successful.J Dr. John Hull gives an analysis of 112 cases, of Avhich 90 Avere successful.§ HalmagrandJ the able annotator of Maygrier, collected betAveen the years 1835 and 1839 fifteen cases of Caesarean operation; of these, twelve of the mothers and thirteen of the children survived, Avhile three of the mothers and two of the children Avere lost; thus one mother in five died, and one child in about seven. These facts are Avell worthy of meditation, and in connexion Avith them it may be added that, in each of the fifteen cases recorded by Halmagraud, the only cause for resorting to the operation Avas a rachitic condi- tion of the Avoman. This author well asks, Avhether this extraor- dinary comparative success may not in part be due to the cir- cumstance that the operations Avere performed early, and before * London and Edinburgh Medical Journal, p. 542. f Premier volume des Memoires de l'Academie de Cliirurgie. X Loder's Journal, vol. ii., p. 759 7t>0. fc$ Observations on Cesarean Operation. Manchester, 179S. P. 292. j Nouvellea Demonstrations d' Accouchements. Par Maygrier, p. 461. 634 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the system had become exhausted by fruitless effort. These statistics, it will be perceived, are beyond all contrast in favor of the Caesarean section over craniotomy. I desire it to be distinctly understood that my preference for the extraction of a living child through the abdomen of the parent, over its mutilation, is not an opinion of very recent date, nor has it been arrived at, I trust, Avithout due consideration. It is the opinion I have held and inculcated during my professorial life, as can be attested by the numerous pupils and others avIio have resorted to our University for instruction. In my translation of Chailly's MidAvifery* (1844), I emphatically expressed my vieAvs upon the question of craniotomy in the following unequivocal lan- guage: "In truth, it needs some nerve, and for a man of high moral feeling much evidence as to the necessity of the operation, before he can bring himself to the perpetration of an act, Avhich requires for his OAvn peace of mind the fullest justification. He Avho would wantonly thrust an instrument of death into the brain of a living foetus, Avould not scruple, under the mantle of night, to use the stiletto of the assassin ; and yet, hoAV frequently has the child been recklessly torn piecemeal from its mother's Avomb, and its fragments held up to the contemplation of the astonished and ignorant spectators as testimony undoubted of the operator's skill! Oh ! could the grave speak, how eloquent, Iioav damning to the character of those Avho speculate in human life, Avould be its revelations!" Such, gentlemen, Avas my language in 1844; and noAV, in 1861, AA'ith a more matured judgment and a riper experience, I am, if possible, the more strengthened in my con- viction. Therefore, in the fulness of my faith, I have no hesitation in saying that, if the child be alive, the xooman at the completion of her pregnancy, and it be made manifest that the maternal passages are so contracted as to render it physically impossible that a living child can be extracted per vias naturales, I should between the two resources—craniotomy and the Ccesarean section—not hesitate to decide in favor of the latter.\ I am quite aAvare that this opinion, so emphatically stated, is at variance Avith the general vieAvs of the profession on this subject; but it has one merit, if no other, it is sincere, and founded upon Avhat I believe to be an honest analysis of all the evidence. In more than one instance on record it has been shoAvn that embryotomy has been had recourse to, and living children mutilated, Avhen the women in subsequent labors Avere * A Practical Treatise on Midwifery. By M. Chailly. Translated from the French. Fifth edition, p. 385. + It is proper here to remark that if it be ascertained the child is a monster (although alive), or that it is affected with disease, which would result in its destruc- tion soon after delivery, this might constitute an exception to the rule. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 635 delivered by means of the Caesarean section, Avith safety both to themselves and their offspring.* Dr. Charles S. Mills, of Richmond, Va., reports a case of Caesa- rean operation of more than ordinary interest, in Avhich he saved both mother and child. The special interest of the case consists in the important fact that efforts were first made, because of the indis- position to resort to the Caesarean section, to deliver by embryo- tomy. His associates in counsel were Drs. Deane, Bolton, and DreAv. The following is the language from the record : " It was noAV proposed that the patient should be anaesthetized, and an effort made to reach the abdomen of the child in order to eviscerate it, if, after a more thorough examination, it should appear that the child could then be brought away. This Avas accordingly done, and Dr. Bolton Avith great difficulty succeeded in passing tAvo fingers through the superior strait so as to reach Avith their extremities the abdo- men of the child, but could make no use of them to conduct an * The following case I take from the North American Medical and Surgical Jour- nal, No. XXIV., October, 1831, p. 485, reported by George Fox, M.D.: Mrs. R„ twenty-six years of age, was married 16th of May, 1830, and on the 14th of June, 1831, was in labor with her first child. Dr. George Fox was called to her assistance, and, finding that there was deformity of the pelvis, requested tlie counsel of Profs. James and Meigs, and Drs. Lukens, Hevvson, and J. R. Barton. It was concluded, after repeated examinations, that the antero-posterior diameter did not exceed two inches. "The question arose as to what was to be done. The Caesa- rean operation was thought to be attended with so much risk to the mother aa almost to bo necessarily fatal, some of the most distinguished surgeons being entirely opposed to its performance; and Dr. Physic, who was called upon for his opinion on the propriety of this operation, was decided and positive in his opposition to it; under the weight of such authority, tlie idea of the Caesarean operation was aban- doned." It was then determined to perform cephalotomy, and Prof. Meigs agreed to undertake it. Before he commenced the operation, however, Prof. M., conceiving, after further examination, that "cephalotomy would be attended with as much risk to the life of the mother as the Caesarean operation, thought it better to call another consultation to reconsider the propriety of performing the Caesarean operation." The consultation resulted in the opinion that the child was dead. Cephalotomy, there- fore, was performed. On the 22d of June, 1833, this same female was again in labor with her second child. Prof. Meigs was called in, and performed a second time the operation of cephalotomy. But we not told that in this case the child waa dead; therefore, it is to be presumed it was alive. On March 25, 1835, this heroic woman was taken in labor with her third child. Dr. Joseph G. Nancrede was her physician, and, after mature deliberation, decided that the Caesarean section was the only appropriate operation in her case. Dr. Nancrede requested the counsel of Prof. Gibson, who concurred in opinion with him. Accordingly, in the presence of Dr. Nancrede, Prof. Dewees, Dr. Dove, of Richmond, Prof. Horner, Dr. Beattie, Dr. William Coxe, Dr. Theodore Dewees, and Dr. Charles Bell Gibson, the distinguished professor performed the operation with entire success, saving both mother and child. November 5. 1837, Prof. Gibson was summoned to this patient, who was again in laU'r with her fourth child I! He again performed the Cesarean section, and with the same success, saving both mother and child. These facts must carry with them their own comment. 636 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. instrument Avith certainty or safety to the mother, and was of opinion that it Avould be impossible to deliver the child through so narroAv a passage even if he could succeed in eviscerating it. Being still loath to resort to the Caesarean section, until every effort to deliver per vias naturales had been tried and failed, the presenting leg was noAV enveloped in a bandage, and, the mother still being under the influence of chloroform, gradual but very poAverful trac- tion Avas made, hoping still to force doAvn the body into the pelvis. The greatest force AA'hich could be applied without risking the laceration and separation of the limb, produced no other effect than to bring doAvn the thigh a little loAver. Upon consultation, it Avas noAV unanimously thought that the Caesarean section should be made Avithout further delay." Fortunate, indeed, Avas it that the attempt at embryotomy proved abortive, for it enabled Dr. Mills, through the exercise of his skill, to saAre tAvo lives, one of Avhich would necessarily have been sacrificed, and the other subjected to more or less hazard.* Dangers to the Mother of the Ccesarean Section.—Let us now, for a moment, inquire in what consist the dangers to the mother in this operation. They are enumerated as folloAvs: 1. Shock to the nervous sytem ; 2. Hemorrhage, or an escape from the uterus of the liquor amnii into the peritoneal cavity; 3. The possibility of a portion of the intestines becoming compressed and strangu- lated, either in the opening of the abdominal parietes or uterus itself; 4. Inflammation involving the uterus, or peritoneum. In reference to these several dangers, the most serious is perito- neal inflammation together Avith its complications; and yet, from the statistics Ave have given, it would appear that the peril from this influence is not extravagant. Indeed, Ave have numerous and extra- ordinary instances of recovery after serious injury to the peritoneum and intestines from traumatic causes, such as the goring of an ox,f stabs in the abdomen, or the rude and unskilful cutting into the gravid uterus by unprofessional hands.J Cases, too, are recorded and accepted as reliable, in Avhich Avomen have undergone the * Monthly Stethoscope and Reporter, July, 1856, p. 427. ■j- Fritz records a singular case, also witnessed by Naudot, of a pregnant Avoman having been gored in the abdomen by the horn of an ox; on the following day the wound was enlarged by means of a bistoury; the foetus was extracted, and the mother recovered! (See Yelpeau's Mid., p. 548.) X The Cesarean operation was performed on a female in Ireland, named Alice O'Neal (1733). by an ignorant midwife, Mary Dunelly; the instrument employed was a razor; she held the lips of the wound together with her hand till some one went a mile and returned with silk and the common needles which tailors use; with these she joined the lips in the manner of the stitch employed ordinarily for harelip, and dressed the wound with white of eggs. The woman recovered in twenty-seven days. This case, incredulous as we may be disposed, is regarded as perfectly truth- ful.—Edinburgh Medical Essays, vol. v. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 637 Caesarean operation after rupture of the womb, and have survived. These facts, I think, tend to demonstrate that, if all things be equal, the positive danger from inflammation per se is not as grave as is generally imagined ; and this brings me to the repetition of one of the major propositions, that the serious peril of the Caesarean sec- tion is, in a great measure, due to—at all events, it is greatly en- hanced by—the unnecessary delay of the operation, Avhen the Avoman's strength is exhausted, the womb and the adjacent organs fretted, and sometimes even inflamed through the jointly abortive efforts of nature and the injurious officiousness of the accoucheur; so that, oftentimes, a broad foundation for fatal results is already laid before the first stroke of the surgeon's knife. As to the other alleged dangers, such as the passage of blood or liquor amnii from the incised womb into the peritoneal cavity, or the strangulation of a fold of the intestines, Avhy these, I contend, are not necessarily incident to the operation; they are chargeable to the carelessness of the assistants, whose duty it is, by efficient service, to see that these various contingencies do not occur. But the shock to the nervous system, you may urge, is a A'ery important complication. Yes, gentlemen, this argument, I admit, Avas not without force, and great force, too, before the introduction into the lying-in room of that sterling boon to suffering Avoman— anaesthetics. It is in operations like the Caesarean section, in Avhich the nervous system is thrown into tumult and disorder, and where psychical causes have an unbridled sway, that the magic of anaes- thesia discloses its full triumphs. Under its influence, the human system, emancipated for the time from the operation of external impressions, is lulled into more than the quietude of sweet and unbroken sleep. "We have, therefore, in anaesthesia an important addition to our therapeutic agents Avhich, when judiciously em- ployed, cannot but afford most happy results; the subjection in which it holds the nervous system, under capital operations, is dis- played not only in the unconsciousness of pain, but in the shield it affords against the consequences of the shock otherwise so apt to ensue. Indeed, if the importance of the uterus in its various connexions Avith other portions of the economy be recollected, it cannot appear strange that a lesion of this organ should be followed by marked pathological effects on the nervous system, and that these results on the nervous mass should, before the introduction of anaesthesia, have been prominent among the causes of the comparatively great fatality of the Caesarean section. As a general rule, it has been observed that Avhen death ensues soon after the operation—say tAvo or three days—it is in consequence of the grave concussion sus- tained by the nervous system, as is evinced by the symptoms, Avhich, under these circumstances, so speedily develop themselves, 638 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. such, for example, as a general sinking of the forces, vomiting and hiccough. In these cases, I repeat, in which death so rapidly folloAvs the operation, the true cause of destruction is not inflam- mation of the peritoneum, uterus, etc., but is to be traced to the profound impression to which the nervous system has been sub- jected. Post-mortem Ccesarean Section.—Before describing the manner in which—AA'hen indicated—the Caesarean operation is to be per- formed, it is proper I should remind you that it sometimes becomes necessary to resort to this expedient even after the woman is dead ; and the practice is founded upon the AA'ell-known fact that the foetus does not necessarily die simultaneously with its mother. Indeed, there are numerous instances cited in which the post-mortem Caesa- rean section is alleged to have been had recourse to twelve, tAventy, and even forty-eight hours after the demise of the parents, and the children extracted alive; but a due degree of caution is to be exer- cised before accepting these cases as proved ; in most of them, it is quite probable that a state of syncope was mistaken for death. It is important, for the assured safety of the child, that no time be lost in its extraction after the death of the mother. There is, among others, one example recorded which, I believe, stands un- contradicted, and has received the very general assent of the pro- fession. I allude to the extraordinary case of the Princess of Schwartzenberg, AA-hose death occurred in Paris in 1810 under the most painful circumstances. She was one of the gay party partici- pating in the pleasures of a ball given by her brother-in-laAV, the Austrian ambassador. During that night of festivity there was an appalling conflagration which, together Avith other victims, caused the death of the princess, who was far advanced in gestation. On the day succeeding her death, a living child was removed by the Caesarean operation. This case, however, although well authenti- cated, Avhile it proves the possibility of the foetus in utero surviving its mother for several hours, should be regarded as a very rare ex- ception to the general rule ; for it is conceded that, as a principle, the child dies either before, shortly after, or simultaneously with its parent. Yet, notwithstanding this general fact, it is abundantly shown that numerous children have been saved by the post-mortem Caesarean section. It is an interesting circumstance that one of the earliest legisla- tive acts among the Romans provided that no pregnant woman should be admitted to sepulture until her child had been removed by this operation: Negat lex regia mulierem qu/ppregnans mortua sit, humari antequam partus ei excidatur ; qui contra fecerit, spem animantis cum gravida peremisse videtur. In recognition of the propriety of this ancient laAv, and with the view of carrying it out practically in the sense in which it was no doubt originally intended, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 639 the Senate of Venice, in 1608, proclaimed the imposition of severe penalties upon every medical man, Avho should attempt this opera- tion on a woman supposed to be dead, Avithout exercising as much caution as if she were alive.* History mentions more than one instance in which an incision had been made into the abdomen for the purpose of extracting a child from its supposed dead parent, Avhen it Avas subsequently shown that she was still living! Hence, in all cases of post-mortem Caesarean operation, it is the first duty of the surgeon to be morally certain that the life of the mother is extinct; and, in order to avoid all error, to keep constantly in mind the sensible and conservative enactment of the Venetian Senate, to Avhich allusion has just been made. Peu (1694) had the honesty to record a thrilling case, Avhich occurred to him, and about Avhich, therefore, there can exist no doubt. He says, in the early part of his practice he was requested to attend a young primipara in her accouchement; on his arrival at the house, the friends of the patient informed him that she had just expired, and so he thought himself; he proceeded at once to extract the child by the Caesarean section, but the instant he commenced his incision the woman gave a shudder, accompanied with grinding of the teeth, and a movement of the lips—un tressaillernent accom- pagne de grincement des dents et de remUment des levres !\ How the Operation should be Performed.\—I have already said, Avith unequivocal emphasis, that one of the essential elements of success in the Caesarean section is to commence the operation early, before the patient has become exhausted, and her system fretted by ill-advised interference on the part of her medical attendant; anel I now state without qualification—that it is the duty of the accoucheur to ascertain at an early period of the labor AA'hether the circumstances of the case are such, in his sound judgment aided by experienced counsel, as to justify a resort to this expedient. The moment the question is decided affirmatively, further delay is not only unnecessary, but fraught Avith danger. Supposing, therefore, that this material point has been duly determined, the next question arises—Should the patient be made acquainted Avith the nature of the operation '? Here, again, I may perchance differ with my pro- fessional brethren ; but I am clearly of opinion that it is infinitely better, so far as the result is concerned, that the mother should be kept in partial ignorance; tell her, for example, that it has become necessary for the safety of her child and the termination of the * The King of Sicily (1749) passed the sentence of death on the physician, who failed to perform the Caesarean section on a female dying in the latter months of gestation. f La Pratique des Accouchemens, p. 334. X Prof. Fordyce Barker reports an interesting case of Cesarean section in the American Medical Times, Jan. 26th, 1861. 6-10 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. labor, that you should interpose and assist nature, but sedulously keep from her the fact that you are about to lay open her abdomen and womb for the purpose of extracting the infant. Such a revela- tion, common sense tells us, Avould be received by the suffering AA-oman with terror, acting injuriously on her nervous system, and thus, to an extent at least, presenting a barrier to recovery. But how, you may ask, can the operation be performed Avithout the knowledge of the patient ? The ansAver to this question brings me to a most important point, and it is this—-place her under the influence of anaesthesia, lull her into unconsciousness, and make her blissful in her ignorance. These preludes having been decided upon, care should be taken to empty the bladder; the patient should be on her back, Avith the lower limbs slightly flexed; at least tAAro assistants will be needed, Avell supplied Avith soft, delicate sponges. Things being thus pre- pared, the question presents itself—In Avhat Avay is the incision to be made ? One author recommends the oblique, another the trans- verse, Avhile a third urges a vertical opening through the linea alba. Each of these, it is contended, has its advantages and disadvantages. The vertical incision through the linea alba is most commonly resorted to, and this I shall describe. In selecting this point for the opening into the abdominal cavity, there is no fear of Avounding the epigastric artery, nor is there any division of muscular fibre, and there is much less hazard of involving the intestines, than in either the oblique or transverse incision. Again : the uterus is opened in the central portion of its long axis, and in a direction parallel to its muscular tissue. On the other hand, the section through the linea alba is objected to by some, because, it is alleged there Avill be danger of injuring the bladder; and, also, as the tissues embraced in the opening are exclusively fibrous, the healing or cicatrization of the abdominal incision will necessarily be more or less tardy. These objections are not of much moment, for the bladder can be amply protected by evacuating its contents, and the comparative tardiness of the cicatrization is of very little consequence. The surgeon, placed on the right of the patient, with his two assistants on the opposite side, makes Avith a convex bistoury his incision from six to seven inches in length, commencing at the umbilicus and passing tOAvard the pubes. This first incision Avill lay open the abdominal cavity, which, of course, Avill expose to view the peritoneal covering; this membrane should be cautiously incised below, so that the index finger may be introduced; a probe- pointed bistoury is then carried along the finger for the purpose of incising the peritoneum* to an extent corresponding Avith the * In order to avoid the incision of the peritoneum, Jorg in 1806, and Ritgen in 1820, proposed an operation which should lay open the vagina, instead of the ante- rior plane of the uterus. More recently this suggestion has been carried out in THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 641 external opening; great caution is to be exercised by the assistants as soon as the abdominal cavity is laid bare in steadying the uterus, and preventing the protrusion of the intestines; if this protrusion should occur, the intestines are to be gently compressed and re- placed by delicate Avarm sponges. The peritoneum being divided, the next stage is the incision of the uterus itself. This must be done discreetly, not by one abrupt stroke of the knife, but gradually, so that when the cavity of the organ is exposed, the membranous sac, if it should have preserved its integrity, may not be too suddenly opened, or the foetus involved in the incision.* It is recommended to carry the incision into the uterus as high up as possible, so that the inferior point of the opening may not be as low down as the opening made into the abdomen. This precaution will, after the organ has contracted, prevent the escape of the lochial discharge into the abdominal cavity. It may possibly occur that the placenta Avill be so situated as to be included in the incision made into the uterine Avail—it Avould be a rare cir- cumstance, however, for this mass is seldom found attached to the anterior plane of the organ—if so, do not become alarmed, but pro- ceed at once to extract the foetus, as if the accident had not Paris by A. Baudelocque, Jr.; the operation is called elytrotomy, and is performed as follows: The incision commencing near tlie spine of the pubes is extended, parallel with Poupart's ligament, to the anterior superior spinous process of the ilium. Carefully avoiding the epigastric artery, the abdominal parietes are divided; the peritoneum is then not incised, but pushed away from the iliac fossa into the excavation; the upper portion of the vagina is thus exposed, and a free incision being made into it, the index finger is introduced into the opening for the purpose of bringing the os uteri fully in the direction of the wound made in the abdomen; this transposition may be facilitated by pressing with the other hand the fundus of the organ backward. The os uteri being brought in correspondence with the open- ing made in the abdomen, the delivery is to be committed to nature, and the child expelled by the foree of uterine contraction. Plausible as this operation may ap- pear—to me it is the very reverse—it failed completely in the hands of Baudelocque, and I am not aware that it has ever succeeded. * There exists a difference of opinion as to whether the Caesarean section should be performed before or aftt-r the escape of the liquor amnii. If the amniotic fluid have not escaped, there will certainly be less danger of injuring the child with the knife, for the fluid will, to a certain extent, interpose between the surface of the foetus and the walls of the uterus: on the contrary, should the membranous sac be entire, there will be the danger, as soon as it is penetrated, of the fluid escaping into the peritoneal cavity. My own opinion is, that it is preferable to operate before the rupture of the sac; and as soon as the womb is laid open. I should advise, if possi- ble, the introduction of a catheter into the os uteri for the purpose of rupturing the membranes, and thus affording an escape to the fluid through this orifice. If this cannot be accomplished, then it would be good practice to puncture the sac below the incision made into the uterus, and in this way the fluid would find its exit through the mouth of the organ, which would prevent the possibility of its passing into the peritoneal cavity. The assistants should, at all events, be on the alert, and, in the contingency of the sudden penetration of the sac by the bistoury, be prepared with sponges to prevent the flowing of the amniotic liquor into the abdomen. 41 542 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. occurred—in the following manner: Should the head be near tho opening, seize it gently by placing the index-fingers below the inferior maxillary bones, and employ proper extractive force; if, on the contrary, the breech be there, Avithdraw it first ; if any other surface of the foetus present at the opening, introduce the hand very gently, and seize the feet, and thus deliver the child. As soon as the child is extracted, if it be alive, a ligature is to be applied to the cord, and then separated from its mother. What about the placenta? It is recommended by some authors to proceed at once, the moment the child is in the Avorld, to remove the after-birth. In the event of complete detachment of the pla- centa or hemorrhage in consequence of partial detachment of this body and inertia of the uterus, there cannot be tAvo opinions as to the propriety of the practice ; but in the absence of these contin- gencies, the rule I hold to be a bad one, and more or less perilous to the mother. Therefore, my advice to you is this—let nature do the work of separation, if she is not too long in performing it; and the moment the detachment has been accomplished, which may be ascertained by slight tractions on the cord, then the mass is to be brought away, care being observed to remove Avith it the mem branes, for if they be permitted to remain in the uterus, their pre- sence will result in more or less irritation and distress to the patient. Be careful, also, after the AvithdraAval of the after-birth, to remove any coagula of blood from the uterine cavity. But suppose nature does not promptly detach the placenta, Iioav long Avould it be judicious for the accoucheur to delay interference ? If in five or ten minutes after the extraction of the child the placenta should not have become separated, it Avould, I think, be imprudent to Avait longer; the accoucheur should then introduce his hand through the incision, and cause the artificial detachment in the manner described in a previous lecture. If the extraction of the after-birth be folloAved by inertia of the Avomb—a circumstance quite unlikely to occur—a small piece of ice momentarily applied to the lips of the opening Avill generally suffice to awaken tonic contrac- tions of the organ. Dressing the Wound.—One of the advantages of the operation by the vertical incision is, that there are no vessels exposed, and hence no hemorrhage; however, in cutting into the uterus itself, some of the uterine arteries may be involved, but the bleeding can be readily stayed by the assistants making pressure on the orifices AA'ith the finger; soon after the extraction of the after-birth, the wound contracts, the incision made into its AA'all is reduced to one or two inches, and in this AA-ay all hemorrhage is arrested. For the purpose of closing the Avound in the abdomen, the interrupted or twisted suture is usually employed; adhesive strips should be placed in the intervals of the suture, and care taken to leave the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 643 lower extremity of the Avound open to afford escape to matter, etc. Nothing, of course, is done with the incision made into the uterus, for it unites speedily through the process of nature.* As soon as the external Avound has been closed by means of suture, the whole should be covered with a piece of linen spread Avith simple cerate ; over this should be placed a compress supported by a circular bandage. It would be Avell, as a general rule, after the dressing has been com- pleted, to administer a composing draught for the purpose of quiet- ing the system, and inducing sleep. The rest of the treatment is to be conducted on general principles, in accordance with the develop- ment of circumstances.f * Although, aa a general rule, it is true that the lips of the wound into the uterus do become united through the contractions of the organ, yet this is not always the case. \ It may not be out of place, as connected with the current literature of the question, to observe that it has recently been proposed by Dr. Cristoforis to substi- tute for the Ciesarean section and symphyseotomy what he terms the reseclio subpe- riostea of the pubic bones, including the horizontal and descending rami. He sug- gests first to enucleate the bones from their periosteal covering, in the hope that it will subsequently be filled by osse'ous deposits. He records four experiments on dogs, in which this deposit of bony matter followed the enucleation. [Ann. Univ. 1858. LECTURE XLII. Vaginal Caesarean Operation, or Vaginal-Hj'sterotomy—Indications for this Opera- tion—Two Cases in Illustration by the Author—Embryotomy—Moaning of the Term—Amount of Pelvic Contraction justifying Embryotomy—Dangers and Fatality of the Operation—Difference of Opinion among Authors ns to the Circum- stances indicating Embryotomy—The Case of Elizabeth Sherwood, as reported by Dr. Osborn—The Dangerous Precedent growing out of that Case—Evidences of the Child's Death in Utero—What are these Evidences?—Conflict of Sentiment among Writers on this Question—Great Caution necessary in forming a Judgment —Analysis of the Evidence—Too General Use of the Perforator and Crotchet— Melancholy Results of this Fondness for Embryotonw—Case in Illustration—Mod' of Performing the Operation of Embryotomy—In Hydrocephalus, what is to be done?—Decollation—When to be resorted to—Evisceration—When indicated— Cephulotripsy—Meaning of the Term—When to be employed. Gentlbaien—HaA'ing disposed of the subject of the abdominal Caesarean section, it is now proper that I should describe to you the vagincd Caesarean operation, sometimes called vaginal-hystero- tomy. This operation may be necessary Avithout any deformity of the pelvis, or any disproportion betAveen it and the foetus, occasioned by an increased size of the latter. The usual causes indicating the necessity for the operation are traceable to some peculiar condition of the mouth of the uterus—for example, occlusion of the os uteri at the time of labor, or a hard, unyielding state of it, from scirrhous development, or a fibrocartilaginous change. Again: it may .some- tunes happen that the cervix of the organ is so completely mal posed, either retro-verted or ante-verted, that it cannot be brought to its normal situation by the best directed manipulations of the accouch- eur. Under any of these circumstances, the Avhole force of the parturient effort islost; there is no response to the contractions of the uterus, and the danger necessarily becomes complicated, involving the safety of the mother from rupture of the organ, the intervention of convulsions, or positive exhaustion of her vital forces ; the destruction of the child AA'ill also be hazarded from long-continued and undue pressure. It is, therefore, Avhen the labor is obstructed by one or other of these several conditions, manifestly a question for the sound judgment of the accoucheur as to the time of resorting to an ope- ration for the relief of parent and child—I repeat the terms parent and child, for it will be his duty, in cases like these, to proceed to artificial delivery the moment he is assured that nature is unable to overcome the obstacle, and not tarry until the mother is on the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 645 borders of death from exhaustion, or the child sacrificed by pro- tracted compression. I here reiterate what I have previously stated : interference should be opportune, so that in its exercise the maximum of good may be accomplished—the saving of the lives of both mother and child. I have had the good fortune to perform the vaginal Caesarean operation tAvice, and with the most satisfactory results. These cases are of more than ordinary interest in several particulars; in the hope that they may prove instructive, and Avith a demand on your kind indulgence, I shall present them to you in detail as originally published :* December 19, 1843, Drs. Vermeule and Holden requested me to meet them in consultation, in the case of Mrs. M., Avho had been in labor for twenty-four hours. On arriving at the house, I learned the folloAving particulars from the medical gentlemen : Mrs. M. Avas the mother of tAvo children, and had been suffering severely, for the last fourteen hours, from strong expulsive pains, Avhich, however, had not caused the slightest progress in the delivery. She was taken in labor Monday, December 18, at seven o'clock p.m., and on Tues- day, at seven p.m., I first saAv her. Her pains were then almost constant; and such had been the severity of her suffering, that her cries for relief, as her medical attendants informed me, had attracted croAvds of persons about the door. As soon as I entered her room, she exclaimed, " For God's sake, doctor, cut me open, or I shall die ; I never can be delivered without you cut me open." I Avas much struck Avith this language, especially as I had already been informed that she had previously borne tAvo living children. At the request of the medical gentlemen, I proceeded to make an exami- nation per vaginam, and must confess that I Avas startled at Avhat I discovered, expecting every instant, from the intensity of the con- tractions of the uterus, that this organ Avould be ruptured in some portion of its extent. I could distinctly feel a solid, resisting tumor at the superior strait, through the walls of the uterus; but I could detect no os tincae. In carrying my finger upward and backAvard toward the cul-de-sac of the vagina, I could trace tAvo bridles, extendinor from this portion of the vagina to a point of the uterus, Avhich Avas quite rough and slightly elevated ; the roughness Avas transverse in shape, but with all the caution and nicety of manipula- tion I could bring to bear, I found it impossible to detect any open- in . Submur. Hydrarg. gr. x. Pulv. JalapsB gr. xv. " Antimonial. gr. ij. M. Let this be followed in tAvo hours Avith the annexed draught: $. Sulphat. Magnesise 3 ij. Infus. Senna; f. 3 iv. Mannse 3 i Tinct. Jalapaa f. 3 i M. If free purgation be not accomplished, I should have recourse to Croton oil, Avhich is a favorite remedy Avith me in these cases; it 696 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. acts promptly and thoroughly, producing full serous discharges; it stimulates the intestinal mucous surface, thus causing a poAverful derivative influence, Avhich necessarily diminishes the engorged con- dition of the vessels of the inflamed peritoneum. B. Olei Tiglii gtt. iv. Sacchar. Alb. 3 ii. Mucil. Acacia? f. § ij. M. A teaspoonful every half hour until free catharsis folloAvs. When the boAvels have been properly evacuated, it is essential to attend to that important emunctory—the skin ; and Avith the combined A'ieAv of diaphoretic action, and calming nervous irrita- bility, one of the folloAving poAvders may be administered every tAvo or three hours: R.. Pnlv. Doveri gr. xxiv. " Ipecac gr. vi. Divide in chartulas xij. The diet should consist, until the inflammatory stage has subsided, rigidly of diluents ; a free use of the nitrate of potash, either in gruel or Avater, will be found of advantage—say gr. xij. of the potash to a tumbler of the fluid, three or four times a day. We have an important adjuvant in blisters, after the intensity of the disease is someAvhat broken ; instead, hoAvever, of placing them on the abdomen, I greatly prefer applying them on the inter- nal surface of the thighs, immediately over the femoral arteries. Order one or tAvo blisters, as the indication may be, each 4 inches by 6 ; keep up a free discharge by means of the epispastic oint- ment, and oftentimes the best results will ensue. I haA'e said nothing of the specific influence of mercury in this disease. Except as a purgative at the commencement, I have but little faith in the remedy. I have seen repeated instances of the entire failure of any benefit from ptyalism, Avhether the mercury be administered internally or through inunction. Much has been said in commendation of the internal use of tur- pentine. It has been highly extolled by Dr. Brenan, of Dublin, and many able practitioners have endorsed his views. There can be no doubt of the efficacy of this medicine in relieving the tym- panites, Avhich is so usual an accompaniment of the affection. Half an ounce of the turpentine, Avith the same quantity of castor oil, every six or eight hours, Avill be found often effective in removing the intestinal flatus ; and frequently it Avill mitigate the intensity of the pain as a counter-irritant to the abdomen. I may here remark that, in cases of severe tympanites intestinalis, I have found much benefit in large enemata of tepid Avater. It is needless to THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 697 observe that, as soon as the disease has yielded to the remedies, the recuperative powers of the system are to be aided by stimu- lants, tonics, and nutritious diet. In the adynamic form of the disease—that form characterized at the very commencement by a sinking of the forces, depletion is not to be attempted. Here, the vital forces, as far as may be, should be maintained. Stimulants, nutriment, and pure air are very une- quivocally indicated. But, alas! hoAV often are our best-directed efforts made negative by the inexorable demands of the merciless foe. The sulphate of quinine, although by no means a neAV sug- gestion, has recently found favor in the hands of M. Beau, at the Hopital Cochin, Paris. He administers it in large doses, preceding its employment by an evacuation of the boAvels. M. Beau states that the efficacy of the remedy consists in giving it to an extent to produce head-troubles, such as vertigo, deafness, &c, and these results should be continued for several days.* I should not here neglect to speak of the opium treatment, both in the sthenic and ataxic varieties of the disease, more especially Avhen lesion of the peritoneal covering exists. As far as I know, the administration of large closes of opium in peritonitis, altogether unconnected Avith child-bearing, Avas first introduced to the atten- tion of the profession by that eminently practical clinical teacher, Dr. Graves, of Dublin. The first time he resorted to this remedy in peritoneal inflammation Avas in 1822 ; it Avas the case of a Avoman in Avhom the inflammation set in after the operation of tapping for dropsy. Dr. Graves says, "the case seemed so hopeless, and the agony the patient Avas suffering so intense, that I Avas induced to order opium for her in very large doses; she also got Avine ; to my great astonishment she recoA'ered."f Dr. Stokes, another of Dub- lin's eminent practitioners, subsequently employed opium in that most perilous form of peritoneal inflammation springing from per- foration—in one case which recovered, he gave 105 grains in addition to Avhat had been administered by injection.J Prof. Alonzo Clark, of the College of Physicians and Surgeons of this city, has employed opium in heroic doses during the prevalence of puerperal fever at the Bellevue Hospital, and Avith good suc- cess^ * Bulletin de l'Academie de Medicine, t. xxi. p. 81. \ For the conjoined experience of Drs. Graves and Stokes on this point, I refer . the reader to the fifth volume of the Dublin Hospital Reports. t Clinical Lectures on the Practice of Medicine. Vol. ii., p. 244. 8 Some interesting details furnished by Prof. Keating, the able annotator of Dr. Ramsbotham, touching Dr. Clark's experience with opium in puerperal fever, will be found in Ramsbotham's System of Obstetrics, p. 534 I may here, however, be permitted to quote the following as an evidence of the extraordinar}' extent to winch opium may be administered without fatal results. Prof. Clark says : " Regarding the tolerance of opiates in some of these cases—at the risk of being charged with 698 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. It is an interesting fact that when opium is administered in these cases so as to produce incipient narcotism, the respiration be- comes sensibly affected. Dr. Clark, Avith the respiratory move- ment reduced to 12, and, as a general rule, the pulse below 100, Avith the concurrence of other favorable symptoms, such as a subsi- dence of the pain and tenderness, with diminution of the tympanites, gradually lessens the quantity of the drug, and finally discontinues it. Prof. Fordyce Barker speaks highly of the veratrum viride as a remedy in puerperal fever; it certainly exercises a marked control over the frequency of the pulse, and he observes, " in no disease have I seen its value more strikingly exhibited."* It requires extreme caution, and should not be employed except under circum- stances in which the most unceasing vigilance as to its administra- tion and effects can be exercised. rashness and trifling with human life—I will make some extracts from case seven. The treatment was commenced at 10 a.si., on 26th of Dec, two grains of opium hourly. A 2 p.m., no change in the symptoms, dose increased to gr. iv.; at 3, gr. iv.; at 4, gr. v.; at .3, gr. v.; at 6, gr. viii.; at 8, gr. x.; at 9, gr. xij.; at 11, sol. morph. sulph. (16 gr. to f" 3 i) 3 iss.; at 12, 3 i.; at 1± a.m. (respiration 6). 0; at 6 a.m., (respiration 12), opium gr. xij.; at 10, sol 3 i-; at 12 m., opium gr. xij.; at IA p.m., sol. 3 ij-; at 21, 3 ij.; at 3 \ opium, opium gr. xxiv.; at 5, gr. xij.; at 6t, sol. 3 ijss.; at 7^, 3 ij.; at 9, opium gr. xiv.; at 10, gr. xvj.; at 11, gr. xviij.; 28th, at 1 a.m., sol. 3 ijss.; at 2, 3 iv.; at 34;, opium gr. xx ; at 4, sol. 3 ijss.; at 5, 3 iii.; at 6, 3 iijss.: at 6£, opium gr. x.; at 7, sol. 3 iijss.; at 8, opium gr. xxij.; at 9.^, sol. 3 iv.; at 10, 3 iij.; at 11$-, 3 iij.; at 12, 0. Thus this woman took, in tlie first 26 hours of her treatment, opium lxviij. and sulph. morph. gr. vij.; or counting one grain of sulph. morph. as four grains of opium, one hundred and six (10(!) grains of opium. In the second 24 hours, she took opium gr. cxlviii., and sulph. morph. Ixxxj., or opium four hundred and seventy-two (472) grains ! On the third day, she took 236 grains; on the fourth, 120 grains; on the fifth, "A grains; on the sixth, 22 grains; on the seventh, 8 grains; after which, the treatment was wholly sus- pended. This woman was not addicted to drinking, and, after her recovery, she assured me repeatedly that she did not know opium by sight, and had never taken it, or any of its preparations, unless it had been prescribed by a physician. This is, perhaps, ' horrible dosing.' and only justifiable as an experiment on a desperate disease; yet, this woman is alive to tell her own story, as are several others, who took surprising quantities of this drug. But later observations have shown that the tenth to the thirtieth part of this maximum is sufficient in controlling the disease." * Remarks on puerperal fever, New York Academy of Medicine, Oct. 1857. LECTURE XLV. Puerperal Mania; its Pathology—Is it a Phrenitis, or is it essentially a Disease of Exhaustion and Irritation ?—Opinions divided; Necroscopical Researches—At what Period of the Puerperal State is Mania most apt to Occur?—Esquirol's Sta- tistics—Frequency of the Disease—Is Puerperal Mania liable to recur in a Subse- quent Birtli ?—The Opinion of Dr. Gooch and others on this Point—Causes of Puerperal Mania—Predisposing and Exciting; Hereditary Influence—Symptoms —Rapid Pulse and Continued Restlessness—What do they Portend ?—Diagnosis— Puerperal Mania and Phrenitis, Distinction between—Prognosis—Records of Hospitals for the Insane; Records of Private Practice—Duration of Puerperal Mania—Is Permanent Aberration of Mind Probable in this Disease ?—Treatment —Marshall Hall and Bloodletting—Opiates—Their Importance—Moral Treat- ment. Ge:ntlemen—Puerperal Mania will occupy our attention to-day ; it is one of those affections incident to the puerperal Avoman, Avhich always to a greater or less extent has its melancholy surroundings. Imagine, for instance, a young mother, Avho has a feAV days since given birth to a child, to be suddenly deprived of her reason! Her mind has surrendered to the encroachments of morbid action, she is no longer cognizant of events as they pass, and is thus cut off from the inexpressible pleasure not only of intelligently gazing upon, but of ministering to, theAvants of her neAV-born infant, whose Aery condition of dependence makes it an object of additional interest. Indeed, the affection very naturally throavs a gloom over the house- hold, and is a subject Avell Avorthy the attention of the medical man. This malady may manifest itself during gestation, at the time of labor, or some days subsequently ; again, it may become developed during the progress of lactation, or it may folloAv Aveaning. Instances have been recorded of its having occurred in very sensitive Avomen immediately after conception. Pathology of the Disease.—-There is no general agreement as to the pathology of this disease. By some it is supposed to be an inflammation of the brain and its membranes—a veritable phre- nitis; Avhile others maintain that it is a disease more or less of exhaustion and intestinal irritation consequent upon the puerperal period. Without attempting to deny that puerperal insanity may, under circumstances, be the result of phrenitis, yet I think accurate clinical observation abundantly proves that, as a general rule, it is connected Avith a dilapidated condition of the forces. Some of the 700 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. most marked cases of melancholia—one of the forms of mania—I have ever Avitnessed, sprang from the exhaustion of undue lactation. The nervous system of the menstruating, the pregnant, parturient, and nursing female is liable to various modifications—so many concussions, if you please, the tendency of Avhich is to impair to a greater or less extent its equilibrium, and thus dispose it to nume- rous derangements, one of the phases of Avhich may be mania, or melancholia. I do not mean to. be understood that mere exhaustion will necessarily occasion mania; but Avhat I do believe is this, that there is a peculiar specific sensitiveness in the sexual organs of the female during the puerperal period, AA'hich, under the influence of debilitating and other exciting causes, may so far affect the integrity of the nervous economy, as to generate certain morbid phenomena— in one case Ave may have hysteria, in another melancholy, in another convulsive movements, and in another partial or complete loss of reason. It is by no means a rare circumstance for some of these abnormal developments to present themselves during men- struation, in the course of gestation, or at the time of labor, or after the completion of this process. In brief, I believe that, as a general rule, puerperal mania is a sui generis insanity, and its pecu- liarity is traceable to certain agencies acting on the sexual system, and the subsequent re-action of this system on the nervous mass. It is quite probable that the discrepancy of opinion in regard to the pathology of the disease may have arisen from a Avant of proper discrimination in the results of necroscopical researches—for in- stance, it is Avell shown by these researches that, in Avhat may be designated general insanity, evidences of inflammation of the brain and its membranes, may be regarded as the rule. But, according to the best observers, among Avhom mav be mentioned Esquirol,* such is not the fact in the examination of those, Avho have died of puerperal mania. At what Period of the Puerperal State is Mania most apt to Occur ?—Although puerperal mania Avill occasionally exhibit itself during pregnane}', and after Aveaning, yet it is generally con- ceded that it is most liable to become developed a feAV days after delivery, and in the progress of advanced lactation. The folloAving tables by Esquirol are not Avithout interest: In 1811, 1812, 1813, 1814, there were eleven hundred and nineteen insane Avomen admit- ted into the Salpetriere, of Avhom ninety-tAvo were affected Avith puerperal insanity; of these, 16 were attacked from the first to the fourth day after delivery ; 21 from the fifth to the fifteenth day ; 17 from the sixteenth to the sixtieth day ; 19 from the sixtieth day to the twelfth month of lactation ; 19 after Aveaning. Frequency of the Disease.—This affection cannot be considered * Des Maladies Mentales, 1838. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 701 as of rare occurrence. Among seventeen hundred and nineteen cases of insane Avomen in the Salpetriere, there were 52 cases of puerperal mania, and Dr. Haslam reports 84 cases among 1644 Avomen admitted at Bethlem. Is Puerjiercd Mania liable to Recur in a Subsequent Birth.— This is certainly an interesting inquiry—for when a female has once suffered from this affection, nothing can be more natural than that the husband and friends should be solicitous as to the proba- bility of its recurrence in a future parturition. One of the most practical writers on the disease under consideration, Dr. Goooh, is quite emphatic on this point. He says: " I have attended many patients, Avho came to London to be confined because they had been deranged after their former lying-in in the country ; except in one instance, not one of the patients had a return of their disease !''* Such, too, is the tendency of the testimony presented by other eminent observers. I must confess it is adverse to my oavii personal experience. I once attended the wife of a clergyman from the South in her third labor; she had previously borne tAvo living chil- dren, and in each of her confinements had been attacked with puer- peral mania. The labor in which I attended her was in all respects favorable, but in defiance of every caution, on the fifth day after delivery puerperal insanity set in.f I have a patient in this city, Avhom I have confined five times. In the two first confinements nothing remarkable occurred. In the third, tAvo days after the birth of her child, her husband was compelled to absent himself on urgent business; thirty-six hours after his departure, she lost her reason, and. had a tedious convalescence of ten months. Twenty months from the period of her recovery she was again confined; and mania was again developed. In her fifth parturition she suf- fered no mental aberration. I could cite tAvo other cases, Avhich have occurred to me in consultation, one AA'ith Dr. White of this city, the other}. Avith Dr. Brown, of Little Falls, in Avhich both patients became affected Avith puerperal mania in tAvo consecutive deliveries. It may be that these cases Avill be regarded as coinci- dences, and do not bear the relation of cause and effect. HoAvever this may be, it seems to me that with the predisposition necessarily induced by a preA'ious attack, together with the constant dread of a recurrence of the malady, the nervous system AA'ill be so agitated as to render it not at all improbable that mania having once become developed will be liable to exhibit itself at subsequent periods. Under the circumstances, it would at least be judicious to maintain * Most Important Diseases of Women, p. 120. + Hereditary influence no doubt had its sway in this instance, for both the father and the paternal uncle of the lady died maniacs. t In this case, too, there was hereditary predisposition, for the mother of the patient had suffered from puerperal mania soon after the birth of her only child. 702 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. a guarded opinion, and at the same time to exercise a safe measure of vigilance against the operation of all exciting influences. Causes.—These may be divided into the predisposing and excit- ing. Among the former, may be placed prominently hereditary in- fluence ;* a delicately organized nervous system keenly alive to moral and physical impressions; unusual sensibility of the sexual organs ; and, in my opinion, a previous attack is entitled to be ranked among the predisposing causes of the affection. The exciting causes may be sudden mental emotions, Avhether of a depressing or elevating character ; disordered digestion ; disease of the uterus, or other of the genitalia; exhaustion from undue lactation, or from hemor- rhage, through the changes produced in the nervous system. Wean- ing is regarded by some Avriters as an excitant to puerperal mania, but I do not think it entitled to much prominence ; if it Avere so, the disease Avould assuredly be apt to develop itself frequently in Avomen who, from want of proper feeling or other circumstances, do not suckle their children ; this, hoAAreA'er, is shoAvn not to be the case. I am disposed to think that some of the instances of mania, which have been referred to Aveaning, are due to the exhaustion consequent upon protracted lactation rendering the Aveaning a necessity. Symptoms.—The symptoms indicative of puerperal mania have no special identity, and are subject to variations. Indeed, a very practical division of the disorder has been made into Avhat is deno- minated mania and melancholia, each characterized more or less by symptoms differing from each other. Mania ordinarily occurs soon after delivery, while melancholia is more liable to manifest itself as the result of the exhaustion of undue lactation. In mania, there are usually all the indications of agitation and excitement—great irritability of temper—suspicion is a common symptom; sometimes there will be marked obstinacy and moroseness; the husband and infant become objects not only of indifference, but of actual dislike; there may or may not be febrile excitement; the pulse is some- times unchanged—and again, it is rapid with more or less fever. The patient will occasionally become extremely violent both in man- ner and language, and much vigilance required to prevent her inflicting injury upon herself or child. A very uniform and early symptom is restlessness soon after delivery—an inability to sleep— the patient is Avakeful, throwing herself about the bed, and some- times sighing. This state of watchfulness, I cannot too emphati- cally remark, should always be regarded Avith apprehension, and as far as may be, means promptly employed to procure sleep. Usually the digestive functions are much disturbed, as indicated by the coated, slimy tongue, irregularity of the boAA'els, defective urinary * Dr. Burrows says that if the truth could always be ascertained, more than one half would probably be found to owe their origin to this cause. [Commentarios on Insanity.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 703 secretion ; the patient, although hungry, Avill sometimes evince an indisposition to eat merely from obstinacy; this latter fact I have noticed on more than one occasion. In the other form of mania— melancholia—the symptoms are someAvhat different. Here, in lieu of excitement and violence, there is marked depression of spirits— there is, if I may so term it, a deep melancholy pervading every look and act of the invalid ; she is silent, listless, and indifferent to everything passing around her; the pulse is normal, AA'ith more or less deranged digestion. In one Avord, she is an object painful to contemplate, and it is one of those pictures in real life Avell calcu- lated deeply to impress the observer, and call forth his sympa- thies. Diagnosis.—From Avhat has been said of the symptoms and divisions of this disorder, the diagnosis cannot be difficult. The time and circumstances of its occurrence Avill also aid in facilitating a just opinion. Puerperal mania might possibly be misapprehended for phrenitis, but proper attention Avould soon reveal the error. In the latter affection, the hard and quickened pulse, the heated sur- face, the suffused eye, the intolerance of light and noise aviU very soon tell the story to the vigilant physician. Prognosis.—Many Avill be the anxious inquiries as to the proba- ble issue of the disease, and these inquiries Avill be directed to two points—in the first place, whether the disorder is likely to termi- nate fatally—and secondly, if not, Avhether the mind Avill be perma- nently affected ? I need not chvell on the constancy AA'ith Avhich these appeals will be made, and the pressing urgency for a response. It, therefore, is the duty of the practitioner, by a proper apprecia- tion of the statistics of the affection, to be able at least to approxi- mate a truthful decision. It has been Avell remarked that the data furnished by the records of hospitals for the insane are not proper guides as to the results of this disease under other and more favora- ble circumstances.* The fact, I think, is Avell shoAvn by the folloAving reports: in ninety-two cases recorded by Esquirol, fifty-five re- covered, six died, and thirty-one incurable, or one in three; Dr. Ilaslam .says, of eighty-five admitted into Bethlem, only fifty recovered, and thirty-five incurable ; Dr. Buitoavs reports fifty- seven cases, of Avhich thirty-five recoA'ered, and eleven incurable; among the thirty-five recoveries, twenty-eight occurred during the first six months. Private practice, I repeat, presents no such melancholy experi- * Dr. Gooch very truly observes, that the records of hospitals contain chiefly accounts of cases, whicli have been admitted because they have been unusually permanent, having already disappointed the hope, which is generally entertained and acted upon, of relief by private cure; the cases of short duration, which last only a few days or weeks, and which prove a large proportion, are totally overlooked or omitted in the inspection of hospital reports. 704: THE PRINCIPLES AND PRACTICE OF OBSTETRICS. cnce. It is perfectly safe, under ordinary circumstances, to give a favorable opinion as to the termination of the disease, both as regards the restoration of body and mind. I say under ordinary circumstances, for there are occasionally certain conditions of the disorder AA'hich portend a fatal result, and it is proper that, they should not elude the attention of the practitioner. These condi- tions are now admitted by the ablest physicians as of great moment in forming an accurate diagnosis—they are the rapid jntlse, and continued restlessness at the very inception of the malady. When these tAvo phenomena exist conjointly, they are to be regarded as tokens of no good. Happily the great majority of cases are not characterized by the quickened pulse, although Avatchfulness is a common attendant. I may here remark that the reason for the apprehension of danger from the rapid action of the heart, and the continued loss of rest, is of easy solution—these two symptoms will of necessity draw largely on the strength of the patient—there is no repair to the debilitated forces, and death, in these cases, may justly be attributed to ex- haustion of the system. Duration of Puerperal Mania.—In most instances, puerperal mania is of short duration, not unfrequently yielding to judicious treatment in a feAV days or weeks. Sometimes, however, the re- coA'ery is protracted, and the loss of reason, more or less complete, Avill continue for many months. According to the most reliable data on the subject, Avell sustained by clinical observation, it may be affirmed that the average duration of the malady is from one to six months, Avhile the permanent aberration of mind is the rare exception. Treatment.—A ripe and experienced judgment is essential to the proper treatment of this disease. The thoughtless practitioner, governed in his therapeutics by mere symptoms, Avill be extremely apt to commit a grave error in the management of the malady. The excitement and violence of the patient he AA'ill probably attribute to vascular fulness, a phlogistic state of system—it may be to phrenitis. With this view of the case, he Avill of course resort to depletory measures, the first of Avhich Avill be the free use of the lancet. This is oftentimes a fatal mistake. Puerperal phrenitis, it Avould be Avell to remember, is among the very rare occurrences of the lying-in room; and it cannot be too emphatically borne in recollection that puerperal mania is, as a general rule, a disease of exhaustion and irritation. If the practitioner will but keep this cardinal fact before him, he Avill have the key to the treatment. I was forcibly struck some years since Avith the remark of that saga- cious observer, Dr. Marshall Hall—he says, " On being called to a case of puerperal mania, I have long been in the habit of asking whether the patient has or has not been bled; on this greatly de- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 705 pends the result of the case; if blood has been freely taken, the patient Avill probably die; if otherwise, most puerperal cases of mania issue well." If this language of the distinguished physiolo- gist Avere incorporated into a maxim, and inscribed upon the tablets of memory, well, indeed, would it be for the invalid attacked with puerperal insanity. If Avhat has been said be true—that puerperal mania is most commonly a disease of exhaustion and irritation, then it Avould follow as a legitimate consequence that the two broad indications are to repair, as promptly as may be, the Avaste the system has under- gone, and, secondly, to allay the nervous irritability. Let me here ask—what is the most efficient, and, indeed, the only mode of re- pairing Avaste under these circumstances ? Is it not through proper nutrition ? But nutrition is not an exclusive process—it is but one link in a chain of processes. Food taken into the stomach will not necessarily nourish—its nutrient properties will depend upon its being properly digested; and if you Avish ingesta to be converted into good blood, one material prerequisite is—that the chylopoietic functions shall be in good condition. I think I may say, without fear of contradiction, that a A'ery uniform attendant upon puerperal mania is a disordered digestion, as is shoAvn by the coated tongue, foetid breath, loss of appetite, and irregularity of the boAvels. Therefore, with such indications, the first thing to do is to admi- nister a cathartic, say gr. vi. submur. hydrag. with gr. xii. pulv. rhei; let this be followed in six hours by castor oil, or the follow- ing draught: B Sulphat. Magnesias 3 i Infus. Senna? f. "f iv Mannae 3 i Tinct. Jalapse f. 3 i M. One half this to be taken, and if not effectual, the remaining half in four hours. In these cases of coated tongue and foul breath, great benefit will sometimes be derh'ed from an emetic of ipecacuanha—gr. x. to gr. xii. in half a tea-cup of warm Avater. When the boAvels have been properly evacuated, it is most im- portant to quiet the nervous system ; if the patient can be early put into a state of repose—if the exhausting and harassing watchful- ness be speedily arrested, the best results may be predicted. For this purpose, opiates, in some of their various forms, must be re- sorted to ; but it should be recollected that it is most desirable to make a prompt impression, and, therefore, a full dose should be administered at first, followed subsequently by a smaller quantity as circumstances may indicate. If there be nothing in the idiosyn- 45 706 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. crasy of the invalid to contra-indicate it, a grain or more of solid opium may be given, or thirty or forty drops of the tincture; one half grain or more of morphine Avill sometimes act admirably; 10 grains of Dover's poAvder ; or the folloAving may be prescribed : B Syrup. Papav. f 3 vi Mucil. Acacia? f 3 iii Sol. Sulph. Morphia? (M.) gtt. xx. M. A table-spoonful every half-hour until sleep is obtained. Hyoscya- mus and camphor, five grains of each, Avas a favorite prescription Avith Dr. Gooch, especially Avhere opiates could not be tolerated. It can scarcely be necessary to enjoin, that Avhichever of these reme- dies may be employed, they should be repeated according to the emergency of the case, and the sound discretion of the physician ; nor should they be resorted to if there be heat of system Avith much thirst. Cooling but gentle aperients, together Avith diaphoretics, will soon remove these latter symptoms. The spirits of mindererus, a table-spoonful every tAvo or three hours, will be found a suitable diaphoretic for the purpose. If there be much heat about the head, evaporating lotions to the part Avill be of service, together with warm Avater fomentations to the feet; and if there be an approach—as sometimes Avill be the case —to stupor, blisters behind the ears may be applied with marked good results. The diet to be of easy digestion, and nutritious—and Avhen not contra-indicated, animal food may be allowed freely. On the same principle, also, malt liquors, in proper quantity, will aid in accomplishing the object in view—the building up of the dilapi- dated forces. In one Avord, the judicious physician, seeing the indications, and fully appreciating the surroundings of each case as they may present themselves to his observation, must be the judge as to the special manner of adapting his therapeutics. I have said nothing of the moral treatment of puerperal mania; good nursing—by good nursing I mean discreet nursing—has much to do AA'ith the recovery. What the patient needs is the exercise of that oftentimes rare commodity in the sick-room—common sense. Above all things, let her be protected from the intrusion of inquisitive and talkative friends. Quietude is Avhat she most needs —great caution should be observed to avoid either in conversation or acts all causes of irritation; the nurse should be reminded that the patient is never to be left alone, for instances have occurred in AA'hich females, affected with this disease, have taken advantage of their solitude, and committed acts of personal violence. One of the material points in the moral treatment of this affec- tion, is to exercise a judicious restraint, Avithout permitting the patient to become conscious that there is the slightest surveillance THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 707 over her actions. This is the perfection of good nursing. It is important, as she convalesces, to have her mind agreeably occupied in some way most congenial to her tastes—pleasant conversation, drives in the country, music, painting, etc., are all so many re- sources, which may be advantageously resorted to. In those examples in which the mind of the patient continues unsettled, accompanied by violence,* rebellious to ordinary restraint, the question will of course arise as to the necessity of removing her to some Institution fitted for this special class of cases. The alternative, however, I should be indisposed to adopt except under the most urgent necessity. * The soothing influence of ether will oftentimes exhibit itself most beneficially in quieting the violent agitation, occasionally found to accompany this disease. LECTURE XLV I. Etherization—Its Importance; Antesthesia—meaning of the Term—Anresthetics in Midwifery of Recent Discovery—in Surgery, of Ancient Date; The Anaesthetic Agents now in use—Sulphuric Ether, Chloroform, and Amylene—Sulphuric Ether first employed as an Anaesthetic by Dr. Morton; in Parturition, by Prof. Simpson; its first trial in America, in Labor, by Dr. Keep, of Boston—Chloroform; its Introduction by Prof. Simpson; Amylene; Dr. Snow—Comparative Safety of Sulphuric Ether, Chloroform, and Amylene—Cardiac Syncope and Paralysis of the Heart from Chloroform—Indications for the use of Anresthetics in Parturition— Should they be employed in Natural Labor?—Their value in Instrumental and Manual Delivery—Anresthetics in Infancy—Influence of Etherization on Contrac- tions of the Uterus; on Mother and Child—Flourens on the Nervous System in Etherization—Time and Mode of resorting to Anresthetics in Parturition—The Pulse; how affected by Etherization—Relaxing Effects of Etherization—Case in Illustration. Gentlemen—It must be universally conceded that the contribution Avhich science has made to suffering humanity—anaesthesia, or insensibility to pain—Avhether under the surgeon's knife, or during the throes of labor, should be regarded as among the most sterling offerings of the human mind. The term anaesthesia, in our day, is employed to designate a partial or positive unconsciousness through the administration of AA'hat are knoAvn as anaesthetics—more espe- cially ether and chloroform. But while employed in this sense, it is well to recollect that the true signification of the Avord is a loss or privation of feeling. Although the introduction of anaesthetic agents into the lying-in chamber for the purpose of diminishing the anguish of the parturient Avoman, is of recent origin, yet the idea and actual practice of having recourse to certain agents Avith the A'iew of preventing suffering under surgical operations is of very ancient date. You will read, for example, in the older Greek and Roman authors, minute directions for the administration of their favorite mandragora as the great remedy for soothing pain ; while, again, among the Chinese, the Indian hemp seemed to possess superior anaesthetic charms. I do not propose, however, either to discuss in detail, or enter into the history of the interesting question of anaesthetics. I desire simply to present some general remarks touching their origin, employment, and results, during the progress of parturition ; Avith this vieAV, I shall endeavor to indicate under what circumstances, in my judgment, etherization or anaesthesia AA'ill be a justifiable resort. It is needless to remind you that the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 709 first introduction of these agents into the lying-in room was Aery generally hailed by what may be properly denominated a Avild enthusiasm; and, as too often happens in the advent of new remedies, there was more zeal than judgment displayed in their administration. Hence, Avith some practitioners, anaesthetics were had recourse to in every case of labor; the one idea seemed to prevail—the accomplishment of child-birth without pain. W^ith such an unrestricted and indiscriminate employment of these agents, tAvo consequences were inevitable, viz. their abuse, and to a degree, loss of confidence in their virtues. The Anaesthetics now in Use.—The anaesthetic agents which have received more or less the sanction of the profession are: 1. Sulphuric Ether; 2. Chloroform; 3. Amylene. It may not be out of place very briefly to allude to each of these substan- ces. 1. Sulphuric Ether.—Without intending to take any part in the controversy as to Avhom is due the credit of suggesting the anaesthetic properties of sulphuric ether—whether it be Dr. Horace Wells, Dr. W. T. G. Morton, or Dr. Charles T. Jackson,* all countrymen of ours—it is, I think, universally admitted that the original administration of ether to prevent the pain of an operation was by Dr. Morton ; this occurred on the 30th of Sept. 1846, the ether being administered, by inhalation, to a man from whom Dr. Morton extracted a tooth without causing the slightest pain. Prof. Simpson was the first to resort to this agent in parturition, which he did on the 19th of Jan., 1847, and became satisfied of its anaesthetic properties without its interfering Avith the parturient effort. In our oavii country, sulphuric ether Avas administered for the first time in labor, April 7th, 1847, by 1ST. C. Keep, M.D., f of Boston, Avith most satisfactory results. It is an interesting fact that sulphuric ether Avas given, by inhalation, both in surgery and midwifery, for a period of several months in America and in Eu- rope, previously to the introduction of chloroform ; and, as far as I have been enabled to ascertain, not a single fatal case had occurred under its administration. It was, if I may so term it, not only in good repute, but had gained the very general confidence of the profession both here and abroad, until, as Ave shall presently see, the force of circumstances caused it measurably to give place to another anaesthetic—chloroform. 2. Chloroform.—When sulphuric ether had been tested, and its anesthetic properties most satisfactorily demonstrated, .anxious for something still better, Avhich Avould be free from certain sup- * The reader may be interested in a perusal of "A Defence of Dr. Charles T Jackson's claims to the Discovery of Etherization." Boston, 1848. + A report of the case will be found in the Boston Medical and Surgical Journal, April 14th, 1847. 710 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. posed objections, the untiring mind of Prof. Simpson, ahvays in the pursuit of truth and improvement, developed the fact that chloro- form possessed in a marked degree anaesthetic virtues. The learned Professor subjected his OAvn person to experiments, Avith a view of testing the value of the neAV agent; the reader will be more than amused Avith the graphic description by Prof. Miller, of the scene, Avhich ensued in Dr. Simpson's dining-room, when he and his two friends, Drs. Duncan and Keith, had placed themselves under the influence of chloroform.* The personal experiments Avith this sub- stance Avere most satisfactory to the gentlemen, Avho had submitted themselves to its influence; and the result Avas a paper from Prof. Simpson,f which although it provoked controversy, soon gave popularity to the neAV agent in the lying-in chamber, and, in a measure, caused its adoption as a substitute for sulphuric ether. One of the very first to have recourse to chloroform after the pub- lication of Prof. Simpson's paper, Avas Prof. Murphy,J of the London University—it Avas most successful in his hands, and he is since entitled to be ranked among its Avarmest advocates. 3. Amylene.—We are indebted for the discovery of this substance to M. Balard,§ Prof, of Chemistry in Paris, who brought it to the attention of the profession in 1844 ; and to Dr. John SnoAV,|| is due the credit of having been the first to employ amylene as an anaesthe- tic, Avhich he did in Kings College Hospital, in Nov. 1850. lie made several experiments on animals, and inhaled small quanti- ties of it himself. Dr. Snow, after resorting to it in a number of operations, believes it to possess certain advantages ovor chloroform in many cases. Although it has not as yet been generally employed either in America or Great Britain, it has been extensively used, AA'ith favorable results, in Paris, Strasburg, and other places on the Continent. Comparative Safety of Sulphuric Ether, Chloroform, and Amy- lene.—On this question, more particularly in reference to the two former agents, the opinion of the profession is divided. The fact, however, is very certain, that the statistics derived from the admi- nistration of the two substances preponderate greatly in favor of sulphuric ether, as a safe and reliable anaesthetic. When chloroform destroys life, it would appear, from an analysis of the recorded fatal cases, that it does so through a peculiar influence exercised on the heart's action—a cardiac syncope, or what has been designated a paralysis of the organ. On the other hand, it has been satisfacto- * Surgical Experience of Chloroform, by Prof. Miller, pp. 10, 11. \ An Account of a New Anaesthetic Agent as a Substitute for Sulphuric Ether m Midwifery and Surgery, by J. Y. Simpson, M.D. Edin. 1847. X Chloroform in Child-birth, by Edward Wm. Murphy, M.D., 1855. § Annales de Chimie et de Physique, torn, xii., p. 320. | On Chloroform and other Anresthetics, by John Snow, M.D. London, 1858. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 711 rily shoAvn by experiments on animals, by Dr. Snow* and others, that sulphuric ether is incapable of producing sudden death by stoppage of the heart's action. As for myself, I have some time since abandoned the use of chlo- roform, and have recourse exclusively to sulphuric ether, which I haA'e always found safe and reliable. I have had no experience Avith amylene, yet it has received very high commendation from those who have tested it. Dr. Snow has employed it in seven cases of labor Avith the most entire satisfaction ; aud he says "the great case Avith AA'hich it can be breathed, OAving to its entire Avant of pungency, is a decided advantage it possesses over both ether and chloroform." With such testimony in its favor, it is not unreason- able to believe that it is destined to occupy an important place among the anaesthetic agents.f The Indications for Anaesthesia in Parturition.—In reference to the particular circumstances justifying the use of anaesthesia in the lying-in room, there is no concurrence of opinion among accou- cheurs; on the contrary, there is much diversity of sentiment. With some it is the universal habit in every case of labor, no matter hoAV natural and auspicious it may promise to be, to resort at once either to sulphuric ether or chloroform. This, it seems to me, is really abusing a good thing. Labor is unquestionably a natural process—it is, indeed, entitled to be designated in strict physiolo- gical language a function. If this be so, is it right to interfere Avith a function, properly so called, as long as its exercise is normal, and AA'ithin the true record of nature ? I think not. Again, there is another argument, Avhich has always struck me Avith force, Avhy anaesthesia should not be employed in a natural parturition, and it is this—the female, at the most interesting period of her life—the time of labor, should, all other things being equal, have her mind unclouded, her intellect undisturbed, her judgment fully adequate to realize and appreciate the advent of a neAV and important era in her existence—the birth of her child. Therefore, I shall advise you not to resort to anaesthetics in natural and ordinary labors, except in * Dr. Snow, in his excellent work already alluded to, records in tabulated form fifty deaths from chloroform, and in all the cases (45) in which the symptoms which occurred at the time of death are reported, there is, he observed, every reason to conclude that death took place by cardiac syncope, or arrest of the action of the heart. In forty of the cases, the symptoms of danger appeared to arise entirely from cardiac syncope, and were not complicated by over-action of the chloroform id the brain. Again, he says, I am aware of only two deaths, which have b^ recorded as occurring during the administration of ether, and it is not probable th. the death in either case was due to the ether. I hold it, therefore, he continues, to be almost impossible that a death from this agent can occur in the hands of a medi- cal man, who applies it with ordinary intelligence ani attention. [Op. citat. p. 262.] 4- The pupil may consult with advantage, " A Treatise on Etherization in Child- Birtli." By Prof. "Walter Channing, M.D. Boston, ISIS. 712 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the event of certain contingencies AA'hich, in the judgment of the accoucheur, Avould justify their administration. The employment of these agents will be proper in cases of operative midAvifery, Avhe- ther instrumental or manual; in cases of unusual pain accompanying the labor; in instances of rigidity or an unyielding condition of the mouth of the Avomb, vagina, or perineum ; in a woman of excessive; "nervous irritability ; in certain cases of irregular contraction of the uterus, in AA'hich the strength of the mother is severely tested Avith- out a corresponding progress in the delivery ; in many cases of puerperal convulsions, provided there is no tendency to cerebral congestion ; in spasmodic contraction of the uterus before the birth of the child, and subsequently to the birth, the placenta being retained by the spasm of the organ. In some conditions of preg- nancy—for example, Avhere there is a degree of undue irritability of system, or the hysteric manifestation, or where it becomes neces- sary to extract a tooth ; and I may remind you that I have on seve- ral occasions derived marked benefit from the administration of sulphuric ether in cases of rebellious dysmenorrhcea. Let me here add that, in the irritability and convulsions of children,* etheriza- tion Avill oftentimes exhibit the happiest results. Tlie Influence of Anaesthetics on Uterine Contraction.—One of the original and chief objections to the employment of anaesthetics in midAvifery Avas the apprehension, advanced by some authors, that they so completely controlled the action of the uterus as necessarily to expose the patient to all the hazards consequent upon inertia of the organ—such as hemorrhage, „ Proftrntor of Midwifery, University College, London ; Obstetric Physician, University Col- lege Hospital; and formerly Assistant-Physician to Dublin Lying-in Hospital. One rol. 8va. Price |1 75, free of postage. Illustrated by Seventy Engravings. " This la a very excellent treatise on Obstetrics."—American Journal of Med. Scien.n. " It has high claims upon the attention of the profession; even old practitioners may consul! 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Throughout, the work is illustrated by wo<><'.- oufs exhibiting the different stages of labor, the organs involved, and the inslr.imeurs ernplo\ ed In delivery."—^. Louis Medical and Surgical Journal. "Tho student will find It replete with accurate and lucid Instruction."— LondonMed.O tuetU "This is an excellent beok. It is commended to us by the position and rich practical expe- rlonoe of the author. It is comprised within limits which will not exhaust while it improve*, and Is not so expensive ss to make it a very serious question whether it shall be bought or net. it consists of thirteen lectures, on important matters; embracing, m short, what it behooves every practitioner to know, and to know thoroughly."—Motion Medical A Surgical Journal. "The mechanism of parturition, the keystone of correct operative midwifery, is detailed with singular clearness and perfection. The chapters on Natural Labor leave nothing to be desired, while those on Difficult Parturition—and how embarrassing, how wearying cases of this l.ind are, every one engaged in obstetrical practice^but too well knows—seem to us to supply fullv the wants of the sludent as to their causes and the remedy. We earnestly recommend Ii to the learner as the monograph, par excellence, on the subject"—The Annalist. " As an elementary treatise on the Obstetric art, and as a text-book for students, we are ol opinion that Dr. Murphy's Lectures should rank very high. The style is plain, simpie, con- oise, and agreeable; and the principles of practice taught are based upon an enlarged view oi tbe philosophy of the art, as well as ample practical experience."— Western Lancet. These Lectures " contain a large amount of sound practical matter. From a careful perusal of them, we feel satisfied that not the student merely, but also the practitioner, may derivs much valuable information, conveyed In a pleasing and unassuming style."—Dublin Quar- terly Medical Journal of Science. A MANUAL OF DISEASES OF THE SKIN. From the French of M. M. Cazbnavb oh on diseases of the skin, now in the hands of the profession, wnich ia so universally accepted as reliable authority, aa that of Cazenave and Schedel."—Ohio Med. and Surg. Journal. " This is the second American edition of a valuable work upon diseases of the skin, and con- tains not only the notes of the American editor, Dr. H. D. Bulkley, but also those of Dr. Thoa. H. Bunress, editor of the English edition. It is direct, full, and explicit In Its descriptions. anil conveniently arranged for reference."—New Hampshire Journal of Medicine. ""Thiols eminently a practical work, and we know of no tr.j»tise on skin diseases bet>»r suited to the wants of the general practitioner. 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The Practitioner's Pharmacopoeia, and Universal Formulary; Containing Two Thousand Classified Prescriptions, selected from the practice of the most eminent British and Foreign Medical authorities, Ac, &c. By JOi™ FOOTE, M.R.C.8., London, with additions by Benjamin W. MoCrbady, M.D., Professor of Materia Medica and Pharmacy in the College of Pharmacy, N. Y., JtoBt part exceedingly well executed. It Is the cheapest work of th» kind evor published in tbfe country."—American Journal of Medical Science*. "The text and plates both being excellent, the book is a treasure Indeed,"—Boston Mmti'^ and Surgical Journal. Wood's Medical Catalog ut.. LECTURES ON THE ERUPTIVE FEVERS, aH NOW IN TUB C0CE8E OP DELIVERY AT 8T. THOMAS' HOSPITAL, LONDON. By GEORGE GREGORY, M. 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Price 87 ^ cents " Dr. Stewart has the advantage of an established reputation as an author on the diseases of Infant* and children: we know of no one among us better qualified, both by previous study and habits of csrei'ul observation and correct reasoning, to do iustice to the subject of this fssuy."—New Y>rk Maiical Times. S. S/4- W. Woods Medical Cat.,,1,-,,.- A Treatise on Venereal Discaseo. BY A. VlDAL (DE CASSIS), *nrgeon of tbe Venereal Hospital of Paris; Author of the Traite de ratholegle Externe et 4e Medecine Operatoire, Ac, Ac. \V 1 T M COLOkKO PLITEH. Translated and Edited by GEORGE C. BLACKMAN, M.D., reiiow of tbe Royal Medical and Chirurgioal Society of London, «kc, Ac. "fhird edition. Price $3 60, free of postage. " One of the most valuable works tbat has recently been issued from tbe press."— Medical JRi»! miner & - Wo regard the present work as tbe best general treatise that has ever been published on Syphilis, and are much miBtaken if it does not soon become the authority of the day. Th« colored illustrations are the most beautiful and faithful things of the kind we have yet seen."— Medical C hronicU. "The best general treatise on Syphilis extant"—Laxgston Pabkeb, Surgeon to the Queen's ff'VjHtal, Birmingham. "To every country practitioner we say, obtain the work of Vldal. Theprecepte are excellent, W;» plates magnificent."—(raorpfa Blister and Critic " We do not know a bette •."—New Jersey Medical Reporter, " We have never seen a bbok on this subject which appeared so well calculated to meet the wants of students and young practitioners as this."—New Hampshire Journal of Medicine. " A better work than this of M. Vldal's is not extant"— Western Lancet. •' Of inestimable value to the practitioner, both for its principles and practice."—Arew> Orleans .VfiUcal and Swpical Journal. " A library In itself, full of valuable hints and landmarks, whereby tho physician may as«M his own experience and reason to unravel the knotty points, and decide on the more difficult i'losrious arising in venereal surgery."—Peninsular Journal of Medicine. " We most cordially recommend It to the consideration of our readers."—Upper Canada .Journal. "One of the most complete and useAiI treatises on syphilitic diseases we know."—Southern SftHlietil and Surgical Journal. Microscopic Anatomy of the Human Body, IN HEAL'J'H AND "DISKASK. Illustrated with numorons drawings in color, by Arthur Hill Hass/lll, M.B.; Member of Royal Collego of Surgeons of England, Ac., Ac. With addition* to the Text and Plates, and an Introduction, containinz instructions in Microscopic Manipulation, BY HENRY VAN ARSDALE, M-D. Price $7, free of postage. 2 vols. 8vo., to, plates. u Every page of it Is a banquet unfolding the marvels of creative wisdom and power. Such .'■\fraordinitry displays of the minute organization of the Internal mechanism of oar bodies, in lie two conditions of health and disease, create a strange feeling of wonder and amaasement While the work tenches how to understand appearances, it also points out the physiological functions and anatomical relations of parts. In short, the why ana tbe wherefore In the sub- jects treated of are presented in a clear light."—Boston Medical and Surgical Journal. " We express the conviction, forced upon u«. after several years' consultation of simllai v.'«rks, while pursuing microscopical studies, tbat there is none better arranged and Illustrated, af.al of Meet> nine and Surgery. " It is not merely a scientific, but it is furthermore a practical treatise; and In both characters It equally sustains a high character. The getting np of the Illustrations is exquisite; each one -irras a perfect picturei"—Medical ChronicU. "The most complete in this department"—Nelson's American Lancet. " It Is magnificently published. It is the only complete work of the kind In tbe English lan- guage, and reflects Ugh credit upon its learned'and Indefatigable author."—Southern Medical xnd Suraical Journal. > > > > T >>> ■ ,r ? > > > * 3P * --^ym > jfi> *S ^*>:t< > »» - - .- ;S>>JX> > \ V , ■» > > V , >> >. > >■! ^ > **• V^. ^ »> J? ' .-*- > *v* vS» .> ■ *> > * j»-,'> -S- • -*» ^ -^- >^ v>«6'>. >:s> -^ "->>-T> ~W»?J'£. 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