■■!'. ^ ; i ^m 11 tei:-."-!!r}ii?!i -mx* mm ■Mm NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Serrice THE PRINCIPLES AND PRACTICE OP OBSTETRICS. BY GUNNING S. BEDFORD, A.M., M.D., PROFESSOR OF OBSTETRICS, THE DISEASES OF WOMEN AND CHILDREN, AND CLINIC iL OBSTETRICS, IN IUK UNIVERSITY O* NEW YORK ; AUTHOR OF " CLINICAL LECTURES ON THE DISEASES OF WOMEN AND CHILDREN.'1 Ellustratrti bg JFout €oIor«i 3Litfjograpf)ic plates anti Ninfta'itint BBEooli ISngraoings. Mnltnm restat adhuc operis, multnmque restabit, nee ulli nato, post mille saecula, praecludetur occasio aliquid adjiciendi. Seneca, Lib. I., Epiat. lxiv. */<>7?"*.»:.V FOURTH EDITION, CAREFULLY REVISED THROUGHOUT, AND ENLARGED. NEW YOEK: WILLIAM WOOD & CO., 61 WALKER STREET. 1868. LMHp \8G8 Entered according to Act of Congress, in the year eighteen hundred and sixty-one, tj GUNNING S. BEDFORD, (d Uw Clerk's office of the District Court of the United States for the Sunttern District at New York. To THE ALUMNI AND STUDENTS^ WHO HAVE ATTENDED rHE AUTHOR'S LECTURES ON OBSTETRICS IN THE UNIYERSITY OP NEW YORI AKD TO WHOSE UNIFORM COURTESY AND KINDNESS HE IS SO GREATLY INDEBTED, ftfris Volume is gffetttorratelg $tbicait&. PREFACE TO THE FOURTH EDITION. The present Edition of the Principles and Practice of Obstetrics has been thoroughly revised, and some important additions made, which, I trust, will not be unacceptable to the reader. Besides alluding more par- ticularly than I had previously done to the interesting subjects of Anaesthetics, and Twin-pregnancy, I have devoted an entire Lecture to the complications of Preg- nancy, in which are discussed various topics of impor- tance, such, for example, as Chorea, Paralysis, Jaundice, etc., which cannot, I think, fail to elicit the attention of the Obstetric Student. New York, 66 Fifth Avenue, January 1, 1868. 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 Prsevia, 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, Eeproduction, Pregnancy, Foetal Nutrition, Puerperal Convulsions, and other kindred topics. Manual, Instrumental, and Premature Artificial Delivery Iiave 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 preface. vii 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 instructions 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. viii preface. 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 affection. New York, 06 Fifth Avbnttm, Oct. 25,1861. PREFACE TO THE SECOND EDITION. A.N 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" 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. If arch, 1862. PREFACE TO THE THIRD EDITION. AGAIN has the grateful duty devolved on me of returning thanks to the Profession for the continued—and I hope I may say without egotism—unexampled patronage extended to the " Principles and Practice of Obstetrics." It is now but thirteen months since the book was first presented to the world, and my Publishers admonish me that a Third Edition is called for. To say that its reception is beyond my most sanguine hopes, and that I am deeply impressed with a sense of the obligation im- posed by this prompt recognition of my labors, would be but the reiteration of a self-evident truth; and I may add, that both the pleasure and obligation are greatly enhanced by the fact that, in the short period which has elapsed since the work was issued from the Press, it has already been recommended as a Text-Book in nine of our medical colleges. What greater honor can an Author claim at the hands of his Peers—what higher incentive to future effort I These influences, if my life be spared, shall not be lost upon me. Again, also, I have most cordially to thank the Medical Press, here and abroad, for theii continued commendatory and flattering notices. This Edition has been carefully revised and enlarged; besides additions to the Text throughout the volume, it will be seen that a lecture on Phlegmasia Dohns has been incorporated. New Yobs, 66 Fifth Avenue, Dec. 1862. CONTENTS. LECTURE I. POSITION AND BONES OF THE PELVIS. Midwifery an Exact Science—The Passage of the Child through the Maternal Organs is founded 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 Innominate—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, AKTTCTJXATTONS, AXES, AND DIVISIONS OF THE PELVIS. Uses of the Pelvis—Articulations, or Joints of the Pelvis—Do these Articulations during Pregnancy become Eelaxed ?—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 Pelvia in Connexion with the Soft Parts—Its Measurements. . .-......12 LECTURE III. DIVISIONS AND PRESENTATIONS OF FOETAL HEAD. Pcetal Head; its Regions, Diameters, Circumferences, Extremities, Sutures, Fonta- oelles—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. ... 27 X CONTENTS. LECTURE IT. MECHANISM OF LABOE 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 Fistulse—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- 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 Organi of Generation—Structure and Uses of the Ovaries. .... .... 79 LECTURE VII. MENSTRUATION. Functions of the 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........................93 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 tie " 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" 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................K*9 xii CONTENTS. LECTURE IX. DEFINITION AND DIVISIONS OF PREGNANCY. Pregnancy; Definition and Divisions of—Is Pregnancy a Pathological Condition?— The Uterus and Annexas 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 Mammas 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—03dema 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. xiii 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 ol Tissues of Cervix—Cervix does not Lengthen—Error of Madame Boivin—Promi- nence of Os Tincse—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 or 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 —Hlustration—Contraction of Abdominal Walls mistaken for—Final Cessation ol 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.........................1'fi 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 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. . 192 xiv CONTENTS. LECTURE XIV. EXTRA-UTERINE PREGNANCY. Exira-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 Foetation—Areola and Tumefaction of Breasts—Hlustration—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 iu the Abdominal 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 Fasces in the Rectum- How distinguished from Retro-version—Hernia of Gravid Uterus..... 232 CONTENTS. XV LECTURE XVII. PLACENTA AND ANNEXJE OF FOETUS. The Annexae 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. Roid 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 F03TUS. 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 Mialhe—Albu- minose—Influence of Parent upon Progeny—Transmission of Hereditary Disease— Change in the Circulation as soon as Respiration is established—Puer Caeruleus— Does the Foetus Breathe in Utero?—Intra-uterine 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 ActioB —Whytt—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 Fcetus, all Causes of Abortion—Disease of the Placenta and Abortion- Abortion sometimes the Result of Habit—Phenomena of Expulsion in Abortion —The Pfein 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.........296 CONTENTS. xvn 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 Parturu 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- Sequard'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; Fatty 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 t—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 :'n Natural Labor; 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 Writers with regard to Version and Forceps Delivery in Face Presentations—Presentation of 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; maybe 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 Brachet, 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 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» CONTENTS. XLX 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. . . 3? 2 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— Mammas 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—Retentioa 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—Gutter'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—Thrombus of the Vulva —Weed or Ephemeral Fever.........4"4 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—Signs 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- fcetation; meaning of the term—The Possibility of Super-fcetation 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-fcetation in a Double Uterus; the instance recorded in the Encyclographie Medicale—Objections to Super-fcetation 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-fcetation.......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 bo 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 PRJEVIA, 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 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 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 xxii CONTENTS. LECTURE XXXIII. PUERPERAL CONVULSIONS--CENTRIC. 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 Ursemic 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 Urajmia, 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. . 604 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 FOE 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. XX111 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—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, 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—The instru- ment may be employed when the Head is at the Inferior Strait, in the PelVw 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 Pofition—The Head in the Pelvic Cavity diagonally, the Occiput regarding the Left Lateral Portion of the Pelvis, the Face at the 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 beiLg 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 ?—Camper's 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 Face 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 Caesarean Section —Statistics of each—Deduction—The Casarean 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 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—Researches and Statistics of M. Philan-Dufeillay . ......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 justifying 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— Cephalotripsy—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 Fcetal 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-Sequard; its influence on contraction of non-striated muscular fibres—Induction of Abortion—Is it ever justifiable! . 663 XXVI CONTENTS. LECTURE XLIV. PUERPERAL FEVER. Puerperal Fever—Synonyms; its Fatality most Fearful—What is Puerperal Fevei 1 —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 confined 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. Ameth'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 XLVI. PHLEGMASIA DOLENS. Phlegmasia Dolens, although generally incident to the puerperal state, is not always so—It may develop itself in the non-puerperal woman, and also in the male sex • but little understood by the early Fathers—Mauriceau the first to direct special attention to it—His Views of its Pathology—The Views of Puzos and Levrot—. CONTENTS. XXVT1 Historical Sketch of the Disease—Mr. White, of Manchester—Mr. Frye, of Glouces- ter—Dr. Ferrier—Mr. Hull—M. Albers—M. Bouillaud—Professor Davis, of Lon- don—Dr. Robert Lee—Is Phlegmasia Dolens a Crural Phlebitis ?—Dr. Macken- zie, of London—Is Phlegmasia Dolens a Toxaemia ?—Synonyms—Causes of the Dis- ease; Symptoms—Why is ffidema a Symptom of Phlegmasia Dolens ?—Causes of Dropsical Effusion; the relation between the oedema of Phlegmasia Dolens, and Obstructed Venous Circulation—Proof—Are the Veins Absorbents ?—Lower's Ex. periments—Boerhaave; Van Swieten, Hoffman, Morgagni, Cullen—Majendie and Bouillaud—The (Edema of Pregnancy—How Explained—Which of the Inferior Ex- tremities is most liable to Phlegmasia Dolens?—The Causes of the Difference—At what Period after Labor does the Disease most usually occur?—Frequency of Phleg- masia Dolens—Statistics—Diagnosis—Prognosis—Progress, Duration, and Termina- tion of the Disease—Complications—What are they ?—Purulent Collections—Their Consequences—Peritonitis—Metro-Peritonitis—Treatment of Phlegmasia Dolens— Its Indications—Local Applications with the view of diminishing Pain. . . 708 LECTURE XLVII. ANAESTHETICS. Etherization—Its Importance; Anaesthesia—meaning of the Term—Anaesthetics in Midwifery of Recent Discovery—in Surgery, of Ancient Date; The Ansesthet'c 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 Anesthetics 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..................... 720 LECTURE XLVIII. CHOREA—PARALYSIS—JAUNDICE. Chorea as a complication of Pregnancy—Its connection with the Uterine Organs— The Spinal Cord and Muscular action—Chorea and Rheumatism—Rombergs opinion—Rilliet's views—Is Chorea a blood-poisoning?—When does Chorea manifest itself in Pregnancy?—Does Chorea ever occur in Pregnancy without previously developing itself in Childhood?—Is Chorea frequent in Pregnancy?— A case of labor with Chorea—Shoulder presentation—Version—Safety of Mother and Child—Pregnancy complicated with Paralysis—Is it dangerous?—The fol- lowing forms may present themselves in Pregnancy, at the time of Labor or after delivery : Paraplegia, Hemiplegia, Amaurosis, Facial Paralysis, etc.—Centric and eccentric causes—Interesting case of Paraplegia from pressure of fibrous tumor in Pregnancy—Excision of tumor and Safety of Mother and Child—Pregnancy complicated with aberration of mind—Pregnancy complicated with Jaundice— What is Jaundice?—It is a Toxaemia—Is Jaundice necessarily dangerous as a xxviii CONTENTS. complication of gestation ?—Does miscarriage or premature labor ensue as a con- sequence ?—Treatment of ordinary Jaundice—Fatal epidemic of Jaundice in the island of Martinique, described by Dr. Saint Vet—Death preceded by Coma, and always fatal. LIST OF ILLUSTRATIONS................xxix CATALOGUE OF AUTHORS REFERRED TO AND QUOTED . . . xxxi ALPHABETICAL INDEX ................747 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. ns. "<» 1. The bones of the trunk........................................... 2 2. The anterior surface of the os sacrum............................... 4 3. The posterior surface of the sacrum................................. 6 4. Tie lateral surfaces of the sacrum.................*................ 5 5. The coccyx..................................................... 5 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................................................ If 12. The planes and axes of the pelvis.................................. 18 13. The central curved line, or axis of excavation........................ 2i 14. The course pursued by the foetus in its exit.......................... 22 15. Diameters of the upper strait of the pelvis........................... 25 16. Diameters of the lower strait of the pelvis........................... 26 17. The occipi to-mental, occipito-frontal, and vertical diameters of 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, 41 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 80. The pelvimeter.................................................. 68 81. Method of vaginal examination 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 86. Double uterus and vagina......................................... ™ rxx LIST OF ILLUSTRATIONS. no. pa«i 36. Continuity of the fallopian tube with the cavity of the uterus........... 90 37, 38. The muscular structure of tho uterus............................ 127 39. The uterus in its natural state..................................... 157 40. The uterus at the third month of gestation.......................... 157 41. The uterus at the sixth month of gestation............................. 159 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.................................... 244 45. The foetal surface of the placenta................................... 247 46. The maternal surface of the placenta................................ 247 47. The knotted cord................................................ 252 43. Presentation of the face, first position.............................. 341 49. Descent of the face............................................... 342 50. 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 o5. The os uteri fully dilated—membranous sac unruptured................ 359 56, 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 66-73. Illustrations of the manipulations in podalic version in vertex pre- sentations............................................. 531-534 74. Extraction of the arm........................................... 535 75. The production of the movement of flexion........................... 537 76. Delivery of the breech............................................. 549 77. Delivery of the feet.............................................. 551 78. Delivery of the knees............................................ 551 79. First position of the abdomen..................................... 556 80, 81. Second position of the right shoulder with protrusion of the arm...... 561 82. Application of blunt hook......................................... 567 83-88. Author's obstetric instruments.................................. 579 89. Introduction of the male branch of the forceps........................ 587 90. Introduction of the female branch.................................. 588 91. The forceps locked....................................... # # ( 539 92. Forceps applied, and disposition of the hands......................... 589 93. Gradual extension of the head in forceps delivery............... 590 94. Complete extraction of the head......................... 5P,g 95. Forceps applied after the extraction of the trunk.............. 609 96. Perforation of the cranium in hydrocephalus............... 661 97. The curved instrument with an internal cutting border.......... 66i 98. Cephalotribe or embryotomy forceps....................... gg3 99. Application of the cephalotribe..........................f....... qqa CATALOGUE OF AUTHORS REFERRED TO AND QUOTED. Albers, 710. | Andral, 106, 129, 133. Arneth, 462, 465, 686. Astruc, 206. Atlee, 301. Bachetti, 213. Bailey, 429. Balard, 722. Baly, 113. Barker, B. Fordyce, 543, 639, 698. Barnes, Robt., 271, 285, 477, 575. Barry, Martin, 39, 117. Baudelocque, 36, 38, 69, 146,150, 452, 627, 641, 657, 663. Beau, 697. Beck, Snow, 87. Becquerel, 129, 134. Bell, Sir C, 271. Bemiss, 263. Bernard, 246, 262. Bischoff, 118, 184. Blot, 135, 508. Blumenbach, 151. BlundeU, 400, 628. Boerhaave, 131. Boivin, Mad., 37, 126, 158, 165, 240. Bouillaud, 86. Boulard, 87. Bounder, 343. Bowditch, Dr., 429. Bowman, 115. Braun, 272, 505, 515. Brenan, 696. Breschet, 104, 122, 205. Bretonneau, 220. Briere de Boismont, 98. Broca, 116. Brodie, Sir Benj., 371. Brown-Sequard, 190, 271, 312,319,331, 371,401, 507, 513, 678. Brucke, 136. Buffon, 310, 442. Burns, 67. Burrows, 502. Busch, 67. Callisen, 712. Campbell, 515. Camper, 23,151, 602, 622. Capuron, 522. Carpenter, 91, 263, 510. Carriere, 716. Carua, 312. Cazeaux, 39, 127, 168, 220, 663. Chailly, 634. I Charrier, 691. Chassaignac, 426. Christison, 510. Churchill, Dr., 33, 39, 339, 344, 348, 390, 431, 442, 444,461, 503, 538, 574, 629, 667, 673. Clark, Alonzo, 697. Clarke, SirC, 155, 300. Clarke, Dr. Joseph, 27, 67, 630. Clay, Charles, 221, 303. Cloetta, 87. Cohen, 678. Collineau, 75. Collins, 339, 344, 437, 496, 693. Coste, 83, 91, 115, 119, 242. Cristoforis, 643. Crosse, 446, 449. Cruveilhier, 273. Cullen, 506. Cummings, 417. Dalton, 91, 113, 250. Danyan, 694. Davis, 67, 204, 340, 575. De Graaf, 318. Denman, 144, 465, 562, 582. Depaul, 134, 682. Deville, 126, 127. Dewees, 67, 146,465, 602. Dieffenbach, 213, 401. Donne, 102, 116. Douglass, 563. D'Outrepont, 98. Druit, 250. Dubois, 33, 35, 38, 96, 131,147,153, 189, 214, 293, 314. Duges, 710. Dumas, 115, 401. Duncan, Matthews, 35, 165, 305. Duparcque, 712. Duplay, 718. Eggert, 177. Elsasser, 144. Esquirol, 503, 700. Fair, Dr. W., 123. Farre, Arthur, 171. Faye, 96. Ferguson, 682, 683. Fernel, 284. Ferrier, 709. Figg, E. Garland, 538. Figueira, 667. Finnell, 204. Flamant, 540. Flourens, 248, 485, 725. Follin, 293. Frankenhauser, 187. Frerichs, 512. Frye, 709. Galen, 34, 417. Gardien, 46, 627. Gariel, 239. Gavarret, 106. Geoffrey St. Hilaire, 265. Gerdy, 51. Geuth, 205. Godard, 116. Gooch, 300, 388, 701. Good, 712. Goodsir, 244, 249, 257. Goubeyre, 505, 515. Graves, 697. Gubler, 421. Guillemot, 267 GuiUot, 262, 422. Guthrie, 710. Haighton, 119. Hall, Marshall, 269, 370 485. Haller, 101, 115, 147. Halmagrand, 555, 633. Halpin, 238. Hamilton, 67, 476. Hammond. 514. Hardy, 447*. Harvey, 114, 150, 210. ■ Hecker, 204. Heim, 213. Henry, 442. Hewitt, Graily, 285. Hewson, Addinell, 30. Hippocrates, 34,131, 135, 218,292,304,338,417, 540. Hirschfeld, 87. Hodge, Prof., 686. Hoffman, 715. Hohl, 211. Holmes, 686. Homans, John, 429 Huguier, 77, 165, 173. Hull, John, 709. Hunter, 87, 153, 235, 242 249, 345, 368, 444. Jackson, C. T., 721. Jacquemin, 75, 172. Jenkens, Conant, 429. Jobert, 86. Johnson, 340. Jones, Bence, 510. Jones, T. Wharton, 498. Jorg, 640, 679. XXxii CATALOGUE OF AUTHORS REFERRED TO AND QUOTED. Kane, Elisha, 135. Keating, 697. Keep, N. C, 709, 721. Keiller, 182. Keith, 662. Kennedy, 191, 240. Kergaradec, 189. Keyser, 632. Kilian, 173. Kiwisch, 396, 677. Kluge, 173. Kohen, 117. Kolliker, 126. Krahmer, 302, 514. Kussmaul, 494. La Chapelle, Mad., 33,37, 268, 431, 602. Lamsweerde, 294. Larcher, 225. Laserre, 689. Lawrence, 710. Le Blanc, 262. Le Cat, 101. Le Gallois, 16. Lebert, 194, 293. Leconte, 136. Lee, Rob., 87, 476, 481, 681. Lenoir, 19. Levret, 158, 449, 632. Liebig, 684. Lobach, 220. Lopez, 442. Lorain, 685. Lower, 715. Lugol, 713. Macaulev, 666. Mackenzie, T. "W., 711. Martin, Ed., 400. Martin, M.. 417, 402* Mattei, A.,'517, 542. Maunsell, 628, 630. Mauriceau, 34, 283, 627. Mayor, 187. McClintock, 403, 447*. Meckel, 126. Meigs, Prof, 30, 91, 301, 570, 686. Meissner, 117, 675. Mende, 312, 442. Merriman, 301, 438, 581, 628, 668. Mettenheimer, 285. Mialhe, 262. Mills, Ch. S., 635. Minot, 429. Monro, 115. Montgomery, 91,115,119, 152, 178, 305, 365. Morgagni, 292. Morton, W. T. G., 709. Mott, Valentine, 538. Miiller, 87, 113. Murphy, 301, 628. Murray, 240. Naegele, 36, 38, 42, 48, 65, 188, 305, 342, 348, 373, 386. Naegele, Jr., 373, 716. Nauche, 135. Newport, 117. Neubert, 104. Nuck, 119. Ogle, 264. Osborn, 67, 619, 627, 652. Osiander, 410. Otis, 429. Ould, 627. Outrepont, 396. Paget, 285. Pajot, 96, 134. Palfyn, 598. Parent-Duchatelet, 173. Petit, 343. Philan Dufeillay, 643. Pitcairn, 506. Plater, 292. Porcher, 386. Pouchet, 115. Power, Dr. John, 101, 314. Priestley, 320. Prevost, 115, 401. Puzos, 218. Querenne, 421. Quetelet, 28. Raciborski, 98. Radford, 476. Raige Delorme, 717. Rainard, 173. Ramsbotham, 39, 348, 442, 444, 562, 673 Rayer, 510. Read, 442. Regnauld, 134. Reid, Jas, 305 Ricker, 539. Ricord, 173. Riecke, 33. Rigby, 66, 360, 386. Ritgen, 667. Riviere, 221. Roberton, 16, 96. Robin, Ch., 115, 149,194, 262, 284, 505,511. Rodericus a Castro, 708. Rodier, 129, 134. Roger, 31. Rogers, ¥m. C, 371. Rokitansky, 294. Rouget, 82, 84, 90. 119. 170, 262. Rousset, 632. Royston, 177. Ruleau, 632. Salomon, 386. Sankey, 717. Savonarola, 135. Scanzoni, 34, 35, 67, 191, 253, 348, 395, 461, 663. Scholer, 367. Schwartz, 471. Schwerer, 539. Semmelweiss, 686. Sharpey, 242. Siebold, 710. Sigault, 622. Simon, 633. Simpson, Prof., 28, 35, 39 184, 220, 253, 301, 312. 435,471,475,514,544, 722. Sinclair, 340. Smellie, 598, 627. Smith, Stephen, 429. Smith, Tyler, 39, 292, 312, 432, 443, 467. Snow, 722, 723. Spallanzani, 115. Stokes, 697. Stoltz, 36, 38, 87, 168, 666, 67 ff. Storer, H. R., 678. Struve, 717. Sydenham, 506. Szukiss, 97, 100. Tanner, 273. Tardieu, 682. Tarnier, 685. Tenner, A, 494. Tessier, 302, 682. Thomas, T. Gaillard, 464 Tiedemann, 87. Todd, 115. Tournie, 228. Trask, Prof. Jas. D., 471, 477, 573. Trousseau, 685. Valentin, 115, 117. Valleix, 711. Van Pelt, Jos. K. J., 30 Van Swieten, 131, 144, 268, 294, 304, 541. Veit, Dr., 28. Velpeau, 24, 188. Verdeil, 262. Virchow, 83, 194, 204 206, 253. Vogel, 691. Vogt, 246. Von Glisczynski, 470. Von Ritgen, 373. Webb, Prof, 10S. "Weber, 242. Weidemann, 251, 627 Wells, Horace, 709. West, 42, 453. White, J. P., 452. White, of Manchester, 709. Whitehead, 266. Wigand, 542. Yvrilliams, C. J. B., 506. Wright, 541. Wyer, 717. Young, 712. SUPPLEMENT TO CATALOGUE OF AUTHORS REFERRED TO AND QUOTED. Albers, 710. Andral, 716. Bland, 717. Bouillaud, 710, 716. Callisen, 712. Carriere, 716. Collins, 402.* Cullen, 715. 4 Davis, Professor, 710. Duges, 710. Duncan, J. Mathews, 446. Duparcque, 712. Duplay, 718. Elsberg, L., 401.* Faust, C. J., 447. Forbes, 717. Frye, 709. Good, 712. Guthrie, 710. Hippocrates, 708. Hoffman, 715. Hull, John, 709. La Chapelle, Mad., 402.* Lee, Robert, 710, 712, 717. Levret, 708,709,712. Lower, 715. Lugol, 713. Mackenzie, T. W., 711. Majendie, 715. Mauriceau, 708, 709, 712. Morgagni, 715. Naegele, Jr., 716. Philips, 717. Puzos, 708, 709, 712. Rayer, 712. Rodericus a Castro, 708, Sankey, 717. Siebold, 710, 717. Struve, 717. Van Swieten, 715. Virchow, 711. Von Ritgen, 716. White, of Manchester, 709, 712. Wyer, 717. Young, 712. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. LECTURE I. Midwifery an Exact Science—The Passage of the Child through the Maternal Organs is founded 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. Gentlemen—The science of Midwifery, so far as it relates to the expulsion of the child and its appendages through the maternal organs, is an exact science. Expulsion is both a physiological and mechanical act, and is the product, in part, if I may so term it, of a play of certain physical principles. What, in fact, is a natural delivery, but the operation of a motive-power acting on a body with the view of causing its passage through a given space ? This motive-power is the contracting womb; the body is the fetus; the space consists of the bony pelvis, and the various soft parts directly connected with the parturient effort. But no force which the uterus can bring to bear will enable it to accomplish the delivery of the child, unless there be a proper proportion between the foetus and the organs through which it has to pass; and, therefore, it may be asserted, that the natural expulsion of the child through the maternal organs is the result of adjustment; or, in other words, of a correspondence between the various portions of the foetus, and the canal through which it makes its exit. If this be so—and the further we progress in the investigation of the subject the more convinced will you become of the truth of the proposition—it follows, as a necessary consequence, that the paramount duty of the obstetric student is to study nature, and understand the admirable mechanism she has instituted for the purpose of securing to the child a safe transit through the maternal passages. With a knowledge of this mechanism he will be enabled, 1 2 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. when nature is contravened by circumstances beyond her control, to act as her substitute; and, by judicious interference, to save the lives of both mother and child. Without this knowledge, on the contrary, his interference would be criminal; for it could lead to nothing short of disaster or death. Allow me, then, thus early to urge upon you a profound respect for nature ; her temple is the proper place for the student of midwifery; there it is that she discourses most eloquently, though silently, and the best obstetri- cians will be those who have worshipped the most zealously at her shrine. Our science is but the portrait of nature, and the fidelity of the picture is commensurate with the skill of the artist. As preliminary to a proper appreciation of the mechanism of labor, it will be necessary for you to become thoroughly acquainted with the anatomy of the human pelvis, both as regards its bony structure, and the various soft parts directly connected with it. The foetus and its annexse, together with the uterus and its appendages, will also constitute topics for attentive study. Before commencing a description of the individual bones of the pelvis, it may not be out of place to direct your attention, for the moment, to the position it occupies in the skele- ton. It is situated at the inferior ex- tremity of the vertebral column, with which at its posterior and upper sur- face it articulates, forming, at this point of union, an important projec- tion known as the sacro-vertebral prominence, to which we shall have occasion, hereafter, more particularly to allude. The pelvis is supported below by the two femoral bones, the heads of which are respectively re- ceived into the acetabula. Thus, it forms the lower boundary of the abdominal cavity, and at the same time affords accommodation to the rectum, the bladder with its excretory duct, the uterus, etc. This position of the pelvis is not without interest, for you cannot but observe the signal advantage it imparts to the parturient woman, in the efforts neces- sary for the expulsion of the child. In consequence of the two important emunctories or outlets, the bladder and rectum, being Fig. i. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 3 situated within its cavity, nature is enabled, at the time of child- birth, to bring into active exercise, in addition to the contractions of the uterus, the various muscular forces employed in the expul- sion of the excrements from the system. By reference to Fig. 1, it will be seen that the pelvis, in the upright position, presents a marked obliquity to the horizon, form- ing what is sometimes described as the inclination of this canal. The perpendicular line, exhibiting the axis of the trunk, instead of passing through the centre of the upper plane or strait, falls on the symphysis pubis, while the line which really represents the centre of the plane, intersects the perpendicular at an acute angle. When it is recollected that the usual position of the female is the erect one, the advantage of this inclination of the pelvis, during the period of pregnancy, will at once be appreciated; for, if the axis of the superior strait and that of the trunk were identical, the necessary physical result would be the descent of the gravid uterus into the pelvic cavity, causing undue pressure on the adja- cent viscera, and other pathological derangements, which would materially interfere with the full development of a healthy gesta- tion. Bones of the Pelvis.—The adult pelvis is composed of four bones, viz. the sacrum, coccyx, and two ossa innominata. The two former constitute the posterior wall of the pelvis, while the innominata, one on each side, form the lateral and anterior bounda- ries of the canal. You will read in the books that, while the adult pelvis has but four bones, the foetal pelvis numbers fourteen. The reason of this difference is easily explained. In the system of the young subject, ossification not being complete, the sacrum presents very distinctly five pieces, and the coccyx three, making, for these two bones, eight pieces: while each os innominatum presents three divisions, making, for the two innominata, six pieces; so that, five for the sacrum, three for the coccyx, and six for the inno- minata, give the fourteen of which the foetal pelvis consists. But, when the process of ossification is completed, which occurs about the time of puberty, these various divisions become consolidated ; so that, in adult age, the pelvis is composed only of four bones, instead of fourteen, as was the case in early life. The os sacrum (Fig. 2) is triangular in shape, situated at the posterior and central portion of the pelvis, below the last lumbar vertebra, above the coccyx, and wedged in, as it were, between the two ossa innominata. Its structure is mostly spongy, covered by a thin layer of compact tissue; hence, proportionate to its size, it is remarkable for great lightness, which is increased by th• onth THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 145 nant she ceases to have " her turns"—that in cases in which a female desires to conceal her situation, she will sometimes mark her linen with blood, in the hope of imposing upon the practitioner and others, in reference to her true condition. Is Ovidation incompatible with Gestation ?—It would seem in perfect keeping with the physiology of ovulation that this function, as a general rule, should cease as soon as fecundation has been accomplished, and its suppression continued during the entire period of the gravid state. The relations of the uterus and ovaries, when fecundation has been effected, become, for the time being, changed. The former constitutes a new centre, and there is a constant increase of fluids toward it in order that it may be enabled to accomplish the nutrition and development of the fetus. The ovaries, on the contrary, although they do actually become enlarged during pregnancy, surrender their special function—the periodical ripening of the ovules. This, I repeat, is undoubtedly the rule; but, like all rules, it has its exceptions. The fact that a menstrual flow is possible in gestation necessarily involves the admission of ovulation; for the sanguineous discharge which ordinarily cha- racterises the menstrual period is but the product of ovulation. At the same time it must be admitted that the regular catamenial evacuation through the term of pregnancy must be regarded as an extremely rare exceptional circumstance; and when it does con- tinue after the early months, the discharge of blood can only pro- ceed from the cervix or upper portion of the vagina, the connex- ion of the ovum writh the internal surface of the organ being such as to prevent any portion of this surface from constituting the source of the discharge. As menstruation, when it takes place during pregnancy, is most apt to occur in the first two or three months, it might possibly be confounded with a threatened miscarriage; the distinction, how- ever, would consist in the more or less regularity of its recurrence, and its periodical cessation, together with the fact of an absence of any appreciable cause to which the discharge of blood could be ascribed. It should also be recollected that the appearance of the catamenia, in consequence of the congestion accompanying it, would itself, in the earlier period of pregnancy, be likely to provoke miscarriage. Hence, in cases like these, the importance of sound judgment; let the patient, at the time, be kept quiet, and, if ple- thoric, the abstraction of a small quantity of blood, with a soluble condition of the bowels, would be indicated. If, on the contrary, she be in an opposite condition—nervous and irritable—then the soothing influence of antispasmodics or anodynes is the resource. There are, however, other conditions of the uterus than a threatened miscarriage, which might possibly be mistaken for the catamenia—such as a polypus, ulcerated carcinoma, or even a 10 146 THE PRINCIPLES AND PRACTICE OF OBfeTETRICS. fibrous tumor developed within the uterine cavity, each of which would be accompanied with more or less sanguineous discharge, and it may also be added that the hemorrhage consequent upon placenta praevia might, under certain circumstances, lead to embai rassment in diagnosis. Menstruation only during Pregnancy.—The experience of Dewees, Baudelocque, and others, seem fully to establish the circum- stance—and examples are given by these writers—that, as exceptional cases, some women menstruate during their gestation and at no other time. Deventer cites a remarkable case in which menstruation occurred during gestation only, in four successive pregnancies. In- stances, well authenticated, are also recorded showing the possibility of impregnation before the first menstrual eruption, and also after the final cessation of this function, so far, at least, as the sanguineous discharge is concerned; and, again, you will meet sometimes with examples of pregnancy during the period of lactation before the reappearance of the catamenia; so you see, gentlemen, that the cata- menia, whether present or absent, establishes nothing, per se, 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, with Depraved 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 vomiting 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 montus 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,J 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. X " 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 OBSTETRICS. 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 among 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 ptyalism or 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 fetor, 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, peradventure, 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 mamma? 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 Secretion of Milk—The 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 V' i,/\TK Kifth .Month J '*■:'' A K E 0 L A OT T EIE B RE A S T 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 annexa? 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- mae 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 vrhile 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 which 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. R. 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- menial 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 effect of restoring the function, entirely removing the engorgement of the mamma. I have seen several cases of hypertrophy of the breasts following amenorrhoea, and the hypertrophy has always yielded on the restoration of the menstrual function. f Baudelocque, L'Art des Accouchemens, torn, i., p. 188, in 8w. 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 may be 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 dysmenorrhcea dependent upon chronio 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 Boon 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: if 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 what 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 wThole 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 pari * Signs and Symptoms of Pregnancy. 2d Edition, p. 97. Sev-fnth Month. '2B. .' •>-'-t [ dicale, p. 168. 1857.] 214 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, which consists in an incision of the abdominal walls for the purpose of extracting the fcetus, and thus equalizing the chances of life between it and its parent. Now, this is a mode of procedure which should not be resorted to Avithout 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—there 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 power 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 advisable to make an incision into the vagina, and remove it through this passage; and this will be more particularly indicated in cases in which the fcetus can be felt distinctly pressing down 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 fcetus through the vagina—made an incision into the vaginal wall, and also into the oyst, with a view of terminating the delivery by means of the forceps. He soon found, however, that there were firm and resist- ing adhesions between the head and sides of the cyst, which caused him to abandon the operation. In the course of a few 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 was convales- cent in two months from the time of the operation. * In the interstitial and fallopian varieties of extra-uterine foetation, the cyst is supplied 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 which the operation of gastrotomy may be resorted to. Suppose, for example, after having carried the fcetus 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 whether it would 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 with but one motive to govern that judg- ment, viz. the greater welfare 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 weeks 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 warm fomentations, and, if necessary, opened, so that a passage may be afforded to the fcetus; 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, when 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 with success. He records thirty cases in which gastrotomy was performed, or the breach dilated, and of these, twenty-eight recovered. In twelve cases of gastrotomy, resorted to after the suppurative process was well advanced, ten were successful. In nine cases operated on, when the fcetus was still alive, or soon after its death, all were fatal. * Medical Times and Gazette, London, July, 1860. | 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 Pregnane}'— 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—Larcber's Opinion respecting Hypertrophy of the Heart—Pain in the Abdominal 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. Gentlemen—I have remarked, in a previous lecture, that preg- nancy cannot, strictly speaking, be regarded as a pathological or diseased state. But while this fact is conceded, yet, on the other hand, it is not to be forgotten, that many of the sympathetic phenomena characteristic of gestation will 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 while 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 workings of the system in health, that it becomes converted into a pathological result. Let us illustrate this point. You know very well, that the im- portant office of the kidneys is to secrete urine, through which 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, we should clearly have substituted a pathological state for what, under ordinary cir- cumstances, is strictly a physiological function. The same thing occurs frequently in pregnancy. For example, there is scarcely a sympathy evoked 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 with 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 was 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 were predicated upon this basis their views 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 woman in the fourth, seventh, and end of the ninth month—these being the respective periods in which 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 were 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, which 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 which these organs are more or less in close sympathetic alli- ance. Then, gentlemen, so far from teaching these crude generalizations of the ancient school, which 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 218 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. circumstance complicating that condition, which broadly indicates the necessity of loss of blood. For instance, in all acute diseases, in cases of actual plethora, as shown by the bounding pulse, flushed countenance, headache, etc.; in threatened abortion, with 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, with good effect. Cathartics.—It was 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, which were supposed to be due to a constipated state of the bowels. 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 will 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 without 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 know how 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 few months since : A married lady, aged twenty-seven years, one year married, was in her seventh month of gestation. Her health had always been good, and particularly so since her marriage. Nothing of any im- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 21.9 portance occurred during her pregnancy, with the exception of the ordinary phenomena incident to this* condition, until the night of Dec. 23d, when, being in her seventh month, she was suddenly attacked, while in bed, with vertigo, followed by loss of conscious- ness, and stertorous breathing. But a few minutes elapsed before I was 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 word, 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 always. 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 which I was 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 warm water, and, with some little difficulty, caused her to swallow it. In a few moments it took effect, and you would 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 went on to her full term; and I had the pleasure, in two months from that time, of presenting her with 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, would have sacrificed two lives, and thrown into the deepest grief a devoted husband, whose anxiety on the occasion bordered almost on bewilderment. To show you that emetics are not incompatible with 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, when indicated, with as little reserve as under any other circumstances. I shall now briefly allude to some of the disorders of pregnancy, which 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 within 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; two 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 with laudanum; chloroform, em- ployed in the same way, has been found useful. Equal parts of lemon juice and cold water, say a tablespoonful of each, or the same quantity of lime water and milk, two or three times a day; two or three drops of tincture of nux vomica, every two 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 with very striking benefit. Its strength should be 3 j. of belladonna to § i. of adeps; a small por- tion to be smeared on the cervix once or twice a day, a& may be indicated. It should be applied with the finger, and not through the speculum, for the reason that this instrument may, especially THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 221 in sensitive women, induce premature action of the uterus. The following, known as the potion of Riviere, has been in much repute, and may be resorted to oftentimes with advantage: R. Acid Citric.........gr. xxxvj Syrup. Sacchar........£3 viij. Potassae Bicarbonat......gr. xxxvj Aquae Destillat........f. f iv. The citric acid to be dissolved in one half of the water, av>d then add the syrup; the bicarbonate of potash to be dissolved in the remaining portion of water, and a tablespoonful of each adminis- tered successively. Should the vomiting be aggravated by a con- stipated condition of the bowels, 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: R. Pil. Colocynth Comp., ) r _ _jr l '>-... 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 two 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 will occasionally, gentlemen, meet with cases of rebellious vomiting, accompanied by a distressing weight in the vicinity of the uterus, with 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 very 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. He 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 'he inflammation. 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 bowels, 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 bowels during gestation is the exception, while a ten- dency to constipation is the general rule; and if this be so, the true reason of this circumstance is certainly worthy of a moment's thought. Not 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 without occasion- ally bringing about more or less derangement in the healthy or natural functions of the particular organs with which 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 bowels 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 will 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 water, and again one or two of the follow ing pills may be administered according to circumstances: R. Massae Hydrarg., ) .. „ . J °' Uagr. xn. Saponis, r e j 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 with 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, with 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 bowels; whether the pain and tenesmus have continued for several days; and if you have reason to believe the rectum to be filled with faeces without 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 fiecal matter, or, if you prefer it, you may introduce a small spatula, and thus rid the rectum of its contents. 4. Diarrhoea.—Pregnant women are occasionally subject to an opposite condition of the bowels, viz., diarrhoea; and it is well 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. Have 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 faecal matter, and more or less profuse diarrhoea will 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, sweep the wThole intestinal canal, remove the offending cause—the accumulated fiscal matter—and you will not only arrest the diarrhoea, but restore your patient to health. There 224 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. is, however, gentlemen, what may be called the diarrhoea 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 will 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 tablespoonful of the following mixture may be given with good effect two or three times a day: R. Cretae Misturae, f § vj. Tinct. Opii, 1 " Catechu, Vaaf3j. " 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 followed 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 with the use of saline cathartics and moderate diet. The quantity of blood to be abstracted must rest with the judgment of the practitioner. In the latter months of gestation the female will oftentimes complain -of distressing palpitation, which 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 may be 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 walls 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 with this opinion is, that the hypertrophy of the left ventricle will explain the bellows sound so frequently detected in gestation, and which, therefore, is not to be regarded, in this case, as necessarily connected with fatal organic lesion of the organ. 6. Syncope.—Young married women, in their first pregnancy, are very apt to be attacked with 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 week 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, while again it will continue for a longer period, producing much disquietude on the part of friends. It may take place at any time, and without 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, where it was well ascertained that organic disease of the heart had previously existed.f It is, however, not without danger, under certain circumstances, to the child ; for example, when the syncope is long continued, the inter- ruption of the proper supply of healthy blood to the fcetus may result in its destruction. Allow me, here, to call your attention to an important distinction between 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 Medicale de Paris. 1857. p. 258. f It is proper to mention that there are some few cases recorded of sudden death from syncope during pregnancy, the syncope being the result simply of emotion. 15 226 THE PRINCIPLES AND 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. 7. 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- fering, and the practitioner must be careful not to confound it with 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 sweet 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 warm, will be yery servicable. 8. Relaxation of the Abdominal Parietes.—You will, in women tvho 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 known as anteversion, which, if not remedied, will, 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 when speaking of the causes of obstructed delivery. The remedy for this relaxed condition of the abdominal walls is proper support; it can be afforded by the employment of a broad elastic belt which, 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 upward and back- ward with a view of restoring it to its normal position. 9. Painful Mammas.—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, great local distress, producing at times fever, and other consti- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 227 tutional disturbance. In these cases, you will 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 with some liniment, camphorated oil, laudanum and sweet oil, or a poultice of crumbs of bread, saturated with 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 with 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 will sometimes manifest itself during pregnancy, and, in its aggravated form, it will constitute one of the most pain- ful affections with 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, wrill be observed on the inner surface of the parts, where, 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, the 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 worms will pass from the rectum to the vagina, and two cases have recently been published by Dr. Vollez, in which 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-indicate it, the abstraction from 5 iv. to 3" vi. of blood from the arm, together with saline cathartics, and a lotion applied freely of 3 i. of the borate of soda to Oj. of water, with 3 i. of Magendie's solution of morphia, to be followed by good results. When the parts are ulcerated, I always touch the ulcerated surface with 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 with Castile soap and water, 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 will fail in affording relief. Tonics, together with nutritious diet, will be indicated. There will occasionally be developed a form of pruritus of the genital organs, assuming the character of eczema, which is extremely difficult to manage, often proving obstinately rebellious to remedies. In this particular condition of things, the following treatment has been proposed by M. Tournie, and which 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 with scabs, emollient poultices are first to be employed; when the scabs are removed, the ointment is to be applied twice a day, 3j. of calomel to ^j. of lard; after each application, a powder, 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 woman, there are two 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 always followed by a diminution in their volume, and consequently a lessening of the irri- tation and pressure. Occasionally, however, the bleeding will 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 1RACTICE OF OBSTETRICS. 229 state. In such case, too prompt attention cannot be directed toward the arrest of the hemorrhage. One of the first indications to engage the attention of the practi- tioner in hemorrhoids is to overcome the constipation, and keep, if possible, the bowels soluble, for, as long as the torpor continues there will be but little hope of benefit from local applications; the recumbent posture will also be of service in measurably removing the amount of pressure exercised by the uterus. If the tumors be large, and from their tension occasion much suffering, one of the most effectual remedies will be the application of from two to four leeches, depending upon the judgment of the practitioner. An efficient remedy, also, will be an injection, night and morning, into the rectum, of half a pint of cold water, and the introduction, for two or three hours each day, of the metallic rectum bougie. I regard these latter means of very great value in the treatment of hemorrhoids, especially when they are internal. When it agrees with the stomach, sulphur will be found an excel- lent medicine to administer internally—a teaspoonful may be mixed with honey or molasses, and given once or twice a day. It is gen- tle in its operation, and will, in many cases, exercise a happy influ- ence in diminishing the volume of the hemorrhoids. Let me here enjoin upon you a most important direction, the neglect of which oftentimes, I am sure, leads to much unnecessary suffering on the part of the patient; the direction to which I allude is this : always, after each evacuation of the bowels, instruct the female to intro- duce the protruding piles within the rectum; this can usually be accomplished without difficulty, except in cases in which the tumors have attained a large size. You perceive at once the advantage of the practice. If the tumors remain external to the anus, the conse- quence is they become subject to the full pressure of the external sphincter muscle, and it is this very pressure which so often aggra- vates the intensity of the suffering. Much vesical irritation will sometimes ensue from the presence of the piles, and, unless your attention be specially directed to the circumstance, you will fail in giving relief to the bladder, for the reason that, in lieu of regarding the irritation as simply symptomatic, you will most likely mistake it for, and treat it as, an idiopathic or primary affection. The remedy. of course, is the relief of the piles. 13. Varicose Veins.—Women, during the period of their gesta- tion, are subject to enlargement, or a varicose condition of the veins of the lower extremities. It is the result of the mechanical pressure exerted by the uterus. This enlargement of the venous trunks is, however, not always confined to the lower limbs. It will sometimes be observed in the lower portion of the abdomen, vulva, and vagina. These varicose veins are most likely to develop them- selves during the latter four months of pregnancy, when the pres- 230 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sure is greatest; but they Avill also be observed during the earlier months, particularly in cases in which, as will sometimes happen, there is a predisposition to their formation. The great remedy is a uniform and well-directed pressure, in order that due support may be given to the distended trunks. A properly-adjusted lace-stock- ing will be found well adapted for this purpose, or an ordinary roller bandage, commencing at the toes and continuing up to the knee. In cases of fulness of habit, the occasional abstraction of blood, and saline cathartics will be indicated. It is always advis- able in these cases to allow the patient, as much as possible, to avail herself of the advantage of position—hence benefit will be derived from the recumbent posture and, even when sitting, she should be directed to place her limbs on a chair, so that they may be on a level, or nearly so, with the plane of the body. 14. Cough and Oppressed Breathing.—Some women, and this is more especially the case in nervous, irritable constitutions, are very apt to be troubled with a cough in early pregnancy. This cough is peculiar, and is well worthy the attention of the practi- tioner ; it may, in strict truth, be denominated a nervous cough; it is usually dry, unaccompanied by expectoration, except in some instances there will be a slight sero-mucous discharge; it is parox- ysmal, without fever, and, on an exploration of the chest, there will be an entire absence of all the physical signs, indicating organic lesion of the pulmonary apparatus. Now, what is this cough, and how is its presence to be explained ? It is, unquestionably, one of those examples of sympathy evoked in distant organs, by irritation of the uterus, to Avhich your attention has been so repeatedly directed. This character of cough will sometimes continue rebel- lious to all medication during the whole period of gestation—at other times, it will spontaneously become arrested at the third or fourth month. In cases in which the irritation of the uterus is very marked—as will be evinced by local pain, bearing dowxn, and gene- ral uneasiness about the hips, I have found either the injection of laudanum into the rectum, thirty drops to a wine-glass of tepid water, or the application of belladonna ointment to the cervix uteri, in the proportion of 3j. of the extract to ^j. of lard, very efficient in relieving the cough. The internal administration of the tincture of hyoscyamus, thirty or forty drops in half a wine-glass of cold water, as occasion may require, is also a good remedy. But, gentlemen, during the latter period of pregnancy, especially in the two last months, there will frequently be a cough of a differ- ent kind—it arises from the mechanical pressure of the uterus against the diaphragm, thus encroaching upon the capacity of the chest, and resulting in irritation of the lungs, which, of course, occasions more or less cough. Accompanying it, there will, also, be a feeling of oppressed respiration. Patience here is the most THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 231 certain remedy, for these symptoms will cease as soon as delivery is accompHshed, and frequently in the last two weeks previous to labor, because of the descent of the gravid uterus into the pelvic excavation, thus removing the mechanical disturbance from the diaphragm. However, both the cough and dyspnoea may be pal- liated by keeping the bowels in a soluble state, and if the patient should be disposed to plethora, occasional abstraction of blood will be serviceable. LECTURE XVI. 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. Gentlemen—In the previous lecture, mention has been made of some of the ordinary disorders of pregnancy, arising more or less from sympathetic and mechanical influences, exercised by the gravid uterus on various organs of the economy. We shall now direct your attention to the consideration of other complications of gesta- tion, the result of displacement of the uterus itself. You are well aware that this organ, from its peculiar situation and relations, enjoys a remarkable degree of mobility, and is, therefore, liable, especially in its unimpregnated state, to various displacements ; examples of these you have had repeated opportunity of observing in the Clinic. The uterus is, also, subject to malpositions during the period of pregnancy, and these, although much less frequent than when ges- tation does not exist, are yet attended by more serious consequences. There are three forms of displacement to which the gravid womb is exposed, and it is proper that you should understand their par- ticular bearing upon gestation: 1. Prolapsus; 2. Ante-version; 3. Retro-version. 1. Prolapsus Uteri.—There are three degrees of prolapsus in pregnancy, as there are in the unimpregnated condition; in the first, the uterus has fallen slightly below its normal position ; in the second, it has passed to a level with the vulva; and, in the third, i is completely out of the vulva, constituting a veritable procidentia. The causes of either of these varieties are numerous—such as relaxa- tion of the vagina, or ligaments of the uterus, the presence of tumors in the abdomen, habitual constipation, falls, or blows. When speaking of the changes produced in the uterus in early pregnancy, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 233 you will remember we noted very particularly the important cir- cumstance that, for the first two months, the tendency of the organ is to descend into the pelvic excavation; and this very descent, which is one of the ordinary phenomena of early gestation, may act as a predisposing cause to either of the varieties we have named. As a general rule, the uterus, in the first two varieties, usually, about the fourth month, undergoes spontaneous restoration, by the gradual ascent of the organ into the abdominal cavity. Sometimes, however, this is not the case; and when the uterus presses on the vulva, serious inconveniences will result. For instance, the rectum becomes irritated, giving rise to constipation, and an annoying tenesmus; the bladder, also, is affected. Sometimes, there will be, more or less, a constant desire to pass water; at other times, there is complete retention of urine, requiring the introduction of the catheter. In these cases, it is of great importance to attempt the replace- ment of the uterus, for the obvious purpose of removing the pres- sure from both the rectum and bladder. With this view, the practitioner should gently grasp with his fingers, previously lubri- cated with oil or lard, the cervix of the organ, and make uniform pressure, at first a little backward, and then upward, in a direction parallel to the axis of the superior strait. The patient should be kept in the recumbent posture, and a sponge-pessary introduced, which may be retained in situ by means of the T bandage. It should not be forgotten to have the sponge removed at least once a day for the purpose of cleansing it. After the fourth month, its use may generally be dispensed with, for the uterus, havino- as- cended above the superior strait, will usually remain in the abdomi- nal cavity, without 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 with 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 below 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 doAvnward. You per- ceive, therefore, that without 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 which would most likely ensue from a forced attempt to overcome the difficulty. The catheter, under these circumstances, should be introduced at first horizontally, from before backward, 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 with 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 with the fingers, and making pressure from before backward, parallel to the axis of the inferior, and then upward 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 how 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. H. Ante-version*—Ante-version of the uterus is comparatively of rare occurrence in early pregnancy ; although you occasionally meet with it in women who have borne many children, and whose abdominal walls are consequently so much relaxed as to be inade- quate to afford the proper support to the ascending organ, and it, therefore, falls forward, giving rise to two conditions: 1st, Ante- version ; 2d, An increased prominence to the abdomen. If ante- * There is a broad difference between ante-version and ante-flexion of the 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 which 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 backward; and secondly, an ab- dominal brace, or bandage, is to be appfied for the purpose of retaining the uterus in situ. ni. Retro-version.—Retro-version is much more frequent than ante-version, and may occur in the virgin, in the married woman, who is not pregnant, and it may also complicate pregnancy itself. It is most common when 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 which it rests more or less horizontally in the pelvic excavation, the fundus being directed toward the sacrum, and the cervix regards the internal surface of the pubes. This displacement, when complete, divides, as it were, 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 whether 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 violent move- ment may also produce it. Retro-version will, sometimes, be con- genital ; it is almost always, 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 weight. When this displace- ment has taken place, it is accompanied by symptoms, which, to the 236 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. vigilant practitioner, will generally indicate its nature—for example, there will be more or less uneasiness experienced about the loins, and oftentimes a dragging sensation, irritation of the bladder and rectum, with difficulty in evacuating either; sometimes, it will be 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 impossibility of drawing it off 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, which proved fatal, is mentioned by Dubois, as having been communicated to him by Dr. Mayor. There are examples of this displacement, in which death occurred from the severe local inflam- mation, and consequent constitutional disturbance, resulting from pressure of the retro-verted womb. It will sometimes happen that the uterus, from the serious irritation to which it is exposed, will be thrown into premature action, thus ridding itself of its contents. This, in cases in which it becomes impossible to reduce the mal- posed organ, should be regarded as a most fortunate issue, for it will 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 that she was three months pregnant. A catheter could not be intro- duced, and 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. [Lond. 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 backward. 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, however, 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 wrong. Having told you in what retro-version 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 will be the evacuation of the bladder and rectum, more especially the former. But this is not always readily accom. plished, for the reason that the distended bladder ascends obliquely upward 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 will be inevitable without relief to the bladder, the very 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 faeces may be scooped out with 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 followed 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, with the view of pressing the fundus of the womb 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 be brought a little downward and backward. This simple manipula- tion, adroitly performed, will sometimes result in the restoration of the retro-verted uterus, but not always. 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 following manner : a small rod about twelve inches in length has fastened to one extremity a sort of mop made of fine old linen, and Avell smeared with oil or fresh lard; this tampon is then gently introduced into the rectum; of course, it is soon brought in contact with the lower surface of the malposed organ, and with a uniform but judicious upward and forward pressure, Evrat and others have succeeded in giving to the uterus its natural position. It is, however, to be recollected that, while 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 downward 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 with a view of affording escape to the liquor amnii, and with 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 which it is absolutely impossible to rupture the membranes through the cervix, which, although difficult in this form of mal-position, may, with due care and perse- 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 which shall be the exercise of a uniform pressure simultaneously on the entire lower 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 places 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, with an air reservoir, and a tube, to each of which are attached small taps. The collapsed pessary, having been previously placed in warm 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 way 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 retro-version exists, when, in fact, there is no displace- ment whatever; 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, who have treated their patients for this supposed mal-position, when, upon examination, I have discovered that the symptoms, which had been mistaken for those of retro-version, were clue to circumstances with which dislocation of this viscus had no sort of connexion. Two of the most prominent causes of error will be: 1st. A collection of faecal matter in the rectum ; 2d. A prolapsion of the ovary into the recto-u,terine 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, with fre- quent desire to defecate, together with tenesmus. How, then, is the diagnosis to be determined—and in what way is the true nature of the difficulty to be ascertained ? If it be a collection of faecal 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 vagina, run his finger carefully along the track of the rectum, with a view of ascertaining, whether or not it is unusu- ally distended—if the distension be due to faecal matter, he will be enabled to recognise the fact by slightly pressing upon the rectum, which will enable him to separate the different pieces of hardened faeces, and thus become satisfied that it is their presence, which has caused the symptoms to which we have just alluded. Again, in retro-version, while the fundus is thrown backward into the hollow 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 240 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 follow, as a necessary result, if there be no retro-version, that the patient will, at once, experience an absence of the distressing local disturbances. How are we to proceed in our diagnosis of prolapsed ovary ? In this case, if the ovary have 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 upward without 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 always be done with great caution; as soon as it is sufficiently introduced, the uterus, should it be retro-verted, will, of course, while the sound is within its cavity, become righted in its position ; vf, 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 work on obstetric auscultation, cites the instance of an umbilical hernia of the uterus in a female, who had previously borne several children. It appears that while in labor with her second child, she was attacked with an ordinary umbilical hernia; this continued gradually to increase, when, 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 womb, the organ passing out through an opening above the pubes, which opening was 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. 1*1, the following interesting case of umbilical protrusion of the impregnated organ, having occurred in the practice of Mr. G. 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 foetus could be distinctly felt, 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 Fcetus; The Decidua—-Hunter'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 Liquor Amnii; Origin of—Is it derived from Mother or Fcetus?—Casts of the Uriniferous Tubes found in Liquor Amnii—Uses of Liquor Amnii—Various—Does it contribute to Nourish- ment of Fcetus?—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 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. Gentlemen—We shall to-day speak of the annexae, or appen- dages of the foetus. These consist of the membranes, the liquor amnii, placenta, and umbilical cord. Each one of these appendages has its own special duty to perform during the progress of the reproductive evolution ; when this 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 acted 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. Membrana Decidua.—Until quite recently, it was very gene- rally conceded that the membrana decidua was produced in the manner originally explained by Dr. William Hunter. He main tained that this membrane was a new formation, and resulted in the following 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 vera, in contradistinction to another fold, the decidua reflexa. This latter is produced, according to his theory, as fol- lows : 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 tincae, and the two superior and lateral angles, which are continuous with the two fallopian tubes. Under this arrangement, it would 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 ovule 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 which he has denominated the membrana reflexa. This was the exposition of Hunter ; and, as I have already remarked, until within a very short time, it was the accepted theory. Such, however, is the progress of mind, as is constantly deve- loped in the revelations of scientific research, that what was 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. H. and Ed. Weber, Sharp ey, and others,* that, so far from this membrane being the product of a new formation, it is simply the l'esult of a modified or hypertrophied condition of the mucous fining 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 * Miiller'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 folliclea become much enlarged, and there is poured out from them into the cavity of the uterus a fluid, which 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 partiaUy imbedded in the soft, pulpy mucous membrane, constituting the decidua; the particular portion of the decidua with which the ovum thus comes in contact is immediately the seat of increased nutrition, which causes it to grow or spring up around the ovum, not unlike the fleshy granulations, which 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 what Coste denominates the reflexa.* These two layers of decidua, the vera and reflexa, approach nearer to each other as the ovum increases in development, 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 expeUed 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 were, a bed for the ovum in the earHer 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, 1847 244 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ing, furnished by the mother. The chorion, on the contrary, together with the amnion, appertains exclusively to the foetus, 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 foetal 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 office, which is the nutrition 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, which forms, in the first periods of conception, one of its prominent characteristics. These vilfi constitute so many absorb- ing radicules, through which the fluids furnished by the parent are conveyed from the decidua vera to the embryo, thus supplying the latter with 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 within 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 vilfi. On that portion of the chorion, from which 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 with a vascular loop, between which and the umbifical vessels there is a direct continuity; and the blood of the fcetus is forced through the ves- sels in the villi by the agency of the fcetal circulation. in. The Amnios.—This is the most internal membrane of the Fio. 44. ovum; it is smooth and trans- The Amnios enclosing the Fatus. parent (Fig. 44), and is in 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 informing the sheath of the umbi- lical cord. Bag of Waters.—These two membranes, together with the decidua, constitute the envelopes of the foetus during the term of gestation, and, at the time of parturition, they possess an import- ance well worthy the consideration of the accoucheur. For exam- ple, they, in conjunction with the Hquor amnii, form what is known as the membranous sac, or, in more popular phraseology, the " bag of waters." This " bag of waters," as we shaU have occasion to explain when 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 power of resistance, and, consequently, becomes ruptured at the proper time by the simple contractile efforts of the uterus. But it will occasionally happen that, owing to a greater degree of tenacity, it proves rebellious to every effort of the contracting womb, and the accoucheur is called upon to rupture it with 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, which has caUed 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 who 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 well 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 women 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 walls. 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, aU 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 discharge, in fieu of blood, is colorless. 246 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Source of the Liquor Amnii.—The true source of the fiquof amnii appears to be derived from the parent; and it is claimed to be nothing more than an exhalation, or, as Velpeau 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 foetus commingling with 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 fcetus, while in utero, was 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 when cell-development and growth are more active. Whether the liquor amnii be engaged in affording nourishment to the embryo, we shall examine when 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 fcetus against the effects of any sudden concussion, which 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 foetal 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 between 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, which is found to cover the entire surface of the chorion. We, however, are to examine it as it pre- sents itself in the human subject. The term placenta 13 derived from its supposed resemblance to a flattened cake—this name hav- 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 will sometimes greatly exceed these dimensions, while again it will fall short of them. Divisions 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 likewise has received the name of arbores- cent, for the reason that the distribution of the two 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 Fig. 45. Fig. 49. denominated uterine, is in contact with the uterus ; and, while 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 lobea composing it. (Fig. 46.) Blood-vessels of the Placenta.—Physiologically speaking, it may 248 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be said that the placenta is divided into two distinct portions; one appertaining to the fcetus, and the other to the mother ; for, as we proceed further in the examination of this subject, it will be shown that there are two distinct, independent circulations in the organ ; one on the foetal 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 two circulations are independent of each other. I think there is no fact better esta- blished than this absence of continuity of vascular connexion between the parent and foetus. A contrary opinion has been attempted to be proved by the result of injections thrown into the vessels of the umbilical cord, and which 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 shown that, in every case in which the injection has been recog- nised in the vessels of the mother, it was 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 foetus. These circumstances, now accepted as well-demonstrated facts, surely prove the want 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 fijetus, to which your attention will be directed under the head of the foetal circulation. Flourens and others, it may here be stated, have recently shown 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 fcetal and maternal surfaces of this body 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 with 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 th hypertrophied decidua, while the fcetal surface is composed of the vascular tufts of the chorion, which, as it were, are found to dip down into the thickened decidua. So that, in this latter case, there is no difficulty in separating these two portions of the organ. Foetal 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 fcetal surface of the placenta: The villous tufts, which spring from the chorion, and to which allusion has already been made when speaking of this latter envelope, 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, which 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 with an artery on one side, and a vein on the other. In this way, through the increase and extension of the vascular villi of the cho- rion, the fcetal portion of the placenta is formed; while the maternal or uterine originates from the enlargement of the vessels in the hy- pertrophied decidua, between which, as has already been remarked, these villi dip down. Prof. Goodsir says, " these vessels assume the character of sinuses; and at last swell out (so to speak) around and between the villi; so that, finally, the villi are completely bound up or covered by the membrane, which constitutes the walls of the vessels, the membrane following the contour of all the villi, and even passing, to a certain extent, over the branches and stems of the tufts. Between the membrane or wall of the large decidual vessels, and the internal membrane of the villi, there still remains a layer of the cells of the decidua."* This, then, appears to be briefly the mode of origin of the maternal portion of the placenta. But a very natural question now arises—how is the blood con- veyed from the system of the parent to the uterine surface of the after-birth, and what is the particular mode of union between this latter and the uterus itself? It is brought through what 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. \ 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 tho 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 two surfaces—-one belonging to the foetus, 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 tho placenta the elaborated blood necessary for its nourishment and growth in the manner we shall presently explain. Fatty Degeneration of the Placenta.—It is worthy of note that, as pregnancy draws toward its close, the placenta becomes more hard, and its capillary vessels undergo a peculiar alteration, which consists in the appearance of numerous oil globules in the coats of the vessels, constituting what 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 which 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 which 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 which it underwent increase, is about to return to its original size. Dr. Barnes, of London, has recently given the profession two 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, while the other is in connexion with the umbilicus of the child. It is composed of three vessels, two 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 fcetal 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 fcetus. The student is sometimes apt to become confused when told that the vein contains arterial blood, and the arteries are the chan- nels through which 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 appfies, 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 vessel 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 than 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, known 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 volume 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, when the cord is very small or slender, it is because of the entire absence of this infiltration. The ordinary length of the umbifical cord is from fifteen to twenty inches, which is about the average length of the fcetus at full term. But there are occasional exceptions. For example, cases are recorded in which 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 foetus.* 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, 2546 consisted of a simple coil, while in 684 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 five pounds, and in 28 it exceeded eight pounds. Therefore, it is deduced, thai among the causes tending to the occurrence may be mentioned a long funis, abun- dance of liquor amnii, and a small child. Among 2930 children born at Marburg, 132 were dead, and 251 were still-bom 252 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the latter case, in consequence of the extreme congenital shortness of the umbifical cord, there will be more or less hazard of its sudden rupture during the throes of labor in some portion of its extent, 01 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 when treating more par- ticularly of this form of uterine difficulty. You will sometimes recognise knotted cords, that is, there will be observed in the extent of the funis one or several knots, and these are more particularly noticed in cases in which the cord Fiq. 47. exceeds its ordinary length. (Fig. 47.) It is supposed that this latter circumstance, together with the movements of the fcetus, predisposes to the formation of these knots. I have several times Of 725 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, Gottingen, Wurzburg, Berlin, and Marburg, it appears that of 13,720 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 1"39 to the coilings, and 1*19 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 chi^d in forty only can this coiling be regarded as really the cause of death, it follows that this accident is not entitled to prominent consideration. [Monatssclirift fur Geburtskunde.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 253 met with them, but in no instance have I known them to interrupt the circulation between 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 well 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, was 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 with 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- gastricus for the arteries, are described by Schott and Valentin, and, according to the latter observer, they extend three or four inches from the umbflicus, as is revealed by the microscope." Virchow, however, 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 Geburtehilfe, 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 Fcetal 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 Caeruleus— Does the Fcetus Breathe in Utero?—Intra-uterine Respiration not Essential to Development or Life of Fcetus. Gentlemen—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, would divert us from our present object, and we 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, without 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, without 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 various 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 work. It, however, 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 we 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 word, it may be affirmed, that the object of nutrition is three-fold: 1. Growth; 2. Development; 3. Repair of waste. Beginning with the simple cell, the original nucleus, if I may so term it, of the embryo, we perceive, through the successive stages of growth 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, with all the lights which science has furnished, there still exists more or less dis- crepancy among observers. There is one fact, however, not only full of interest, but well worthy of observation, and it is this—that, throughout the whole fife 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 fcetal life. But when nature is unchecked in her operations, this rapid development interferes in no way with the perfection of the work in which she is engaged. In the brief period of nine months, the small cell, through successive increase and develop- ment, is converted into the full-grown fcetus. What an extraordi- nary achievement, and how demonstrative of the power of Him, to whose 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 what I believe to be the accepted opinions, at the present day, on this subject, I shall briefly consider the ovum in three different aspects: a 1. From the moment of fecundation until its arrival within 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, are three dis- tinct periods of development, each one requiring a supply of elements necessary for the nourishment and growth of the new 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 what is known 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 within the cavity of the uterus, a fresh source is found necessary, which 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. Thia 256 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. tuft nutrition is in more or less active exercise until the second month, when a new arrangement is made through the vascular connexions, which subsist between 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 were divided into two sects, as to the mode in which the amniotic fluid entered the system of the fcetus, with 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 well 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 swallowed by the foetus. On the other hand, there are well-authenticated instances in which this fluid has been recognised in the stomach and intestines, in cases of acepha- lous children; and also where 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 cesophagus ; and, secondly, in cases in which 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 wiU commingle with 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 we shall see, are abundantly provided for through this vascular con nexion. Nutrition by the Placenta.—The placenta, as you know, is com- posed of a maternal and fcetal portion, each of these surfaces having its own particular order of vessels, through which 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 shown, 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 between the two orders of vessels on the foetal and uterine portions of the after-birth, in what way the foetus is benefited by this supply of blood, or, in other words, how it finds passage to the foetal system for the purpose of providing it with necessary nourish- ment. This, however, it will be our purpose to elucidate before we complete the present lecture. Adult and Fvatal Circulation.—Allow me now to call your attention to the foetal circulation. This circulation is marked bv certain characteristic differences, which are not found in the case of the child or adult; and these differences are owing to the im- portant fact, that, in the foetus, existence is a dependent one—it has no power of elaborating the blood essential for its maintenance— this is done by its parent. On the contrary, in the healthy, well- organized child, and in the adult, where life is independent, and the individual elaborates its own 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 what I mean by a brief contrast between the circulatory apparatus as it obtains in the adult and foetus. In both, there is a great central organ—the heart; and in both, also, there are two orders of vessels, viz. arte- ries and veins. In the adult heart there are four cavities, two on the right side, and two on the left. On the right side there are an auricle and ventricle, which communicate with 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 with each other, and containing arterial blood. These four cavities com- municate with each other only through the auriculo-ventricular openings. Now, then, let us turn, for the instant, to the arrangement in the fcetal heart. Here, as in the adult, there are four cavities : two on the right and two 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 with 17 258 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the left auricle, through a small opening known as the foiamen ovale. The only difference, then, in the arrangement of the heart proper, as it presents itself in the adult and foetus is, that, besides the auriculo-ventricular openings, there is in the foetus the foramen ovale, which is the point of communication between the right and left auricle. In the adult, the following 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 with 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 cavse, 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, which 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, which is conveyed through the pulmonary veins to the left ventricle ; from the latter, it passes into the aorta, through the ramifications of which it is conducted to every portion of the economy, imparting sustenance to eacl 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 work 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, whose life is independent of its mother. Let us now follow the course of the blood in the system of the foetus. Besides the peculiarities already pointed out in the circula- tory apparatus of the latter, there is the ductus arteriosus, which appears to be nothing more than an extension of the pulmonary artery, and which 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- lowing 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 fcetus. 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 with 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 which is returned to the cava by the hepatic vein ; 3. The blood which 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 two, for the reason that it has already been distributed to the lower extremities. Well, this volume of blood, derived as you have just seen from three different sources, is conveyed by the ascending vena 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 with the foramen ovale, so that the blood it conveys into the right auricle, instead of mingling with 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- ventricular 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 which 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, which, together with the azygos vein, empty their contents into the descending vena cava—this latter conveys it into the right auricle, from which, 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 lower 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 two points connected with the route of the circulation in the fcetus. 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 which 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 which 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 which 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 which 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 how it is that the impure blood, which 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 words, how it is that its decarbonization is accomplished. One of the theories brought forth to elucidate this question was based on the supposi- tion, that the blood-vessels on the fcetal and maternal surfaces of the placenta were continuous with each other ; and, on this assumption, it was maintained that the impure blood was 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 was returned to the placenta, whence, through the umbilical vein, it again made its circuit in the system of the fcetus. The deductions from this theory are utterly fallacious, for the assumption on which 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 with 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 following is the process of elaboration. The impure blood, as you are aware, is brought from the system of the fcetus to the placenta, through the umbilical arteries; these arteries ramify, and communicate by continuity of canal with the radicules of the umbilical vein on the fcetal surface of the placenta; although there is no direct communication between 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 were, in juxtaposition, so that the impure blood in the umbilical arteries becomes Hberated of its carbonic acid, and is supplied with 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, the representative of the digestive and respiratory organs of the adult. 262 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. oxygen percolating the walls 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 foetus is to afford an escape of its deleterious element, the carbon, which, in the form of carbonic acid, passes into the vessels of the mother, which it can do with impunity to her health. The parent, however, is not content with receiving into her own 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, which is known to be essential to fcetal 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, which 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 which the latter derives its nourishment. Robin and Verdeil have demonstrated that what was supposed by Guillot, Le Blanc, and others, to be casein in the blood of pregnant women and nurses, is essentially albuminose, which, 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 fcetus, and there distributed in the manner already indicated. In this simple but efficient way has nature provided, by the constant escape of deleterious, and the constant addition of nutritious matter, for the growth and develop- ment of the fcetus. In addition to the office which 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, would 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 haa been unknown, and w hich 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 the 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., aU of which I hold to be constitutional taints, may be transmitted either by the mother or father; and this will, of course, depend upon whether the former or latter be affected with the malady thus transmitted. For exam- ple, a scrofulous mother will 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: aU 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 propagated 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, which he emits during sexual intercourse, and which, as you know, 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 the 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 shows no recent syphilitic disorder. For if he has communicated a syphilitic taint to the foetus, the mother may become inoculated with it through her offspring, in the manner just described. [Carpenter's Human Physiology, p. 781.] \ 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 othei poisonous matter, the fcetus, which is nourished by that blood, must necessarily be exposed to more or less danger. There is another interesting feature connected with the condition of the blood during gestation, and it is this : It is not uncommon to find women, attacked with 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 fcetus 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 will produce, costeris 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 whole 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 way, 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, while 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 foetal 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, known as puer cmruleus, or blue disease, so called from the circumstance of the defective passage of the blood. Such a result, however, from imperfect closure of the foramen ovale, is not universal, for it has been shown by Dr. J. W. Ogle, and others, that in many adults the foramen still exists, without occasioning any trouble. Does the Foetus 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 without the respiratory move ment. Under ordinary circumstances, the fcetus is deprived of the 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 fcetus 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 the 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 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 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—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. Gentlemen—I shall to-day speak of an interesting affection, one which 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 involve 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 waste of fife it occasions through the destruction of fcetal 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, when we take into account the numerous instances in which 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 intc * 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 below 30 years. The sum of their pregnancies already terminated, was 8681, or 4.38 for each, of which 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 women, 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 would appear that more than 37 out of 100 mothers abort before they attain the age of 30 years; but as 30 years may be considered comparatively young for the child- bearing woman, it is estimated that abortion occurs in nearly 90 per cent, of those females, who 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 well 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 between the seventh, and before the expiration of the ninth month, it is premature labor. Again : a recent author, Guillemot, divides the subject as follows: 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 was denominated simply an effluxion. But we shall leave these refined minutiae for those who like them, and give you what we think to be more in accordance with 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 the expiration of the ninth month, premature labor. This division is founded upon what 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 now generally admitted that the fcetus is incapable of independent existence—in the event of its being thrown from the uterus—previous to the termination of the sixth month ; so that the law 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 wedlock, 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 law—wisely, 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 was brought into the world before the sixth month in consequence of a fright his mother experienced at sea; when born, he was the size of a hand, and he was put into an oven by his father, for the purpose, no doubt, of making him rise. Fortunio, we 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 writers as to the particular period of gestation at which the female is most likely to abort. A good observer, and a clever woman, Madame La Chapelle, announced, as the result of her experience in the Maternite of Paris, that abortions were more frequent at the sixth month than at any other time. Now, it must be recollected that Madame La Chapelle exercised a remarkable influence as a writer. Her statements were regarded with much favor, and, therefore, it can readily be conceived why it was 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 was 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 sweet oil. It was nourished with the 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, nealthy yo ing 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 complete 1 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 women, in a state of pregnancy, are not, as a general rule, admitted into the Maternite in the earlier months of their gestation ; so thattwhile it may be true the records of that establishment do show that the period at which women 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 who 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, will be more likely to awaken, through reflex or other influences, irritation calculated to terminate in abortion ; and this is particularly observed in two classes of patients, presenting two 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, Redi, Prochaska, and others; but it must be conceded that, with- 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 was supposed that all nervous aberrations producing irritation of the spinal cord, were centric, or in other words, 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 without 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—reflex movement. I have purposely called your attention, incidentally at the 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 why 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 known a lady miscarry from bathing in the ocean. Is it difficult to explain the relation of cause and effect between the cold bath and abortion ? It is but another illustration of reflex influence. It is well known, 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 will 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 well 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 between the mammae and uterus wfil, I think, in part explain why a nursing woman 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 pei cent, of cases in which 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 with 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, which 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, however, 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 know is through a reflected, and not a direct action. To illustrate: suppose a pregnant woman receives a blow on the spine, followed 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 why it is that women who 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 know what connection there is between abortion and anaemia. It has been shown that when 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. Brown-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. 272 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. are not due to the anaemic 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 shown that carbonic acid is an excitor of the muscular system, and, in this way, is to be explained the relation of cause and effect between a bloodless condition of the economy and contractions of the uterus. Albuminuria in pregnant women 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 two ways. 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 fcetus, no matter how produced, is to be regarded as one of the most certain of all the causes of abortion ; and with a moment's thought you will perceive how fortunate this provision is ; for the continued sojourn of the embryo in utero, after its death, would necessarily involve, through its decomposition, the safety of the mother, and hence the necessity for its early ejection, You can readily understand the connection between abortion and disease of the placenta. This latter organ is called upon tc perform a most necessary office; and even its partial separation cannot occur without 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- whelmed by an afflux of blood, constituting what has been so well described by Cruveilhier as placental ap>oplexy. 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 which are known to favor a premature expulsion of the ovum ; and secondly, in the event of a miscarriage, to exercise more than ordinary vigilance in the subsequent pregnancies; and what 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 ovum. 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 with 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 assafcetida.* * 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 any specific disease, is assafcetida. The dose 18 274 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Whatever may be the particular cause of the abortion, the phenomena connected with 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 with premature expulsion of the embryo, these two phenomena—pain and hemorrhage*—will almost always, 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 woman 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 and hypogastric region. It is, in a word, nothing more than the contractions of the uterus, either masked or fully developed, and which, you know, 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, which 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 will be for you to determine as to the character of the pain, and whether it portend danger to the mother and embryo, or whether it be transitory, and will 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, whether they really proceed from the uterus; and, secondly, if so, does the uterus contain an ovum, or, m other words, 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 thr<-e to five drachms before arriving at that period of her pregnancy at which she l:;s 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 woman, especially in the earlier months of her gestation, may have a discharge of blood through the vagina without being at all threatened with a miscarriage. This discharge may be nothing more than menstruation, Avhich, you are aware, 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 flow is not profuse, lasting generally but two 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 with an abortion, the first and obvious duty of the accoucheur is to ascertain whether she be in fact menaced, or whether her fears are without foundation. This, of necessity, will involve a just discrimination of her condition—if she have pain, whether 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 wish very emphatically to remark that it can often be accomplished, even when 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 what 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 which 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 now imagine you are at the bedside of a pregnant female, who 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 two phenomena are posi- tively connected with a threatened miscarriage—what 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 which 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 with her hips slightly elevated. Acidulated drinks, such as lemonade, may be given, or a capital compound under these circumstances will 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 with much benefit, under either of the following formu- laries : Acetat. plumbi, 3ij. Aquae destillat. 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-water, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 277 and appfied 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, now, that your patient is plethoric, with more or less febrile excitement; what 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, which 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 well 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 toward it. In addition to the abstraction of blood, give ten grains of nitrat. potassae in a tumbler of water, with vj. gtt. of tinct. digitalis. Let this be repeated every four or six hours, together with abste- mious diet. It may, however, 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 have experienced much benefit from the injection into the rectum of thirty drops of laudanum to a wine-glass and a half of water; lubricating the os tincae and vagina with the ungt. belladon. (3j. extract belladon. to §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. 3 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 bowels by means of an enema. It may, on the contrary, be that the patient 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 would 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 bowels, 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 well adapted to this end. Allow 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 women of an excessively nervous temperament, who 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 primiparm, the uterus distends with less facility than in subsequent pregnancies; and in women 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 without using friction, the hypogastric region with warm sweet 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 view of miscarriage. The treatment which we have thus very summarily suggested, is intended for the prevention of this trouble, when it is merely threatened. I shall now call your attention, for a moment, to those remedies indicated in cases in which 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 few 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, whenever the hemor- rhage is such as to endanger the safety of the mother, all regard for the embryo must be suspended ; no matter what 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 when the hemorrhage is so profuse as to render it essential to induce the expulsion of the ovum, and, also, when it is certain that the abortion cannot be prevented. In some instances, it is true, this question may be decided without trouble; when, for example, a portion of the ovum—which will sometimes happen—has been thrown 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 which 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 which may present itself at the time. Permit me, however, 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 apparently moribund from exsanguification, and yet they have rallied, and gone on to the full term. These latter examples, however, are exceptions to the general rule. Well, when there is no longer any hope of restraining the abor- tion, or when the woman is flooding so profusely as to endanger her life, the mouth of the uterus will be in one of two 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 will also be in one of two conditions: it will either have partially extruded through the cervix, or it will still be within 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 forward and backward—this very motion of the finger evokes a strong reflex action, which oftentimes results in the prompt expulsion of the ovum. 2. If the os uteri have not undergone dilatation, and the hemorrhage so profuse as to occasion alarm for the mother, then the remedies to be employed are the follow 280 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ing: 1. Cold; 2. The tampon; 3. The secale comutum. 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 miscarriage 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 groat benefit, because of the contraction it produces in the blood-vessels of the uterus. There is now, 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 would be better if it were 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 flow of urine; in this case, the catheter must be used. I would advise you not to allow the tampon to remain, at any one time, in the vagina for a longer period than four hours; it should be withdrawn 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 which necessarily, to a greater or less extent, saturate it. The tampon acts, if I may so say, in a two-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 view. Another efficient remedy in these cases is ergot—the secale comu- tum ; and it is efficient because of its action on both the blood- vessels and muscular tissue of the uterus. It is now 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 in a two-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 with 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. Let us now suppose the ovum is partly protruding through the os uteri: in this case the proper practice is to terminate without delay its expulsion, by introducing the finger, and making gentle tractions upon it. If, on the contrary, the ovum be still within 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 two 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 will 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 within 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, without difficulty be removed. At a later period the uterus will be large enough to admit the introduction of the hand, and in this way 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 will often pass off spontaneously, even after aU 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 wineglass of strong coffee, every ten, twenty, 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 well contracted, and not in a state of inertia, for it would be the essence of folly to attempt to control the exhaustion while the waste gate is still open. In abor- tion, as in delivery at full term, flooding is always 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 Avhich 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 whether 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 would remind you that you will sometimes meet with cases in which there is more or less oozing of blood after the entire expulsion of the ovum; and this will ordinarily occur in women of a leuco-phlegmatic tempera- ment, with a flaccid, muscular fibre; the hemorrhage in these instances is almost always of a passive type, constituting what may be termed passive or atonic metrorrhagia. When called upon tc 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 water, cold from the pump, together with the internal administra- tion three times a day, as may be indicated, off. 3j. of the tincture of ergot in half a wineglass of cold water. LECTURE XX. Moles—Importance of the Subject—Moles variously Classified—Mairiceau'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 Lanisweerde, 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 bo distin- guished from the Hydatiform Vesicle ? Gentlemen—In the course of your practice you will observe, more or less frequently, examples of anomalous substances thrown 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 now before us, it appears to me there is great want of accuracy in the arrangement and description, which the older authors have given of the various matters discharged from the womb; and this want 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 when a female expels from her uterus a substance—known under the vague name of mole—she could only have done so in consequence of intercourse with the other sex. I allude to the learned Mauriceau, who, 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. 284 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. rism, and consequently the wrong 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'une 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, which is also frequently referred to in confirmation of the opinion subsequently advanced by Mauri- ceau: " Nusquam visa est mulier molam sine mare concepisse."f I might, indeed, cite many other authorities in confirmation of the same view, 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 sweeping 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 which 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 what a mole really is; for assuredly, in order that we may have a correct judgment as to the true origin of these expelled substances, we should first have some standard of comparison, which science recognises, as the only means by which we are to dis- tinguish between what is and wdiat 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, which are the product of a diseased or degenerated ovum, and consequently implies a previous fecundation—known as true moles. 2. Those the origin of which has no sort of connexion with sexual intercourse, but which is due to causes altogether foreign to this influence, known as false moles. The True Moles— Vesicidar or Hydatiform Moles.—It has been very satisfactorily demonstrated by Charles Robin, and others, that an alteration in the envelopes of the ovum, with an anomalous * Tome i. p. 599 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 with 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, which 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 new vegetation of villi sprouts out, being identical in structure with the proper villi 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 an alteration and degeneration of previ- ously existing structures. This writer also dissents from the opi- nion, now generally admitted, that the starting-point or cause of the transformation is disease of the chorion, while the effect is the destruction of the embryo. Dr. Hewitt, on the contrary, endea- vors to show that the degeneration is the result of the death of the foetus. His paper embodies much interest, and will amply repay perusal. Dr. BarnesJ has presented an elaborate resume of the whole question with his accustomed ability, and the reader will find much of profit in his valuable contribution. You were told, when 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 growth 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 exhibit a cavity full of a serous liquid, in which are never observed the small gra- nular bodies (echinococci) first described, I believe, by Rudolphy, and which always exist in true hydatids or acephalo-cysts. Should the mole be expelled soon after the death of the young embryo, portions of the latter may be detected in its cavity; but if it pass off 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. X Brit, and For Medico-Chirurgical Review, 1854-5. 286 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. lopment commences—these two 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 will compro- mise the progress of a normal gestation, and lead to the destruc- tion and degeneration of the ovum; so that, in lieu of foetal deve- lopment, the product of conception exhibits a more or less anoma- lous mass, in which, with a due degree of care, there will be recog- nised the alterations of the chorial villosities, if not with the naked eye, at least under the power 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 fcetus may be expelled normal and fully developed, while the placenta will 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 few, and the degenerated ovum will occasionally remain for a long time in the uterine cavity. The latter circumstance may involve character in one of two ways —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 maybe observed in a widow, 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 twins: 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 within the uterus for months after the widowhood of the female. When, therefore I tell you that such contingencies have occurred, is it not import ant that we should be somewhat 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 drawn by some authors of the striking resemblance between nterine moles and certain animals, such as lizards, screech-owls, 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 following interesting case, in which I performed, almost in extremis, an important operation, may not be without 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 saw her, had voluntarily withdrawn 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 would survive but a few hours. Her husband, in his interview with me remarked, that he was without the slightest hope, he and his friends having watched with the suffering patient the two 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 was thready, and beat one hundred and twenty to the minute. Such was 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 was almost inaudible ; in one word, the appearance of the patient was that of a dying woman. 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, with 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 womb, which was dilated to the size of a dollar piece. The parietes of the os uteri thus dilated were extremely attenuated, and did not appear to be thicker than common writing- paper. I found no difficulty in introducing my finger between 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 was no action in the womb; 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 womb, and grasping with 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 with the other hand the upper surface of the tumor through the abdominal walls, alternately elevating and depressing the two hands, it was evident that I embraced the womb itself, which was immensely distended by the growth of the tumor. In making an examination, per rectum, the enlarged uterus was detected without difficulty. These circumstances, together with 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-» elusion that, in the present case, the tumor was exclusively intra- uterine. It will 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 wife, yet, it was my opinion that it could be removed, although the serious hazard was, that the patient would sink under the opera- tion. This opinion was given emphatically, without reserve, and unac- companied by a word 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 survive the removal of the tumor, her sufferings would 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 without delay, remarking that she was prepared to encounter everything, even death itself, with 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 with me the following 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 was attacked with 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 always been regular, with the exception of the last year, during which time they occurred once in two 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, Avho 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 with excruciating suffering. These difficulties about the bladder and bowels continued to increase, and for weeks before I saAv her, she repeatedly passed over ten days without an evacuation—medicines having no effect, and injections, per rectum, immediately returning without bringing away any faecal matter. Her urine was voided in very small quantities, not more than two tablespoonfuls at a time, and it was nearly the color of blood. It was impossible for her to evacuate the bladder, except when resting on her elbows and knees; this position, however, occasioned so much fatigue, that, in her present exhausted condition, she could not avail herself of it. In a word, the agony of this unhappy sufferer was induced almost entirely by the pain consequent upon the attempt to evacuate either the bladder or rectum. With these facts before me, together with a knowledge of the position and bearings of the tumor, it was 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 Avith 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 would be sensibly palliated, and her life possibly prolonged. With 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 following manner: A mattress was 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 fimbs. 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 between the tumor and cervix of the uterus; this 19 290 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. was done with great caution, for the parietes of the cervix were so extremely thin, that indiscreet manipulations would almost cei tainly have produced rupture of the organ. With a view, there fore, of obviating such a result, I thought it more desirable to break up the adhesions of the tumor simply with the finger than incur the hazard of introducing instruments into the uterine cavity. In proportion as the adhesions yielded, I grasped the tumor, and without much effort was enabled to remove it with my hand in fragments. Having brought away in this manner all the solid por- tions, and carrying my hand well into the cavity of the Avomb, 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 which resembled in all its physical qualities, with the exception of the smell, pure pus. This fluid was collected in a vase as it passed from the womb, and half an hour afterward on examin- ing it, we found it no longer liquid, but presenting a solid mass, pearly, like hardened lard. It was 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 was 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 was 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 why the catheter had not been introduced before commencing the operation. In answer to this Arery 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 with a heroism which 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 was 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, which gave sincere joy to all of us, feeling, as we 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 whom she gave a look of recognition. In the morning after the operation, her bowels were spontaneously and freely moved, a large quantity of hard fiecal matter passing away. Subsequently, injections, simply of warm water, sufficed to afford her a daily evacuation, and the urine was discharged freely and without obstruction. Mrs. D. continued to improve in appetite, digestion, and strength; and, although her friends were 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 which 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 womb of this patient was the product of a blighted ovum, and it may be reason- ably asked whether her chances of recovery would not have been greatly enhanced if the tumor had been removed at an earlier period, before the powers of the system had become exhausted by long-continued and uninterrupted suffering. The adhesions, it Avill be remembered, of the shapeless mass to the internal surface of the womb were slight. The stearine, Avhich escaped after the sac was ruptured, I regard as nothing more than the fcetal brain, and other fatty portions of the system, in solution. These circumstances, together with the quantity of human hair removed from the uterus, and the fact that the tumor was comparatively of rapid growth, are, in my judgment, conclusive proof of previous conception. False Moles—Molm 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 will 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 will immediately be interpreted adversely to character; and rumor, with her thousand Avings, will soon con- sign to infamy the purest and most spotless. Remember, gentle- men, that the young girl who has become the object of suspicion is 292 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. worse than the withered flower—nay, she is the upas of society— her very presence is avoided, for the reason that social contact with her begets, as it were, an atmosphere of pestilence, destructive alike to all who 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 with the high crime of murder, and yet it may be in your power to demonstrate with mathematical certainty that you are unstained with the alleged victim's blood. But how different with woman, whose 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 was admitted that substances will sometimes be expelled from the uterus of strong, plethoric young girls, and this, too, in perfect keeping with their chastity. That clever observer, Galen, to whom we are indebted for so much that is sound and practical, contended that, as hens will occasion- ally lay eggs without the tread of the cock, in the same way 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 Avfil be observed oftentimes in congestive dysmenorrhoea. I have, you will recoUect, when speaking of menstruation, reminded you that the catamenial fluid consists of two distinct elements, viz. blood and epithelial mucus. Some writers, 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 were, 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 following 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 pubfished a case of this nature in a paper entitled, M0I03 incipientis frequens dejectio; and Morgagni has described, with * The fact of hens 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 th« 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 thrown from the uterus, which pos- sessed all the characteristics 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 what 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 within 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 which I have just alluded may blast that girl's character if you are not prepared to show that they are in perfect accordance with 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 jjatches, and again it will 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 woman who, at each menstrual period, expelled a holloAV, membranous body, correspond- ing precisely with the shape of the uterus. Besides this membrane, there will sometimes be thrown from the virgin and unimpregnated female, other substances; such, for example, as small, fibrinous masses, which appear, at first sight, to be organized, but oftentimes are simply coagula of blood; and again, there will be observed scales of epithelium, which, 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, which consti- * Follin, Lebert, and others have recognised in the dysmenorrhoeal membrane the following peculiarities, known to exist in the mucous tissue of the uterus: 1. Con^ Biderable 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 Gazette Medicale, p. 729. 1847. 294 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, Avith an undefined central cavity, and a smooth exterior. In none of these substances, of course, will there be the slightest vestige of any of the fcetal annexae, 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 with the following: Lamsweerde * divides moles into two 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 were not suspected of being otherwise." The following is the language of Van Swieten :J " It is certain that all those masses called moles, which contain a human embryo, and those Avhich are formed by the corruption of the little placenta left in the womb, cannot be produced without coition. But it is equally certain that the sarcomas of the womb, and the masses that spring from clotted blood, may be generated without 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 widows 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 what are known as true hydatids have no connexion whatever with a previous conception; they are entirely independent in their origin of any such influence. Therefore, it is a question of unqualified interest to inquire whether it be possible for them to be generated Avithin 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; we have not met with a single example in Vienna, 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. X 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 womb at all incompatible Avith the growth 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 viHi of the chorion ? This ques- tion may be answered affirmatively—under the microscope, and sometimes with the naked eye, when true hydatids exist, it wiU be observed that the cysts are inclosed one within the other; on the contrary, in the hydatiform vesicles, these latter, which may be rounded or oval shaped, are attached to each other by sfight 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 which these bodies, of either class, are discharged from the uterus of an unmarried female or widow, no deduction adverse to the party should be drawn 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; 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. Gentlemen—We have now, in the order of succession of subjects, reached an important and interesting topic—one which 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 with a very simple division of labor, which, 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, we 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 we 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, we propose to discuss the various topics and duties connected with human parturition, under THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 297 the two divisions of natural and preternatural labor—divisions which will not only be recognised as just in the lying-in chamber, but which 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 fcetus; 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 now 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 word, its birth constitutes it physiologically an independent being. This expulsion, hoAvever, of the fcetus and its annexae from the parent womb 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 which, when in completion, constitute parturi- tion. It is this very succession in the order of phenomena, which 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 way 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 which I allude as connected with the accomplishment of labor are, in the order of sequence, as follows: 1 st. 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, which 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, when 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 oAvn inimitable ways, so that when she is embarrassed by cir- cumstances, which 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 we should examine three interesting questions—the period, the causes, and the signs of labor. The period at which 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 well 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. Noav, then, the question arises—can a female be spontaneously delivered before the expiration of this period—or can she retain the fcetus 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 wanting in precision, and for the very obvious reason, that between 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 weeks. 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 weeks constitute, with the exception of two or three days, the true period of fcetal existence. But is this rule so gene- ral—in a word, is it so universal, that it admits of no exceptions ? This is the plain putting of the question—and we shall now 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. Those who 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 foUowing arguments: 1st. The uniform and immutable law of nature in the reproduction of all living beings—a law 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 fcetus 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, who 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 now under consideration, was not con THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 299 fined to the men of the past ages, I shall cite the foUowing impor- tant case, which was tried in the House of Lords in 1825, known as the celebrated Gardner Peerage Case: Allen Legge Gardner, the son of Lord Gardner, by his second wife, petitioned to have his name inscribed as a Peer on the Parlia- ment Roll. The Peerage, however, was claimed by another person —Henry Fenton Iadis—who alleged that he was the son of Lord Gardner by his first, and subsequently divorced wife. It was con- tended that the latter was illegitimate; and in order to estabfish this point, the evidence adduced was 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 wife until 11th of July following. The child, whose legitimacy was disputed, was born on the 8th of December of that year. Therefore, the plain medical question, taking the extreme view, was, 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 days), from July to December, could be considered to be the child of Lord Gardner. If these questions were answered in the affirmative, then it followed that this must have been a very premature or a very protracted birth. There was no pretence that this was a premature case, the child having been mature when born. The question, then, was reduced to this: Was this aUeged protracted gestation consistent Avith medical experience ? Many medical witnesses, comprising the principal obstetric practitioners of Great Britain, were examined on this point. Their evidence was very conflicting—five positively main- taining that the period of" gestation was 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 would cover the birth of the alleged illegitimate child. On the moral side of the question, it was clearly proved, that Lady Gardner, after the departure of her husband, was living in open adulterous intercourse with a Mr. Iadis ; and, on this ground, Lord Gardner obtained a divorce from her after his return. It was con- tended that the other claimant was really the son of Lady Gardner by Mr. Iadis. The decision of the House was, that this claimant was 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 witnesses; 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 was decided against her iUegitimate offspring. On this memorable occasion, the following Avas the opinion delivered by Sir Charles Clarke, certainly a man of no doubtful reputation: "Ihave never'," he said, "seen a single instance in which the laws of nature have been changed, believing the law oj nature to be, that parturition should take place forty weeks after conception." There is an exclusiveness, might I not say, without meaning any disrespect, an arbitrary positiveness in this opinion, which is more in keeping with the dictum of an ancient Roman Emperor, than with 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, who maintained that women never exceeded the ordinary period of gestation. Strange to say, however, as unanimous as these gentlemen were as to the cardinal point-—the immutability of nature with regard to the period of human gestation—yet there was an extraordinary want of concurrence among them as to what measure of time that period really is ! Whether upon the witness's stand, or in the professorial chair, the opinion of a medical man is worth nothing except when m accordance with facts. Hypothesis is one thing; clear and well- 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 well 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 hoAv 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 weeks, 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 worth, I feel that I owe much to his personal kindness, for it was 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, well attested, conclusively show, that the term may be prolonged beyond the usual period,'' he introduces the following case as having occurred within his own experience: " A lady, the mother of three children, became deranged after a severe fever. Her physician was of opinion that pregnancy might have a beneficial effect on the mental disease, and permitted her husband to visit her; but with 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 visits Avere discontinued. Tho lady was closely watched during the whole 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, which will make 287 days; but if the calendar months were not of the shortest period, there would be 276, to which 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, without involving the necessity of showing on what this departure is founded, or the conditions which regulate it. There are numerous other cases recorded by authors of equ il probity, exhibiting not only the occasional pro- traction of gestation, but proving, beyond a shade of doubt, that women will sometimes bring into the world living children before the expiration of the 40 weeks. 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 will 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 which we 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 which the period reached 336, 332, 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, Avhich he deems entirely trustworthy, of 420 days. It is not for me to say that there was probably a miscalculation in some of these extreme cases; but admitting the error, which 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 which 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 law, or is the rule which she 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 with human gestation, and examine the record of reproduction as it occurs in the lower animals, Ave shall find not only substantial, but very convincing testimony that nature is not governed by any uniform law as regards the particular period of pregnancy. The experiments of Tessier, made with great care, and Avith 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, mar.es, 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 cows—and it is impor- tant as weU 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 within a fraction of six Aveeks. In 447 mares —the period of gestation is 335 days—it was noticed that 42 foaled between the 359th and 419th days, so that in them the greatest excess was 84 days. In the sheep and rabbits the same dis- crepancy was recognised; while in the hen, it was remarked that the period of incubation was 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 Tesster : 72 et 11 II 39th it 335 u II 11 40th u 429 il il II 41st 1! 135 11 II II 42d II 33 11 i< i< 43d, II 21 cows calved in the 44th week. 9 ii ii " 45th u 3 i< n u 46th " 5 u u ii 47th ■ i 4 u u k 48th u 1 it n u 51st u 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, which, 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 unknown 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,* whose name is so honorably interwoven with 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, which have occurred in his own practice, he believes that the younger the mother, the shorter is the period of gestation. Thia theory corresponds with the very general belief that the older the animal the more protracted will be the duration of preg- nancy. From all that we 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 words, is there any rule by which 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 midwifery; for you will often be ques- tioned by your patients in regard to the particular period of their gestation with a Ariew of knowing when they may expect their approaching confinement. There are various modes of calculation, and I think they may be classified as follows: 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 * Observations on the Term of Utero-Gestation. By Charles Clay, M.D., p. ». 304 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, et articulum reliquum- que corpus convulsio prehendit et uterum torpor, idque iis, quaa puree sunt, accidit," * Avhich may be rendered into our own tongue thus: It is well understood by those skilled in these matters that the instant a woman conceives, she experiences a general shivering and heat; her teeth chatter, and the articulations with other por- tions of the body are thrown into convulsive movement, while the uterus itself is attacked with numbness, and this occurs even to women quite pure. Van Swieten says, " From many observations, we are assured that women, 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, with good reason, thought to be greater at the time of conception, than when coition is performed, without impregnation immediately fol- lowing." f There is one insuperable objection to this theory of sensations as a guide for computation, and it is, that whatever may occur in individual cases, the fact is abundantly established that occa- sionally Avomen will conceive who do not experience the slightest feeling of sexual pleasure—they are as inanimate as the bed on which they repose; and, under such circumstances, I have known ladies continue incredulous as to their true condition until the very approach of their labor, so fully were they imbued with 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 willing 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 woman 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 term * 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 within her a living being.* IH. 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 would 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 ii " " " " 1 264 u 11 « u " 2 265 ii It II (1 d 1 266 » « « « ii 2 270 " II It 11 ii 1 271 u —Is Super-foetation possible in Animals; Illustration—Can a Woman simultaneously carry a Uterine and Extra- uterine Fcetus ?—Super-fcetation in a Double Uterus; the instance recorded in the Encyclographie Medicale—Objections to Super-fcetation 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 f—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. Gentlemen—We have not yet spoken of multiple pregnancy, or that character of gestation in which there are two or more foetuses within the uterus. Women will occasionaUy bring forth tAvo, three, four, and five children at a birth; and there are recorded instances of a far greater number having come into the world at one parturi- tion ; but these cases are to be accepted with great caution. It would seem that a twin pregnancy occurs in the varying proportion of one in sixty to one in ninety-five cases. Madame La Chapelle records that, in 37,441 births there were 36,992 single deliveries, 444 instances of twins, and but five of triplets; and it is an inter- esting fact that, in 108,000 births in the Hotel Dieu and Maternite of Paris, from the years 1761 to 1826, there wTas not one example of quadruple gestation. In 129,172 deliveries in the lying-in Hospi- tal of Dublin, there were 2062 cases of twins, 29 of triplets, and but one instance of a quadruple birth. While, therefore, instances of three, four, and five children are to be regarded as extremely rare,* yet it is quite evident from these tables, amply confirmed by all practical observers, that such is -not the fact as regards twin deHveries.f * "Non raro femina geminos foetus parit; rarius paulo tres, neque unquam supra quinque." (Haller's Physiologia, 929.) f Dr. Churchill presents the following statistics: Among British practitioners, in 432 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. There, have been numerous theories promulgated in the attempted explanation of the cause of a multiple or plural pregancy, but per- haps they may all be summed up in this general admission—that it is the result of an excessive reproductive power, sometimes possess- ed by the male, and, at other times, alone the attribute of the female. The procreation of twins seems to be peculiar to certain individuals and families. A remarkable illustration of the truth of this, I witnessed in the case of an American lady Avho married a German. This lady I confined three times successively Avith twins; her husband was a twin, and his aunt on the maternal side was deli- vered twice of twTo children at each birth. Placenta and Membranes in Multiple Pregnancy.—The gene- ral rule is that, in plu- ral pregnancy, each foetus possesses its own membranes and placenta (Fig. 63), and,in this particular, it simulates, in all re- spects, a single gesta- tion, with the excep- tion that, sometimes, there will be an inos- culation of blood-ves- sels between the dif- ferent placentae. On the other hand, it will occasionally, though rarely, happen that there is but one placenta for the two children, and it has been suggested by Dr. Tyler Smith that, in these latter instances, the one ovule has contained two yolks, and two germinal vesicles, as is sometimes observed in the casp of birds—one egg Avith a double yolk producing two individuals. The foetuses, in the case of twins, are usually smaller than when there is but one child in the uterus, and there is also a strong predisposition to premature deli- very ; when there are more than tAvo, the labor is still more apt to 257,935 births there were 3431 cases of twin3, or about 1 in 75, and 43 cases oi triplets, or 1 in 5561^; among the French, in 39,409 there were 336 cases of twins, or 1 in 108, and 6 of triplets, or 1 in 6568; among the Germans, in 3*69,080 ther* were 4239 cases of twins, or 1 in 87, and 38 of triplets, or 1 in 9765. Taking tho whole we have 666,424 cases, and 8006 of twins, or 1 in 83, and 87 cases of triplets, or 1 in 7443. The following he gives as the rate of mortality: In. 1298 cases of twins (i. e. 2696 children) 636 were lost, or about 1 in 4; and out of 12 cases of triplets (i. r., 36 children) 11 were lost, or 1 in 3. This mortality, however, which is very large, as Dr. Churchill properly remarks must be qualified, by allowing for the great num- ber of children whose death could not be attributed to the labor. The mortality to the mother in twin cases has been computed as 1 in 20. (Chur- chills Midwifery, fourth London Edition, p. 443.) THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 433 be premature, and the children rarely survive beyond a short time. It must, hoAvever, be admitted that there are Avell-authenticated ex- ceptional instances of the reverse of this latter rule. Dr. Collins cites, within his own knowledge, two examples of triplets having arrived at the full period of utero-gestation, and were reared healthy children. Signs of Twin Pregnancy.—Much has been written touching the signs of tAvin pregnancy, and some authors are of opinion that there are certain indications of the existence of a compound gesta- tion, which are entirely reliable, and are as follows: A greater and more rapid increase in the size of the abdomen ; the division of this latter into two distinct portions by a sort of longitudinal or oblique fissure ; the movements of the fcetus on tAvo surfaces of the abdo- men at one time, Avith a general increase in the ordinary accompani- ments of pregnancy, such as gastric irritability, cedema of the lower limbs, etc. It can scarcely be necessary to say to you that these symptoms, as a guide to correct diagnosis, are without any value ; for there is not one of them Avhich may not, under certain circum- stances, be met with in a gestation in which there is only one child. The most trustworthy evidence, prior to labor, that a twin preg- nancy exists, is the fact that the pulsations of the foetal heart may be detected simultaneously on different portions of the abdomen. But the recognition of this evidence, in order that it may possess its full weight, requires a degree of just discrimination. For ex- ample : You may detect the pulsations of the foetal heart very distinctly at one point, and, on applying the ear or stethoscope to another portion of the abdominal surface, you may, with the same distinctness, likewise have the pulsations increased. These latter may or may not be the beatings of the child's heart. How do you distinguish the sounds ? When speaking, in a previous lecture, of the fcetal heart as positive and unequivocal proof that the female is pregnant, I told you that, between the throes of the mother's heart and those of the fcetus, there was a want of correspondence; or, in other Avords, they are not synchronous—the latter being much more rapid than the former; and another interesting fact worthy to be recollected in this connection is—that there is also a want of synchronism in the pulsation of the two foetal hearts in the case of twins. If, therefore, you should distinctly recognise, through auscultation, the beatings of the foetal heart on opposite portions of the abdominal surface, and they should not be synchronous with each other, it is very conclusive evidence that it is a twin gestation. More than ordinary caution, however, will be needed in this dia- gnosis, for the action of the mother's heart will sometimes be heard through the abdominal aorta, and when, from any special cause, it is accelerated, these circumstances conjoined may lead to an erro- neous judgment. But, after all, it may be asked, cui bono are any of these signs; 28 434 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. for, even if we knew beyond peradventure that the woman ia pregnant with tAvins, this knoAvledge would in no way aid us previous to labor. Not so, however, in a twin-birth, after the first child has been expelled; for, ignorance in this case that there is a second child to be delivered, would not only place the accoucheur in an embarrassing position, but would necessarily subject to more or less peril the safety of the mother; the diagnosis is so simple that error would be without justification. For example: as soon as the foetus passes into the world, the uterus will continue enlarged, and the introduction of the finger within the mouth of the organ will enable the practitioner to feel the membranes of the second child, or, if these be ruptured, some portion of the foetus itself Avould be recognised. Therefore, in all cases of labor, satisfy yourselves the moment the child is born whether there is oris not a second one to follow. Take nothing for granted in the lying-in chamber, which may be reduced to a matter of certainty, for the vagaries of nature are sometimes very curious, and not unfrequently capricious. Twins not always Equally Developed.—In cases of twins it will occasionally happen that one fcetus is healthy, and perfectly deve- loped, Avhile the other bears all the evidences of an early arrest in its growth, and may be either living or dead; this fact is very satisfactory proof that the lives of the two children are quite inde- pendent one of the other.* Again : both children may be fully developed and alive, but one much larger than the other. Cases such as I have just mentioned will very naturally give rise to the idea of super-fcetation, and have been attempted to be explained by some writers exclusively upon this hypothesis; but super-fcetation is not at all necessary for the explanation of the phenomena—they may exist independently of any such influence. For example: this inequafity may be due either to some original defect in one placenta, or funis, or one foetus; or it may result from compression exercised in utero by one child on the other. There can be no doubt of the occasional operation of either of these influences; and it is proper that you should bear the circumstance in memory. A Twin Pregnancy not Incompatible with Natural Labor.—A tAvin pregnancy does not necessarily imply that the labor will not be natural; oi the contrary, you will observe in practice that nature, unless there should be some complication, such as malposi- tion of the fcetus, etc., will be adequate to accomplish the delivery through her own resources. The labor, however, as a general rule, will be more protracted, because the uterus having undergone a * There is no difficulty in accumulating proof of the independence of the two fcetal lives; but the following is certainly a most interesting demonstration of the fact: A pregnant woman was attacked with small-pox and recovered; she was soon after delivered of two children, tho one having received the small-pox in utero, the other not. The case has been reported in the Journal de Medicine, edited by Van- dermeide. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 435 greater degree of distension loses in proportion its contractile toni- city, and, therefore, a longer period is needed for the achievement of the process. And again: when there is more than one fcetus in utero, the organ cannot concentrate its poAver as in a single gestation. There is much variety in the presentations of the two foetuses: but it is estimated that, in about two thirds of the cases, each child presents the head, the largest usually descending first. Again: the head of one child, and one of the pelvic extremities of the other (Fig. 64), will be found at the superior strait. These are the most frequent of the presentations, but they are sus- ceptible of the same variety of modification observed when there is only a single foetus within the womb; and it is also worthy of remark, that malpositions of the fcetus are more frequent in the case of twins than in a single preg- nancy. The following table, exhibit- ing presentations of the foetus in 808 labors with twin children, has been constructed by Prof. Simpson* from the returns of twin births, as observed in the Dublin and Edinburgh Lying-in Hospitals, and among the patients of the London Maternity Charity Reporter. Total number of Cases. Number of Head Presentations. Number of Pelvic Presentations. Number of transverse Presentations. Clarke, Collins, Hardy and ) McClintock J Ram.sbotham, Simpson, Reid, 126 449 190 772 30 48 73 309 122 532 23 25 53 133 62 221 7 22 7 6 19 1 Total, 1615 1084 498 33 Proportions among twin children, 67 in 100 1 in 3 1 in 49f Proportions among all births, 96 in 100 1 in 31 1 in 224 In order that you may appreciate how it is, that two children * Simpson's Obstetric "Works, vol. il, p. 133. f The same tendency to malpresentation also exists in the case of triplets. 436 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. can come into the world without involving the necessity of artificial interposition, we will suppose a twin case, in which the head of each foetus presents. As a general principle, under this condition of things, one of the cephalic extremities is more moveable than the other, and its tendency is to recede slightly, so as to afford more space for the descent of the head of the other fcetus; this recession being much facilitated by the smooth and unctuous state of the parts. But this surrender of place on the part of one of the children does not universally occur, and Avhen it does not, there will necessarily be more or less obstruction to the delivery. So far as the position of the foetuses is concerned, the same rule applies in a twin gestation to which we have already alluded, when discussing the subject of labor in a single pregnancy, viz., in order that nature may expel the children of her own volition, one of the obstetric extremities must present at the upper strait. It should be recollected that, when the first child presents the head, the delivery will be much easier than if the feet should pre- sent, for the obvious reason, that by the time the extremities and body of the child have escaped into the world, the uterus, occupied with the other fcetus, will not be able to throw its expulsive forces so efficiently upon the head as it rests in the vagina, and, conse- quently, from this cause, there will be more or less delay in its birth. Management of a Twin Labor.—Let us now inquire hoAv a twin labor, in which there is no complication, is to be conducted. You are at the bedside of your patient; she is in labor; the child is born; you observe the womb to be still enlarged, and a vaginal examination assures you that the uterus contains another fcetus. In this contingency, will it be proper for you to say to your patient: "Oh! madam! I congratulate you; there is another baby coming!" There is much difference of opinion among authors as to Avhether any such disclosure should be made, until the birth of the second child precludes the possibility of further concealment. Many are of the belief that an announcement of this kind would have an injurious effect on the patient; and whether it Avould or would not will depend very much upon circumstances. For example: some females have an uncontrollable repugnance to become mothers; these, however, are in the vast minority; others, again, may have a passion for children, but either on account of ill health or limited pecuniary means, they may be indisposed to an increase of their little responsibilities. In such instances, the accoucheur will be caUed upon to exercise a sound judgment as to the propriety of prematurely, and Avithout consideration, announcing the approaching advent of a second child after the birth of the first; for Avithout some Uttle diplomacy on his part, the abrupt intelligence might be productive of more or less harm to the patient. On the contrary, you will meet in the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 437 rounds of professional life with women, whose great ambition it is to rear large families; and every additional child is but another link in the chain of their earthly bliss. Here, then, there would not only be no objection, but, on the other hand, every motive for a prompt announcement of the glad tidings. It is, therefore, as you perceive, a mere question of expediency as to the course to be pursued; and that expediency must be governed by the pecufiar circumstances which may surround each case. Management of the Placenta.—This matter being disposed of, the next important consideration is—what is to be done with regard to the placenta belonging to the child, which is already delivered. In the first place, allow me to remark that, in cases of plural deli- very, it will be proper to deviate from the rule I gave you in speaking of a single birth, and, instead of applying but one Hga- ture, two should be employed; not that two are always necessary, but as there are very frequently vascular inosculations between the borders of the placentae, if the umbilical extremity of the cord were left open, the blood, which would escape through it, might prove fatal to the child yet in utero. What are you to do with regard to the placenta itself? My advice is to do nothing. Do not attempt to extract it; but wait until the birth of the second child ; the two placentae are then usually thrown off together. The danger of making any eflbrt to deliver the placenta after the expul- sion of the first child is this—you may too abruptly detach the other placenta from the uterus, and thus incur all the perils of hemorrhage. It will occasionally, however, happen that the after- birth will very speedily follow the delivery of the first child. This, when it occurs, is all right; it is nature's work, and there can be no objection to it. But, remember, there is another child in the womb. What course is to be pursued touching it ? This is an important question, and needs some little consideration. The opinions upon the practice to be adopted are by no means concurrent; they seem to embody two directly opposite principles. For example, you are told, on the one hand, as soon as the first child is born, not to delay, but to proceed at once with the extraction of the second ; and, on the other, you are admonished against the evils of interference, and are strictly enjoined to commit the delivery to nature. The true test, I think, of the Avisdom of either of these exclusive rules, is to con- trast them with what really occurs when nature is left undisturbed, and permitted to pursue her own course Avithout interruption. In the great majority of cases in twin births, statistics show that the second child is delivered by the resources of nature alone, from fifteen to thirty minutes after the birth of the first. In 212 instan- ces recorded by Dr. Colfins, in which the interval is accurately marked, in 38, it was five minutes; in 29, ten minutes; in 48, fifteen 438 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. minutes; in 23, twenty minutes; in 30, half an hour; in 5, three quarters of an hour; in 16, one hour; in 8, two hours; in 3, three hours; in 5, four hours; in 1, four and one half hours; in 3, five hours; in 2, six hours; in 1, seven hours; in 1, eight hours; in 1 ten hours ; and in 1, twenty hours. It is, therefore, incontestably true that the general rule is, that nature, if left alone, will speedily cause the second child to follow the delivery of the first; in view of this important fact, I should advise you, unless some complication such as hemorrhage or con- vulsions should interpose, to wait for at least half an hour before attempting any thing to expedite the birth of the second child; even then, such interference will not always be justifiable; for it will sometimes occur that the second child—for instance, in the case of a premature dehvery—may not have reached its maturity; and there are well authenticated instances of this latter kind, in which the child has continued to remain in utero until its physical organi- zation was so far completed, as to render it capable of an external or independent existence.* It is very generally recommended, as soon as the first child is delivered, to rupture the membranous sac of the second fcetus, with a vieAV of expediting its expulsion. I cannot concur in this opinion, for I do not perceive its utility. According to my own experience, it is far better practice to commit the entire management of the second child to nature, all things being equal. What, in fact, when rigidly analyzed, is a twin labor, free from all complications, and which, consequently, it is within the ability of nature to accomplish without the interposition of science ? Is it not, in strict construc- tion, two successive parturitions developing the same phenomena, and consummated by the same means ? Both require contractions of the uterus, both demand that one of the obstetric extremities of the foetus shall present; and does not nature, in ordinary labor, prove herself, as a general principle, competent to rupture the membranous sac, and does she not usually produce the rupture at the opportune moment ? Therefore, unless there be some positive indication for so doing, I would urge you not to adopt, as a stere. otyped practice, the plan of rupturing the membranes of the second foetus immediately after the delivery of the first; but submit patiently for at least half an hour, to the ministrations of nature herself; and if, after the lapse of this period, there should be no manifestation of progress, it would be desirable, by gentle fric- tions over the abdomen, to endeavor to stimulate the uterus * Dr. Merriman cites the following case reported in the Medical and Physical Journal for April, 1811, vol. xxv., p. 311—in a case of twins, the second child was retained for fourteen days after the birth of the first, and the writer remarks that another instance had come to his knowledge, in which six weeks had elapsed between the birth of the twins.—[Merriman on Difficult Parturition, p. 99.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 439 to increased effort, and it may also be proper to rupture the membranes. There can be no objection to the employment of ergot in these cases, provided always that the child presents naturally; for the uterus is apt, through previous effort, to become more or less defective in action, and the influence of ergot will oftentimes be very marked in evoking its contractility. Should, however, these means fail in producing the expulsion of the foetus, it will be proper, after waiting two hours, to introduce the hand, and bring down the feet; or if the head have descended into the pelvic excavation, the forceps should be had recourse to; the necessity as well as the economy of this mode of practice, are abundantly sustained by the important fact that, according to accurate observation, the second child will usually be sacrificed if more than two or three hours elapse after the birth of the first. In twin labors, it is important that the accoucheur should not leaA'e the room of his patient until the delivery of the second child has been completed; this, as a general rule, should be scrupulously observed. As I have mentioned to you, there are occasionally some exceptional cases in which a compliance with this precept would not be practicable; for there are instances on record in which the second child has not been expeUed for two, three, and more weeks subsequently to the birth of the first. Therefore, while in the observance of the general rule, it will be well to bear in mind the exceptions. The following is an interesting and instructive case of twins,* to which I was called some time since. Mrs. K----, aged 32 years, the mother of three healthy children, consulted me on the 6th of October, 1855, in consequence of an anxiety she experienced in not having felt for the preceding week the motion of her child, she then being about six months pregnant. She remarked that, a few days before consulting me, she had become very much frightened by a horse, and since that time had not felt life. With the exception of words of encouragement, and suggesting the occasional use of the tincture of hyoscyamus with a view of quieting her nervousness, nothing was ordered in her case. On the 6th of November follow- ing, the husband requested me to visit his wife, stating that she supposed herself in labor, and was flowing very profusely, having been troubled more or less in this way for the last week. In an hour from the time I received the message, I saw the patient, accompanied by my son, Dr. Henry M. Bedford, and found her * Placenta previa in a case of twins, which were expelled from the uterus, after a seven months' gestation, with one placenta, one amnion and chorion; both cords inserted into the placenta nearly in juxtaposition; each foetus presenting evidencei of incipient hydrocephalus; and each bearing .marks of having been dead for two OJ three weeks. [See Diseases of "Women and Children, p. 380.] 440 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. with labor-pains just commencing, and flowing quite freely. In making a vaginal examination, I discovered the os uteri dilated and soft, and distinctly felt a doughy substance presenting, which 1 recognized to be the placenta, and wdiich at once accounted for the hemorrhage. With the amount of blood the patient Avas losing, together with the fact that the mouth of the womb was soft and dilatable, it Avas obA'iously my duty to lose no time, but to proceed without further delay to the delivery. In accordance, therefore, with this object, I carried my hand to the neck of the uterus, and separated about one fourth of its attachment to the placenta, Avhich enabled me to feel the presenting part of the foetus, which I soon recognized to be the breech. It was my intention at once, in sepa- rating the placental attachments, to introduce the hand into the uterus, and terminate the delivery by bringing down the foetus. As, however, the uterus contracted with great efficiency soon after I had ascertained the presentation, and as it was quite evident that the breech of the foetus Avas descending into the pelvic excavation, I judged it advisable to submit the birth to nature. The pains increased so rapidly in force, that not more than five minutes elapaed before the expulsion of the fcetus Avas accomplished. As the child was passing into the Avorld, with one hand applied to the abdomen of the mother, I soon discovered that, although there was a sensation of hardness imparted to my hand, the uterus was but slightly diminished in volume ; at the same time my attention was drawn to the peculiarity exhibited by the umbilical cord. It occurred to me, at first view, that it was an example of what authors have described as the knotted cord, tAvo instances of Avhich I have had in my practice. In this character of cord there are dis- tinct knots, formed most probably by the evolutions of the fcetus in utero. I soon observed, hoAvever, that no such peculiarity existed in the present case. The enlarged uterus caused me to suspect the presence of another fcetus, and, in carrying my hand up, my sus- picion was confirmed. The uterus contracted with energy, and, in less than ten minutes, the second fcetus was expelled. Both Avere in a state of decomposition. The peculiarity of the umbilical cord is explained as folloAvs : The cord of one fcetus was completely tAvisted around that of the other in its whole extent, presenting the aspect of the knotted cord. On the expulsion of the second foetus, the uterus became diminished in size, and was felt in the hypogastric region well contracted. I then passed my hand, and removed the placenta. There was but one after-birth ; the two cords were inserted into it nearly at the same point. There was but one chorion, and one amnion. The two foetuses were about equally decomposed, presenting the strong pro- bability that their death was simultaneous. About an hour and a half after the delivery, the foetuses and placenta were seen and THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 441 examined by my colleague, Prof. Van Buren, and also by Dr. George T. Elliot, then resident physician of the lying-in hospital. I should have remarked that the cord Avhich Avas twisted around the other, having its length curtailed, and also decomposed, became detached from the placenta on the birth of the second fcetus. Prof. Van Buren immediately detected, by means of the blowpipe, its place of attachment, Avhich was in juxtaposition Avith the other cord. In reviewing the circumstances connected with this delivery, there are several points of interest Avhich naturally present them- selves to our consideration, and when all the peculiarities of the case are examined they certainly do present an aggregate Avhich is not only unusual, but, in my opinion, without a parallel. What, then, are the peculiarities to Avhich I allude ? They are as follows: 1. Implantation of the placenta over the cervix uteri; 2. One pla- centa, one chorion, and one amnion ; 3. The insertion of both cords into the placenta in juxtaposition; 4. Each fcetus exhibiting evi- dences of incipient hydrocephalus; 5. The probable simultaneous death of the tAvo foetuses. These constitute the peculiarities of the case; and I repeat, in conclusion, as far as my knowledge extends, they stand alone. But what imparts special interest is the fact of one placenta Avhich is single and perfect in itself; not composed of two united into one, the points of union easy of recognition, as sometimes happens in plural gestation, but it is one entire placental mass. There is no double set of membranes; there is, on the contrary, one distinct amnion, and one chorion. In fact, there is here, with the exception of the tAvo cords, precisely what Ave should expect to find in a parturition in which there is but one foetus. Some authors have doubted the possibility of a twin-birth Avith only one amnion, without the cohesion of the embryos. But the case under consi- deration is an unqualified demonstration that it is possible for twins to exist with but one amnion, and yet no cohesion of parts ensue. Another interesting fact connected with this history is, that al- though there is but one placenta, and both cords are inserted into it, yet the umbilical vein and two umbilical arteries belonging respectively to each cord, have a distinct circulation; or, in other words, do not communicate Avith each other. If, to this circum- stance be added the fact that there was not the slightest evidence of decomposition in the placenta, but, on the contrary, an aspect of freshness, such as exists in the case of a healthy living foetus, we then have the curious coincidence of a healthy, fresh placenta coex- isting with two foetuses bearing the evidences of having been dead for some two or three weeks.* This certainly presents a point for physiological discussion. Again: would it have been possible in * There are cases recorded showing that the amnion may also remain for some time without undergoing decomposition. 442 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. thig instance for one foetus to have survived the other, as sometimes occurs in twin births ? My opinion is decidedly in favor of the negative. The mother had a prompt recovery; and is now in the enjoyment of good health. Super-fcetation.—It will be proper, at this time, to allude briefly to the subjoct of super-fcetation, which implies the possibility of a second fecundation subsequently to one which already exists; or, in other words, the possibility of a woman being in gestation with two foetuses of different ages, and consequently generated at differ ent periods. Among the early Avriters there was a general concur- rence of opinion on this subject, and the doctrine of super-fcetation was accepted with singular unanimity. Such, however, is not the case with the men of our own times ; and among others, wrho doubt the possibility of super-foetation, may be named the distinguished authorities—Drs. Churchill and Ramsbotham. There can be no doubt that two fecundations may take place within a very short period of each other; this • fact is irresistibly established by cases, the authority of which is beyond all cavil. Some of you are, perhaps, familiar with an example of this kind quoted by Buffon, and more or less constantly referred to in obste- tric works. It occurred in South Carolina. A white woman, immediately after receiving the embraces of her husband, was coerced, through fear of her life, to have intercourse with a negro; the result being that she gave birth to two children, one white, and the other mulatto. In the American Journal of Medical Sciences for October, 1845, a somewhat similar case is mentioned on the authority of Dr. Lopez. The mother, in this instance, was a negress, and having had in succession intercourse with a white and black man, produced two children, one mulatto, the other black. An extremely interesting instance, in proof of the possibi- Hty of super-fcetation, is recorded by Dr. Henry in his valuable monograph on this subject; it occurred in the Brazils. The natives of that country are copper-colored, but among them are many negroes and whites. A Creole woman, a native, brought into the world at one birth three children, of three different colors, white, brown, and black, each child exhibiting the features peculiar to the respective races. But such freaks of nature are not confined to the human family ; for the same circumstance has been observed in animals. It is related by Mende, that a mare covered first by a stallion, and shortly afterward by an ass, produced at one parturition a horse and a mule; and you will find an analogous case reported by Dr. Read of Andover, with the simple difference that the mare was covered first by the ass, and in two or three days subsequently by the horse. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 443 The cases to which we have referred may, I think, be safely regarded as indisputable examples of super-fcetation; but it should be recollected that, in all of them, if human testimony be worth anything, the procreative acts occurred at short intervals. Very different, however, is it with those reputed instances of a well-deve- loped and mature child being born, followed by another, the period of time varying from one to several months. In these latter cases, in the absence of very positive evidence to the contrary, I should be disposed to refer the phenomena, not to super-foetation, but to an original twin gestation, in Avhich one of the foetuses was developed at the expense of the other, the retention of the second being necessary for its proper subsequent maturity. A very remarkable instance occurred in Strasbourg, the particu- lars of Avhich will be found in the Recueil de la Societe d'Emulation —a woman, aged thirty-seven years, brought forth a mature and healthy child on the 30th of April; on the 17th of September following (about one hundred and forty days after the previous birth), she was again delivered of a fully developed infant. After her death, an autopsy proved that the uterus was single. Dr. Tyler Smith, an accurate observer and reliable authority, mentions the following interesting case as having been seen by him in company with Mr. Eardley. I quote his own words: " A young married woman, pregnant for the first time, miscarried at the end of the fifth month, and some hours afterward a small clot was discharged, inclosing a perfectly fresh and healthy ovum of about one month. There were no signs of a double uterus in this case. The patient has menstruated regularly during the time she had been pregnant, and .Avas unwell three weeks before she aborted. She has since been delivered at the full term."* The tAvo examples just cited, admitting their accuracy—and I see no reason to doubt it—are very strong facts in favor of super-foeta- tion resulting from remote procreative acts; nor do I, for a moment, think them explicable on the ground of a twin gestation. It is now weU established, and I believe the fact has met with universal concession, that a woman may become impregnated while she is carrying an extra-uterine fcetus; that is, she may simulta- neously have a uterine and extra-uterine foetation. Horn, Mende, Montgomery, and others, cite cases in proof of this circumstance. There are also examples of super-fcetation occurring in a double uterus; one of the most notable and trustworthy instances of this nature is recorded in the Encyclographie Medicale, for February, 1849. A female, a native of Modena, became for the seventh time pregnant in 1817; at the expiration of nine months, she was deli- vered of a healthy and fully developed male infant. The placenta * London Lancet, 1,856, for August, p. 131. 444 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. was properly expelled, and the patient soon recovered her health' It was, however, observed that one half of the abdomen continued enlarged, and the moA-ements of a foetus were very distinctly recog nized. A month subsequent to her last parturition, she again brought into the world a living male child, which presented all the evidences of health and full development. Years afterward this woman died of apoplexy; an autopsy was had, and the interesting circumstance was revealed that there Avas a double uterus Avith a single cervix. The objections urged by Drs. Churchill, Ramsbotham, and others, against a true and unequivocal super-fcetation are mainly founded on the supposed impossibility of a second fecundation, while the uterus is already occupied Avith the product of a previous one ; and they maintain that this impossibility arises, in the first place, from the fact that the os uteri is closed by a tenacious mucous plug, and, secondly that the membrana decidua being a complete sac, occluding the mouth of the Avomb as well as the uterine orifices of the fallopian tubes, the spermatozoon cannot gain admission, and, therefore, fecundation cannot be consummated. Let us briefly examine these objections: 1. The mucous plug.—It is now well understood, through the revelations of the microscope, that there is no essential difference in the mucus existing in the cervical canal of the preg- nant woman, and that generally present in the same canal in an unimpregnated female; and as, in the latter case, in order that the fecundation may be accomplished, the spermatozoon must of neces- sity enter the uterus through this mucus, so may it do so when gestation already exists, and thus generate a second fcetus. 2. The membrana decidua.—Until very recently, as has already been remarked, the original description of the membrana decidua, and membrana reflexa as given by Hunter, Avas almost universally adopted by obstetricians; and Avith this adoption, it would at once seem impossible, after the formation of the decidua, for anything to enter the cavity of the uterus, without first pushing the membrane before it; for the decidua, as described by Hunter, is veritably a closed sac, and completely occludes the three openings of the womb, viz., the os, and the two orifices of the fallopian tubes. But Hunter's theory, like many other things which were brilliant in their day, has been compelled to recede before the lights and progress of science; and what once found universal concurrence is now thrown aside. Physiological research, aided by the clever microscopists, has demonstrated that Hunter's vieAV was little less than a fiction; and it is now estabfished beyond a peradventure, that the membrana decidua is but a thickening or hypertrophied condition of the mucous coating of the uterus. It is, therefore, not a closed sac, and, con- sequently, offers no impediment, at least during the early periods of gestation, to the ingress within the uterine cavity of the spermato- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 445 zoon—the true and exclusive fecundating element. These objec- tions, therefore^ in opposition to the doctrine of super-foetation are not valid ; and when we take into account the important and unde- niable evidence on record—irresistible, and, therefore, conclusive— that cases of this description have actually occurred, both in the human subject and in animals, super-foetation must be recognized not only as Avithin the range of possibility, but as having been more than once practically illustrated. Super-fcetation in a Moral Aspect.—There is another vieAV in which this question of super-foetation is to be regarded ; and it will occasionally need the soundest judgment and discrimination on the part of the practitioner, in order that suspicion may be allayed, and the breaking up of the dearest social relations prevented. Let us suppose a case. A gentleman, shortly after the impregnation of his wife, is compelled to leave her on business, which will require an absence of a year. During this time, she brings into the world two children at an interval of some Aveeks. Popular opinion, if it be allowed to poise the scales of justice, will undoubtedly decide against the fidelity of the wife; and the husband, Avhose heart-strings are broken by this unlooked for dishonor, may, perhaps, in the hour of his anguish, apply to one of you to know Avhether it be possible for a woman to be delivered of two children Avithin a short period of each other, consistent Avith conjugal purity. If the case just hypo- thecated should occur to me, and I should be selected as the arbiter of that man's peace of mind, and the aegis against the suspicion of his wife's chastity, I Avould, without hesitation, unless the proof against her should be overAvhelming, decide in her favor—and upon the broad ground that the tAvo births were the result of a twin gestation. According to the doctrine of chances, the presumption of the correctness of this decision Avould be twenty to one ; for, as has already been mentioned, it is not of extremely rare occurrence in twin pregnancy for an interval of days and weeks to elapse between the respective deliveries, for reasons which we have pre- viously stated; Avhereas, on the other hand, super-fcetation may be properly classed among the exceptional phenomena of life. A broader ground still, however, on Avhich such a decision may be based is the Christian principle—it is better that ninety-nine guilty should escape than that one innocent be condemned. Human hap- piness and a AA'ife's honor, I hold, to be too precious to become the sport of a mere contingency; in all cases, therefore, involving the sacred rights of the household, look to evidence, both presump- tive and positive ; and remember, in rendering your verdict, that humane maxim in law—a reasonable doubt is the property of the accused. Deductions touching Twin-pregnancies—-Dr. J. Mathews Dun- 446 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. can* has presented the following conclusions from some of his in- vestigations on this subject: 1. The largest number of twins is produced by women of from twenty-five to twenty-nine years of age; and on each side of this climax of fertility in twins, there is a gradually increasing falling off in their number, as age diminishes on the one side, and increases on the other. 2. Twins are not regularly distributed among births generally ; their production, therefore, is not subjected to the same laws as govern ordinary fertility. 3. The mean age of twin-bearing mothers is greater than that of mothers generaUy. 4. Twins increase in frequency as mothers become older. This forms a striking contrast to the fecundity of a mass of wives (not mothers), which diminishes as their age increases. It accords, however, with the law of intensity of fertility of fertile women. 5. NeAvly married women are more likely to have twins the older they are. 6. While the fecundity of the average individual increases with age till twenty-five is reached, and then gradually diminishes, there is some probability that the opposite is true, so far as regards twins alone ; fertility in twins being greatest when fecundity is least, and vice versd. 7. The actual number of twins, born of a mass of women in different pregnancies, decreases as the number of the pregnancy in- creases. 8. The number of twins, relatively to the number of children born in different pregnancies, increases with the number of the pregnancy. In other words, a woman is more likely to have twins in each succeeding pregnancy than in the former pregnancy. The first pregnancy forms an exception to this rule. 9. In an individual, twin-bearing is of course a sign of high fertility at the time. It also, in a mass of women, shows a high amount of fertility, at least till the time of the birth of the twins. 10. It is probable, though not proved, that twin-bearing women have larger families than women uniformly uniparous. It may not be Avithout interest to refer to a paper by Dr. Arthur Mitchell,f in which he attempts to show that twin-births are an abnormity. In part, this may be regarded as the fact, but its appli- cation is far from being universal. His conclusions are as follows: 1. Among imbeciles and idiots a much larger proportion is actually found to be twin-born than among the general com- munity. * Fecundity, Fertility, Sterility, and Allied Topics. By J. Mathew3 Duncan, A.M., M.D., L.R.C.S.E., F.R.C.P.E., etc. Edinburgh, 1866. f Medical Times and Gazette, November 15, 1862. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 447 2. Among the relatives of imbeciles and idiots twinning is also found to be very frequent. 3. In families, where twinning is frequent, bodily (of defect and of excess) likewise occurs with frequency. 4. The whole history of twin-births is exceptional, indicates im- perfect development and feeble organization in the product, and leads us to regard twinning in the human species as a departure from the physiological rule, and, therefore, injurious to all concerned. 5. When Ave pass from twins to triplets and quadruplets, every- thing we know regarding these latter gives support to the general conclusions in question. The following letter I received some time since from an old pupil of mine, now practising in the State of South Carolina. I do not insert my reply, for the reason that it embodies what I have already stated in'this volume on the subject of twin-pregnancy : Graham's Turn-Out, S. O, ) March 7, 1867. ) Prof. G. S. Bedford, 66 Fifth Avenue, New York: My Dear Doctor—I have just visited a lady who has been de- livered of four healthy male children at one birth. One of the children was born on the 26th of last February, at 11 o'clock A. m., the other three were born on the folloAving day (the 27th), between the hours of 6 and 8 o'clock a. m. There was but one placenta, which was square; cord attached to each corner. The mother is just twenty-five years of age, and is doing well. All the children nurse the mother, and will average five pounds each in weight. Thinking, perhaps, that you had not seen such a case recently, and especially where all the children were living and doing well, I deemed it my duty, as an old student of yours, to inform you of the fact, as obstetrics was always your favorite branch. Please let me know what you think of such cases, and how often they occur. I remain yours very truly, C. J. Faust, M.D. 446* LECTURE XXX. 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. Gentlemen—It remains for us now to speak of an accident which, though rare, will sometimes complicate labor; and it is very apt, also, to be accompanied by more or less hemorrhage—I mean inver- sion of the uterus, in which, when complete, the organ is turned inside out. It is especially proper that your attention should be called to this accident at the present time, for the reason, that frequently it is more or less directly connected with the extraction of the placenta.* In his excellent Essay on Inversion of the Uterus, the late Mr. Crosse f remarks that, in 350 out of 400 cases of inverted womb, which he had collected, the complication Avas a consequence of parturition; of the remaining fifty cases, forty Avere supposed to have been connected with the presence of a polypus in the cavity of the organ. It is maintained by some writers that inversion of the womb is possible, and has actually occurred in Avomen who have never been impregnated, and when the uterus is in a state of entire vacuity. The accuracy of this latter opinion I very much doubt, for it seems to me physically impossible that a contracted Avomb should become inverted unless it contain a foreign substance, such, for example, as a polypoid groAvth, in Avhich case the accident has taken place. One of the pre-requisites of this peculiar form of displacement is necessarily more or less relaxation or inertia of the organ. * It is right, however, to state that inversion of the uterus may take place some days after the delivery of the child, and the removal of the placenta. Ane and Tellier both cite examples of this kind. In the case of the former, it occurred on the twelfth day; in that of the latter, on the tenth day. \ Part II. p. 70. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 447* Causes.—The causes of inversion at the time of labor are di- verse—such as the sudden and rapid expulsion of the fcetus; undue and forcible tractions on the cord, while the placenta is still in adhesion with the womb; violent coughing immediately after the exit of the foetus, etc.; delivery in the standing position, especially when the delivery is abrupt in consequence of increased capacity of the pelvis. It is likewise alleged that too short a cord, either in consequence of a congenital shortness, or because of its encircling the neck or body of the child, should be enumerated among the causes of this accident. My own opinion is that, admitting the cord occasionally to be extremely short—and there are instances of its measuring from six to ten inches only—it cannot with propriety be classed among the causes capable of producing inversion; for admitting the funis to present but eight inches in length, this would be sufficient, after the expulsion of the head, to allow the escape of the remaining portion of the foetus, without necessarily involving the inversion of the womb, through tractions on the cord. Poly« pus, whether of the unimpregnated uterus,* or as an accompaniment of gestation, may result in inversion of the organ; this you can readily understand, for the weight of the polypus, especially if the uterus be somewhat relaxed, would naturally tend to the production of the accident. Inversion is occasionally spontaneous, and this would be more likely to occur in women who have borne many children, in whom the muscular parietes of the uterus are very much relaxed, and the labor rapid. I think, however, the fact must be conceded that, in the great majority of instances, this form of uterine displacement is due manifestly either to carelessness, or gross ignorance on the part of the accoucheur; as an evidence of the truth of this opinion, you will observe that, in well regulated lying-in hospitals, inversion of the uterus is among the very rare complications of labor. It is an interesting circumstance to record that, in 71,000 cases of delivery, which occurred in the Dublin Lying-in Hospital, there was not a solitary example of inversion.f We, therefore, are to look for this accident principally among the records of private practice. There is an interesting case recorded of congenital inversion. It was reported to the French Academy of Medicine by Dr. Williams, J of Metz. The girl menstruated with regularity. * Instances are recorded in which inversion of the virgin womb has occurred, in consequence of the presence of a polypoid tumor. j- No example of acute inversio uteri has ever fallen under our notice, and tho accumulated experience of Drs. Clarke, Labatt, Collins, Kennedy, and Johnson, in this hospital, does not furnish a single instance of the occurrence of this accident, though the number of women delivered during their united masterships amounts tc upwards of seventy-one thousand. [Hardy and McClintock's Practical Observations, p. 223.] X Dublin Med. Press, Nov. 1843. 448 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Grades of Inversion.—The uterus may be either partially oi completely inverted; in the former instance, the fundus is depressed, and the internal surface may or may not reach the os uteri ; whereas, in complete inversion, the inner surface protrudes through the mouth of the uterus—in a word, the organ is turned inside out. When this formidable accident presents itself—and it is in all truth formidable, oftentimes involving the life of the mother—it is of cardinal importance that it should be promptly recognised, for, as Ave shall remark, Avhen speaking of the treatment, the difficulty of restoring the organ to its original position will usually be pro- portionate to the time which has elapsed from the moment of its displacement. Diagnosis.—If you be in attendance upon a female in labor, and inversion occur, there can be no excuse for your ignorance of the circumstance; for you have been told until, I am sure, the repeti- tion must ring in your ears, that, as the child is passing through the maternal organs, your duty is to ascertain, by placing the hand on the hypogastric region, whether or not the uterus responds to the expulsion of the foetus—in other words, whether it is contracted. Suppose, then, in observing this rule—and to neglect it would be extremely culpable—you are unable to feel the uterus at the loAver portion of the abdomen ; but, in lieu of the organ, there should be distinctly recognised a cupped-like depression. Why, what Avould this state of things indicate ? If there be any truth in evidence, the irresistible deduction Avould be that the womb had become inverted either partially or completely. Whether the former or latter, would soon be revealed by the absence or presence of a large tumor protruding into, and sometimes even beyond the vagina. All doubt as to the true nature of the case would be promptly dis- sipated by a digital examination of the tumor itself. For example, if the inversion be incomplete, the finger, in being carried up to the os uteri, would distinctly feel the internal surface of the organ thrown downward, but still Avithin the uterine cavity. On the con- trary, in complete inversion, the tumor will occupy the vagina, and occasionally extend beyond it, while the os uteri will be found above, and, as it were, forming a species of stricture around the upper portion of the inverted organ. In addition to these evi- dences, the tumor would be sensible to the touch, and the placenta attached to the inverted surface, or, if separated from it, the fact of its previous adhesion would be manifest from the peculiar aspect or feel of the part. When the uterus is in a state of complete inversion, the fallopian tubes, ovaries, and uterine ligaments, are necessarily drawn into the cupped-like or funnel-shape cavity formed by the depression of the external surface of the fundus; and there are instances recorded in which the small intestines, the bladder, and a portion of the rectum, THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 449 had also become prolapsed into the cavity. But the descent of these latter organs must rather be regarded as exceptions to the rule.* Is it possible to mistake Chronic Inversion for something else?— In a case of recent inversion, I repeat, it can scarcely be conceived that there could be an error of diagnosis; but where the displace- ment has become chronlfc, there might possibly be some embarrass- ment, and this leads me to dwell for a moment on certain morbid phenomena with which inversion of the uterus might, without due thought, be confounded—such as prolapsus, procidentia, polypus, and other tumors connected with the Avomb. In simple prolapsus of the organ, the apex of the tumor is down- ward, the base upward, and, besides, the os tineas will come directly in contact with the finger. In procidentia, the apex is downward, the base upward, there is also the os tinea? at the most pendent portion of the tumor. In polypus, the base is dowmvard, the apex upward, consisting of a pedicle attached to the uterus; there is of course no os tineas, nor is there, as a general rule, any sensibility on pressure. In inversion, the apex is downward, the base upward, and there is no os tincae to be recognised at the lower portion of the tumor. If, therefore, these distinctive differences be borne in memory, it seems to me that an erroneous diagnosis is barely possible; and yet there are, unhappily, authenticated instances in which a ligature has been applied to an inverted uterus under the conviction that it was a polypoid growth, and the life of the patient thus sacrificed through want of judgment. Death, however, is not always the consequence of removal of the uterus by Hgature, as will presently be shown when speaking of extirpation of the organ. Inversion of the uterus, I have remarked, is a formidable compfi- cation, and very frequently results in the destruction of the patient; death, under these circumstances, may ensue either from excessive hemorrhage, or from shock to the nervous system, and sometimes even from convulsions. Yet, on the other hand, the chronicles of obstetric medicine are not without satisfactory evidence that women have survived for many years this displacement, after having proved rebellious to every effort to accomplish the restoration of the organ to its original position. Mr. Crosse states that, in seventy-two out of one hundred and nine fatal cases, death occurred within a few hours; in eight within a week, and in six others in four weeks; of the remaining twenty-three, one died at the fifth month, occasioned by an opera- * Levret reports a case of an inverted uterus, in a woman seventy years of age, containing a portion of the rectum, bladder, and small intestines, together with the fallopian tubes and ovaries. [Observations sur la Cure Radicale de Plusieurs Polypes de la Matrice. Ob. 8, p. 132. Paris, 1762.] 29 450 THE PRINCIPLES AND PRACTICE CF OBSTETRICS. tion ; one at eight months; three at nine months, and the others at various periods from one to twenty years.* Treatment.—Let us now suppose that you have a case of incom- plete inversion. How is it to be managed? No time should be lost in efforts to reduce the displacement. The patient should have all the advantage of position, being placed on her back, and the pelvis slightly raised above the plane of th# thorax ; it is especially important to remember that, in this form of uterine displacement, there is very commonly retention of urine in consequence of the pressure of the tumor against the neck of the bladder. Therefore, do not omit, as a preliminary measure, to evacuate the urine by the introduction of the catheter. If the placenta be still in adhesion with the uterus, do not on any account make an effort to detach it either by tractions on the cord—for these would only tend to increase the inversion—or by manipulations with the hand carried into the uterine cavity. On the contrary, what you should do is cautiously to introduce the hand within the mouth of the uterus, and with the dorsal surface of the fingers exert gentle but uniform pressure upward against the inverted portion of the organ—and in this way, it will be made, generally speaking, to resume its position; this being accomplished, frictions on the abdomen, a small piece of ice introduced into the vagina, or the administration of ergot— should the uterus not contract with sufficient energy to separate the after-birth—may be resorted to with a view of evoking in- creased action. The placenta being separated, its extraction is to be accomplished according to the rules indicated in a preA'ious lecture. But how are you to proceed with regard to the management of the uterus when in a state of complete inversion ? In this case, too, promptness is one of the great elements of success—indeed, if even a few hours lapse after the accident, it will be extremely diffi- cult to effect the reduction. Therefore, remember that, under these circumstances, action simultaneous, if possible, with the accident will prove the truest economy. In complete inversion, there will be one of two things—the placenta will either be sepa- rated from the organ, or it will be in connection with it. In the former instance, the tumor should be gently grasped by the hand, and a continued but cautious pressure made in the direction of the respective straits of the pelvis. This pressure, if faithfully per- sisted in, will oftentimes be productive of the happiest results— restoring the uterus, and protecting the patient against the annoy- ance and dangers of failure in the attempt at reduction. When, however, the placenta is still adherent to the inverted organ, there is some difference of opinion as to the proper course * Op. cit., p. 170. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 451 to be pursued. Authors are divided upon this subject, some follow* ing the counsel originally, I think, given by Puzos of previously detaching the after-birth, for the reason that in so doing the volume of the tumor Avill be diminished, and the possible danger of its subsequent extraction avoided. Others, again, maintain that the prehminary detachment of the after-birth is not necessary, and they proceed at once to replace the uterus without any reference what- ever to the deciduous mass.* I should advise you, gentlemen, to adopt neither of these sug- gestions peremptorily; it is not wise—and science repudiates the notion—to have stereotyped rules of conduct for the sick room. You should have stereotyped principles, but the application of these principles must be governed by the circumstances, which may sur- round each individual case. Therefore, the plan which I suggest for your consideration is this—if the placenta be considerably detached at the time of the inversion, you may, before attempting to reduce the displacement, complete its separation, and then imme- diately, in the manner already indicated, proceed with your mani- pulations to accomplish the restoration of the organ. All things being equal, it is, in my judgment, far more desirable to attempt to replace the inverted uterus while the placenta is still in connection with it, and for the very substantial reason that, under such circum- stances, the pressure is not made directly against the womb itself— which must necessarily expose it to more or less injury—but the pressure, you perceive, is directed against the intervening object—■ the placenta. It may, however, be that the size of the after-birth will add so much to the volume of the tumor as to render the reduction physically impossible. In such case, of course, the proper alternative is the detachment of the placental mass. After the reduction has been accomplished, the hand is not to be suddenly withdrawn from the aterus, but, on the contrary, it should be continued within tbd cavity until the organ, through its contrac- tions forcibly expels it; this will be the best safeguard against the recurrence of tie inversion. Should every effort fail—and such in the most skilful hands will not unfrequently be the case—care should be taken to return, if possible, the tumor within the vagina and sustain \t in situ by the india-rubber pessary, or a piece of soft sponge, and, if necessary, with the addition, also, of a bandage. It would seem that after the reduction of an inverted womb, the mortality is comparatively slight, for in fifty-tAvo cases in which the organ was restored to its position, death occurred in seven only, or one in 7.3. Spontaneous Reduction of the Inverted Uterus.—-There are * Great benefit will often be derived from the administration of ether, if there be rothing to contra-indicate its use; its relaxing effects will very much facilitate the leposition of the organ. 452 THE PRINCIPLES AND PRACTICE OF OBSTETRICS several cases reported of spontaneous restoration of the inverted uterus, after resisting every attempt at reduction. One of these occurred in the practice of the renowned Baudelocque, on whose authority it has found a place in the historical archives of the pro- fession. I shall present it to you as recorded : Madame Bouchardat was delivered of her first child at Cape Francis, in 1782 ; at the time of the delivery of the placenta, effected by the hand introduced into the uterus, she complained of severe pain, and felt between her thighs the protrusion of a large tumor, which was immediately returned within the vagina. The lady became almost exsangui- nated, and so prostrate that the attending accoucheur was appre- hensive that, if he made any attempt to restore the organ, she would die in his hands. After seven or eight years of suffering, Madame B. visited Paris for the purpose of consulting Baudelocque. This distinguished accoucheur, after a thorough examination of the tumor, decided that it was an inverted uterus: he made several attempts to reduce it, but failed. He prescribed baths and rest. On the evening of the day preceding that appointed by Baudelocque for another attempt at reduction, Madame B. was urged by some of her friends to walk about ber room. When doing so, she fell suddenly in a sitting position on the floor; she complained of an unusual movement in the lower portion of the abdomen, and, for an instant, lost her consciousness. Baudelocque being sent for, was soon at the house, and, on examination, could detect no tumor—it having spontaneously been restored. From this time, the patient improved in health. Having been a widow for several years, she married again, became pregnant, and was safely delivered at full term. This case, remember, I give you solely upon the testimony of Baudelocque. With less weight of authority, I should be disposed to rank it among what may be termed medical delusions. Extirpation of the Inverted Uterus.—When it is impossible to return the uterus, the inversion becomes chronic ;* in this condi- tion, it may or may not cause much inconvenience, and even involve the life of the patient in danger. For example, when it assumes the chronic form, the system may be gradually drained by the oozing, either of blood or mucus, Avhich is so apt to accompany this stage of the displacement. Again, indolent and rebellious ulcerations, induced by the friction of the dress, may ensue, and * There are some exceptional instances reported of chronic inversion of the uterus, in which the organ has been reduced after years of displacement. Amor,o others, may be mentioned the remarkable case, which occurred in the practice of Prof. J. P. White; the organ had been inverted for fifteen years; it was successfully reposited. The patient died sixteen days subsequently of peritonitis. Dr. Tyler Smith reduced an inverted uterus of twelve years' duration; patient recovered. [Foi details of Prof. White's case, see Am. Jour. Med. Sci., July, 1858. p. 13. For Di Smith's, Am. Jour. Med. Sci., July, 1858. p. 270. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 453 these ulcerations so far compromise the safety of the Avoman as to suggest the very delicate and important alternative—extirpation of the inverted organ, as the only chance of safety. In the whole range of obstetric medicine, I know of no more momentous ques- tion than this for the decision of the accoucheur; painful, indeed, is the responsibility of an operation, the very nature of which, to my mind, is horrid to contemplate; not so much because of the danger of the alternative, as that it absolutely unsexes the woman, and makes her existence one of irreparable sadness, more especially if she should not have passed the child-bearing period. I, there- fore, think that the fullest and most undoubted evidence that, aU things fairly and deliberately weighed with the single motive of arriving at the truth, the operation affords the only hope of safety —will alone justify a resort to it. The following table, Avhich I take from Dr. West,* gives the result in fifty cases of extirpation of the uterus for inversion con- nected with parturition. It will be seen that thirty-six of the cases were successful, twelve fatal, and in two instances, although the patients survived, it became necessary to abandon the opera- tion. The total also shows the results of the respective modes of performing the operation—ligature and excision. Whole number Eecovere(L jjied. Operation of cases. recovered. .uiea. abandoned. Uterus removed by ligature in 38 28 8 2 " " " knife in 4 3 1 *' " " knife and ligature 8 5 3 50 36 12 2 The annexed table is interesting, as it indicates the influence of the period at which the extirpation is performed on its fatality : Patients recovered. Died. Total. Under 1 month, 4 3 7 Between 1 and 2 months, 3 3 » 2 " 6 " 3 3 6 « 6 " 12 " 2 3 5 " 12 " 18 " 5 5 " 18 " 2 years, 1 1 « 2 " 3 " 4 4 " 3 " 4 " 2 3 » 4 " 5 " 4 4 » 5 " 6 " 2 2 « 6 " 7 " 2 2 After 12 years, 1 1 " 14 " 11 " 15 " 11 " many years, 2 2 35 11 46 At the commencement of this lecture, I remarked that it waa * Lectures on Diseases of Women. 1858., p. 186. 454 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. more particularly in the walks of private practice that we are to look for the occurrence of inversion of the womb, and that it is, unhappily, too often the direct result of ignorance and wanton brutality. The following melancholy case will, I think, sustain me in this opinion; it occurred some years ago in this city, and became the subject of legal investigation; it, therefore, forms a part of the criminal calendar of New York. It is a dark picture in the affairs of professional life as occasionally exhibited in this metropolis, and, perhaps, such revelations would be more frequent, were it not that the.grave, which receives the victim, too often buries within it the tale of woe which led to that victim's des- truction ! A poor German Avoman was taken in labor, and sent for a Dr. Septimus Hunter, to minister to her wants. The child was deli- vered, but there was some delay in the expulsion of the placenta. It was proved by numerous Avitnesses, in the room at the time, that the doctor had made the most powerful efforts to bring away the after-birth, amid the heart-rending screams of the unfortunate patient, and the most fervent appeals both from her and the friends who surrounded her, that he would desist, and leave the poor sufferer to nature. It was also shown that, during these savage manipulations, the blood flowed profusely from the womb, so that there Avere, in the language of the witnesses, " big pieces Hke liver upon the floor." The doctor, intent upon the accomplishment of his purpose—the removal of the placenta—paid no sort of attention either to the agony of the patient, or the remonstrance of her friends, but continued his unholy work; his cruel efforts Avere in no way diminished, but the shrieks of the patient had ceased; she lay quiet, and without a murmur; bracing his feet against the bed, by one herculean grasp Dr. Septimus Hunter brought away, as he supposed, the placenta, but with it, he likewise tore from the body of that dead woman—the womb!!7 There was necessarily much excitement among the witnesses of that scene of blood; a police officer Avas sent for; Hunter was arrested ; the coroner held his inquest—and the verdict of the jury was: " That the death of the woman was caused by the tearing out of the womb by Dr. Septimus Hunter." The uterus was preserved by the coroner; it proved to be a case of inversion of the organ, Avhich this trafficker in innocent blood had mistaken for the after birth, and thus coolly and deliberately wrenched it from her person ! After the finding of the verdict by the coroner's jury, the case Avas submitted to the Grand Jury, who, after a full hearing of the evi- dence, brought an indictment of murder against Hunter. The trial excited much attention at the time, and the interest of the profes- sion was especially eficited. Several, medical gentlemen were ex- amined, and there was a very general concurrence among them THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 455 that the death of the woman was occasioned by the tearing out of the womb ! It was my good or bad fortune—I cannot say which—to be called as a witness on the occasion ; and I unhesitatingly gave it as my opinion that death was not the result of the tearing out of the womb, but that the woman died from flooding, and that she was dead before the man of blood had wrenched the uterus from her person ! This opinion was regarded as a very singular one—it was at vari- ance with the rest of the medical testimony, and subjected me to a searching cross-examination by the Hon. Mr. Whiting, who at that time held the office of District Attorney. The examination, able as it was, did not cause me to surrender, in the slightest detail, or compromise in any way the broad and emphatic opinion I had given under the solemnity of my oath, and, I hope, with a full appreciation of my duty to the commonwealth. Now, then, gen- tlemen, had I any basis for that opinion, and if so, what was it ? 1st. It Avas proved by numerous Avitnesses—and their testimony was not contradicted—that while the doctor, in defiance of the shrieks of the patient, was engaged in his brutal work, there was profuse hemorrhage from the womb. This testimony was con- firmed by the coroner and jury, who stated that when, soon after the death of the woman, they entered the room, they found the bed and carpet completely saturated with blood. 2d. It was also proved that, for some minutes before the doctor had brought away the uterus, the patient ceased to complain ; she lay quiet, made no manifestation of suffering; and the moment the doctor had achieved his triumph, the friends, in ignorance of what had been done, sup- posing that aU was right, spoke to the patient, told her it Avas all over—Dut the intelligence reached her not—that woman was dead! It was, therefore, upon this testimony that I founded my opinion; for it is absurd to imagine, in the first place, that the woman, if alive, would not have continued to exhibit the intensity of her suffering during the butchery to which she was subjected; and, secondly, the quantity of blood lost sustains the hypothesis that she had expired before the completion of the horrid deed. It was attempted by the learned counsel for the prosecution to show that the bleeding was the result of the tearing out of the uterus, and that, therefore, the defendant was guilty of murder. On this point, too, I underwent a protracted examination, and all that legal acumen could accomplish, was brought to bear in the attempt to elicit from me • an affirmative answer. But I also had a duty to perform, and that was to subserve justice as far as I Avas able to do so. My reply to the question was—that there were, in my opinion, two reasons why the hemorrhage could not be the result of the forcible pulling out of the uterus: 1st. The united testimony of all the witnesses, that the blood had escaped before the womb was THE PRINCIPLES AND PRACTICE OF OBSTETRICS. removed; 2d. That lacerated vessels do not, as a general rule, bleed. My testimony, I believe, had something to do with the verdict rendered by the jury in the criminal trial—instead of murder, Hunter was found guilty of manslaughter, and sentenced for twelve months on Blackwell's Island. It was my duty to testify to the truth, without reference to any collateral issue; I did so; at the same time, I am free to confess that if I had been governed simply by my feelings, and the award of punishment had been left to my discretion, I should have sent the man to the State Prison for life, in order that the bulky walls of that mansion might protect the community against a similar outrage. LECTURE XXXI. Preternatural Labor, divided into Manual and Instrument—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 Prawia; Rules for—Dr. Simpson and Entire Arti- ficial Detachment of Placenta; Objections to—Dr. Barnes and Partial Artificial Detachment.—Ergot in Placenta Prsevia; 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. Gentlemen—We shall now discuss the interesting subject of pre- ternatural labor, by which you are to understand that form of parturition in which nature is so far contravened in her arrange- ments, as to need the interposition of the accoucheur for the accom- plishment of childbirth. Preternatural labor, we have already remarked, may be either manual or instrumental. In the former instance, the introduction of the hand becomes necessary for the termination of the delivery; while, in the latter, a resort to instru- ments is indispensable. Manual Labor.—The causes of manual labor are numerous, and it is important that you should have a clear appreciation of them, in order that its indications may not be confounded with those of instrumental delivery. In the first place, you are to bear in mind that there are many complications, which may present themselves during the progress of labor, and Avhich, therefore, may so far com- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. promise the safety either of the mother or child as to call for the prompt interference of the accoucheur—the interference, how- ever, being limited to the introduction of the hand with one of two objects: either to correct a malposition, and then commit the ter- mination of the delivery to nature, or, if the necessity be urgent, to proceed at once to the accomplishment of the birth by version. It is too obvious to need argument that, when there is much dispro- portion between the foetus and maternal organs, manual aid will be utterly inadequate to the requirements of the case; under these circumstances, a resort to instruments will be the only alternative. For how could you hope, by the simple introduction of the hand, either to enlarge a contracted pelvis, or diminish the size of a foetus disproportioned to the passage through which it is to make its exit ? In strict truth, the essential causes of manual labor will be found in the various malpositions of the fcetus, thus rendering an adjustment of the position absolutely necessary in order that the child may pass; but, at the same time, there are other complications to which we shall presently refer, Avhich will call for artificial interposition; and there may, also, arise the question of alternative of choice between instrumental and manual delivery, the question of alter- native being determined by the peculiar nature and exigencies of the case. The foetus may be said, so far as the possibility of natural deli- very is concerned, to occupy a malposition when, instead of one of the extremities of the ovoid, some portion of the trunk presents at the superior strait; it is also badly situated if the head, in lieu of the vertex, should present its occipital or lateral regions, for, in this case, the disproportion would be such as to render it physicaUy impossible for the head to pass without a previous change of posi- tion ; and again, the same difficulty would occur in presentation of the breech, knees, or feet, if either of these portions should be so placed against any part of the upper strait as to become immovable, notwithstanding the contractions of the uterus. So you are to recollect that not only, in order that labor may be natural, is it required that one of the obstetric extremities of the child shall pre- sent, but it must present properly, and in accordance Avith the ability of the uterus to expel it. Besides the malpositions of the fcetus, there are various accidents, Avhich may so far complicate the safety of either mother or child, as to convert a labor, Avhich Avould otherAvise be natural, into one of manual delivery, or at least into one in which it may become necessary to determine Avhether it would be more judicious to resort to instruments, or terminate the labor by the hand. These accidents are as follows: exhaustion, hernia, prolapsion of the umbilical cord, hemorrhage, convulsions, multiple pregnancy. 1. Exhaustion.—The young practitioner, whose experience ii) 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 yon may have a clear understanding of its true import, and of the indications it involves, I shall divide it into two 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 between these two grades of exhaustion at the bed-side, all possibility of embarrassment Avill be at an end. Relative Exhaustion.—I have scarcely ever attended a case of labor, unless its duration was extremely brief, in which, 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. Now, gentlemen, if you give this phraseology a literal translation, if you take your patient at her word, you will at once conclude that a storm is gathering, and, in your anxiety to do something, you may be guilty of officiousness, which wiU be quite likely to compromise the safety of the woman and her child, and do no great credit either to your judgment or skill. When you reflect, for a moment, on the severe 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 will utterly annihilate her ! But how delusive this opinion of the patient, whose standard of danger is the amount of physical suffering she endures. Not so, however, with 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 nn 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, who a moment before was admonishing every one about her that she Avas exhausted and would certainly die, not only becomes tranquil, but engages in conversation, and even will laugh Avith good heart at a merry jest, which 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 whatever of a dilapidated condition of the vital forces—in a word, the prostration of which the patient complained, and which 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 Avhatever, 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 with unerring certainty that the system is at a Ioav ebb—that it is fast approaching utter dilapidation. There is no, or, if any, but a momentary response to stimulants. The forces will not react. In these cases, which fortunately may be regarded as rare, every 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 without 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 when we speak of the indications and rules for turning. Hernia.—If a woman in labor be affected Avith 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, however, the hernia become irreducible, and increase during the pains of labor so as to place in jeopardy the safety of the patient, common sense at once tells you that the broad indication is to proceed without delay to artificial delivery, according to the rule to which we have just referred under the head of positive exhaustion. Prolapsion of the Umbilical Cord.—This a very serious com- pfication 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 folloAvs 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 follows: a pelvis, which 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 when 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 which 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 women Avho have borne several children than in the primipara, and this arises from the fact that, in the former, the uterine walls 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 favor this complication. Diagnosis.—The diagnosis is not difficult, and may occasionally be determined before the rupture of the bag of Avaters, although, as a general rule, it is more readily arrived at after the escape of the fiquor amnii. In the former instance, the cord may be felt, during the interval of the uterine contraction, through the membranes, and the fact that what 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 between 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 Avill be removed. 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 which there has existed a difference of opinion. Some have supposed that it was in consequence of the blood becom- ing coagulated in the descended portion of the cord ; but it is now very generally conceded that death ensues from the compression exercised upon the funis, thus interrupting the circulation between 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 will 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 foetal heart. Dr. Arneth, of Vienna, mentions four cases under his notice, in which no pulsations had been detected in the cord for half an hour previous to delivery, and in each instance the child was born living. From what has been already stated touching the fatality of this complication to the child, it will 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 fcetus. In doing this, you will have done nothing more than your duty; and whether the child be saved or perish, you will have liberated yourselves from all responsibility, which concealment of the fact would 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, Avhen 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 no< 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, however, is greater after the rupture of the membranous sac, and this circumstance, therefore, is an additional motive why great caution should be exercised not prematurely to interfere with the integrity of the bag of waters. Treatment of a Prolapsed Funis.—What is to be done in cases in which 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, with this view of the subject, oftentimes to do mischief. There are three conditions in which this accident may present itself, each varying 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 weak, indicating that the pressure exercised upon the cord is endangering the circulation between the placenta and foetus. If you will bear in mind these three conditions, and give fuU appreciation to each one of them, your duties in this form of com- pHcation will not only be simplified, but what is very important they will be well 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 would 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 way 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 vigorous, 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 i* 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, however, presents different indications, and something must be attempted to prevent the effects of the compression, which are shown by the fact that the pulsations lose their ordinary force, and become more and more weak. Here, if the compression continue, there is very serious hazard to the child, and now the question arises—What, under the circumstances, is to be done ? Much has been said about the reposition of the prolapsed funis, and, with 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 attetnpt 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. But, gentlemen, it is one thing to talk, and quite another thing to act. I have known many a plausible theory to give way and prove utterly negative, when 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 within the vagina; they are thus brought in contact with the fold of the cord ; this latter should be directed toward one of the lateral and posterior points of the pelvis—most frequently toward 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 way 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 foetus 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 terma postural treatment. The woman, in case of funis prolapsion, " is placed on hei knees, with the head down upon the bed." Dr. Thomas observes ''that the cause* 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, bj 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 holloAv 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 was almost pulseless Avhen returned; in one instance, the forceps was resorted to in consequence of inertia of the uterus. But 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 would very properly subject you to merited rebuke, unless you had a good and justifiable reason for non-interference. There are two alternatives to which recourse may be had in a contingency of this kind—Aversion and delivery by the forceps. It is extraordinary that there should exist among writers on mid- wifery 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 living, and the presenting part remain high up in the pelvis.'' The language just quoted is that of Denman, Avhose name deservedly carries with it great weight. No less an authority on the general question of obstetrics, Dr. Dewees, 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 ther.« 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. But to do so, would, I apprehend, be of little moment. It is more important, I think, to examine, for the instant, the universal propriety of the rule incul cated. 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 only it, bu^ the lubricity of the cord, which ordinarDy constitutes the main barrier to our success. [Transactions New York Academy of Medicine, Vol. IL, Part II-l 30 466 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. The ostensible and only justifiable argument in favor of version in cases such as are now under consideration, is that it toill afford the child the best means of safety. But 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, which cannot be lightly regarded by the accoucheur. How often is the life of the mother involved in peril in the operation of version, and how 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 whether, in full vieAV of all the facts of the case, turning presents the greatest promise of safety to the child, without 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 following 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 why version should not be attempted, for the reason that efficient and regular contractions would 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 have passed into the pelvic cavity, and more especially if it should have reached the inferior strait, then the indication Avould obviously be to deliver without 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, will 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, which is more or less directly connected with placenta praevia. By the term placenta praevia, you are to understand the insertion of the after-birth either completely or partially over the neck of the womb. THE PRINCIPLES AND PRACTICE OF OB&TETEtCS. 467 The almost necessary connexion between this attachment of the placental mass and hemorrhage will be pointed out immediately. The earlier writers promulgated some singular views in explanation of the reason why the placenta is occasionally found implanted over the cervix uteri. Some of them maintained that this was not the point of its original attachment, but that Avhen found over the os uteri, it was the result simply of separation from its former place of insertion, and the'consequent gravitation of the mass toward the neck of the organ. You are to remember, however, that this hypothesis, absurd as it is, was the offspring of those times in which physiology was scarcely in possession of a name, and when, consequently, our present advanced knowledge of embryonic development was one great blank. But even with our present knowledge, there is not a general concurrence of sentiment as to the true cause of placenta praevia. I am very much inclined to the opinion, however, recently suggested, that it is owing to the fact of the fecundation of the ovule after it has passed from the upper to the lower portion of the uterus to the immediate vicinity of the os uteri. This explanation at least possesses the merit of plausi- bility, and is due, I believe, to Dr. Tyler Smith. I have just told you that the placenta may be attached to the neck of the uterus either completely or partially. In the former instance, the after-birth may be said to rest, centre for centre, over the dependent part of the organ; Avhile, in the latter, only a portion of its border is found there. But what is essential for you to remember is, that, in either case, there will be, as a general rule, more or less hemorrhage. Indeed, were it not for the flooding attendant upon this form of presentation, placenta praevia would be altogether without interest. It is, therefore, because of the serious danger in which both mother and child are involved from losses of blood in placental presentation, that it becomes a question entitled to your fullest consideration. I have endeavored, when discussing that subject, to portray to you the imminent peril of the lying-in woman in hemorrhage after the birth of the child; and now you will permit me to assure you that, kindred to that peril, is the hazard which life encounters from the hemorrhage consequent upon placenta praevia; nor must it be forgotten that the danger is more momentous in the latter case, from the circumstance that here, in addition to the safety of the mother, the life of the child becomes seriously involved. Is there a necessary connexion between placenta praevia and losses of blood, and if so, what is that connexion? This is an exceedingly interesting question for the young accoucheur, and its solution will at once point out to him, not only the true danger of this form of presentation, but it will also demonstrate beyond a peradventure the urgent necessity of unbroken vigilance in these 468 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. cases, so trying to the interests of both mother and child, and at the same time so harassing to the practitioner. Well, there is a connexion, and it is simply this : the direct cause of the hemorrhage is the rupture of one or more of the utero- placental vessels, in consequence of the widening or dilatation of the uterine extremity or internal orifice of the cervix. You will remember, when speaking of the gradual development of the uterus, under the influence of gestation, your attention was specially di- rected to the important fact, that, for the first five months, the accommodation of the groAving embryo is provided for exclusively by the increased capacity of the fundus and body of the gravid womb; and it is not until after the fifth month that the cervix of the organ begins, through a process of shortening, to contribute its proportion of space to the wants of the foetus. If this be- really so, and I think there is no doubt of the fact, you Avill at once per ceive hoAV irresistibly, as a general rule, there is deduced from the recollection of this circumstance a most important practical principle in connexion with the question now under consideration. The principle to which I allude is this: that in placenta prmvia, the hemorrhage may commence, not necessarily at the time of labor, but at the sixth month, and may continue at intervals in more or less quantity, until the completion of the delivery at the fidl term. Contrary to the opinion of Stoltz, Cazeaux, Dr. Matthews Duncan, and others, I have endeavored to show you that the shortening of the neck of the uterus in pregnancy commences at its uterine, and not at its vaginal extremity. As soon, therefore, as this shortening commences, it will generally, to a greater or less extent, be at the expense of the integrity of some of the utero-placental vessels, which, in placenta prazvia, constitute an important connexion between the upper portion of the cervix and maternal surface of the placental mass. I say generally, and it is, in a practical point of view, and more particularly as regards a correct diagnosis, important that you should bear the word in memory, for you will sometimes meet with exceptional cases in which, in placenta prazvia, there is no sign of hemorrhage until the commencement of IdSor at the full term of utero-gestation. When, however, the bleeding commences at any period between the sixth and end of the ninth month, it is well to recollect that there is nothing fixed or regular in its recurrence. It will sometimes be sfight, again copious, and may return at an interval of a few days; nor is it announced by any premonitory symptoms, its advent being more or less sudden. In some cases, too, strange to say, through a salutary clot, and the closing of the exposed utero-placental vessels, the woman will pass on to the completion of her pregnancy without the interposition of science. But these are extremely rare instances, and should in no way be relied upon as a reason for inaction on the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 469 part of the accoucheur. On the contrary, it will be his imperative duty, as we shall state under the head of treatment, promptly to interpose as soon as he becomes aware of the hemorrhage, no matter how sfight it may be at its inception. The bleeding in cases of placenta proevia has not been improperly termed unavoidable, in contradistinction to another form of hemorrhage during gestation, designated accidental. In the latter instance, the loss of blood is due to a sudden and partial separation of the placenta, when situ- ated in other portions of the uterus than over the cervix, and the separation is traceable mainly to falls, shocks, mental emotions, or sudden congestions. This accidental hemorrhage may arise, also, from rupture of one or more vessels of the umbilical cord. There is one point essential to note in connection Avith placenta prazvia, more particularly when the after-birth rests, centre for centre, over the cervix uteri, and the point to which I allude is this: the hemor- rhage is more profuse at the time of labor than if it should occur previously to the full term of gestation, for the reason that the effect of a labor-pain is to detach from the cervix a portion of the placental mass, and consequently expose a larger surface of the utero-placental vessels ; and these utero-placental vessels, it must be remembered, have, at the completion of gestation, attained their maximum of development; and, in this latter fact also, will be seen an additional reason for the greater profuseness of the flooding at the period of ordinary parturition. It will sometimes happen that the placenta, through the sponta- neous efforts of nature, will be expelled previously to the child; in this case, the head of the foetus, responsive to the contractions of the Avomb, may act as a wedge against the bleeding surface of the cervix, and thus most opportunely arrest the hemorrhage. Again : if a woman have an extraordinarily capacious pelvis, and the con- tractions be marked by great vigor, the entire ovum—child, pla- centa, and membranes—may be suddenly thrown from the uterus, and in this case, too, if the vacated organ contract promptly there Avill be no flooding. These, however, it is to be recollected, are instan- ces contrary to the general rule. But as they have, and will again occur, it is incumbent to bear them in memory. When the expul- sion of the after-birth is preceded by that of the child, it is impor- tant to recollect that this is the result altogether of the strong con- tractions of the uterus, which, in the first place, have been sufficient to detach the placental mass, and, secondly, to throw it into the world. In these instances, if one of the extremities of the ovoid should present, the delivery is usually accomplished Avithout delay, and the case terminates auspiciously, for the simple reason that the separation of the placenta and the subsequent part of the labor haa been effected in accordance with the natural effort. Malpositions of the foetus, however, are not at all infrequent in placenta praevia, 470 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and this should be remembered, in order that when they do occur their recognition may be prompt. This form of presentation neces- sarily enhances the danger to both mother and child. Symptoms.—If a pregnant female have hemorrhage from the uterus, at any time between the sixth and ninth month of gestation, and on investigation it be ascertained that there is no external cause for the bleeding, and if the blood flow in sudden gushes at inter- vals, even during the quietude of sleep, then the apprehension may arise that the hemorrhage is due to placenta praevia. If the hemor- rhage occur at the time of full parturition, and there be an absence of any of the causes of accidental bleeding, and if the discharge of blood become more profuse as the labor-throes advance, it is valua- ble presumptive evidence that the placenta is over the mouth of the uterus. Diagnosis.—In order that all uncertainty may be at an end, and the question of placenta praevia placed beyond a doubt, it is well to recollect that there is one means by which the accoucheur can arrive with full truth at an accurate diagnosis ;* and this consists in the fact that, if the os uteri be dilated sufficiently to admit the introduction of the finger, he can feel quite distinctly the placenta resting over it. The contact of the finger A\Tith this mass will impart a soft, doughy sensation. It is possible, however, without due caution, to mistake for the after-birth a clot or coagulum of blood. If it be the latter, it will be found movable, and may be readily brought away by the finger. There will, occasionally, exist around the os uteri vegetations, either syphilitic or cancerous, and these, too, may through inattention be confounded with the placenta. This latter body may also sometimes be recognized by the finger through the parietes of the cervix, even when there is no dilatation ; but to accomplish this will require great nicety of touch, and a large experience in explorations of this kind. It is well, also, to recollect that, in placenta praevia, the vessels of the vagina become greatly engorged, sympathizing in this respect Avith those of the lower segment of the uterus, and these arterial pulsations are marked by increased force. Treatment.—The most important and interesting circumstance connected with placenta prazvia is unquestionably its management; * According to statistical compilations from the journal of the Clinical Hospital, at Breslau, made by Dr. Von Glisczynski, (Med. Centr. Ztg.; Schmidt's Jahrb., 102, 5,) placenta praevia occurs not quite as frequently as stated by others, only ninety cases having been there observed in 10,440 deliveries. The first indication is fur- nished by hemorrhage, during the latter third of pregnancy; sometimes as early as the fourth or fifth month. A certain diagnosis is not possible until the placenta itself can be felt. The fact that this abnormity occurs almost exclusively in multipart leads to the hypothesis of defective reorganization of the womb, either fiom several pregnancies following each other in too short a time, or from inflammatory and othel morbid conditions of the same. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 471 for although the fatality of these cases is comparatively great both to mother and child, yet, through prompt and judicious treatment, it may be much diminished.* You may be called to a case of this kind at any period before the completion of gestation, or at the time of labor, when the term of pregnancy has been accomplished, and parturition regularly commenced. We will suppose, in the first instance, the former case. The female may have reached the sixth, seventh, or eighth month; she discovers that she is losing blood from the vagina; it increases from day to day, and, in her anxiety, she sends for one of you. What, under the circumstances, are you to do ? The first inquiry, which would naturally suggest itself to the mind of an intelligent physician, would be—What is the cause of the bleeding ? Is it the result simply of a threatened premature delivery? is it occasioned by some sudden shock or injury, thus presenting an example of acci- dental hemorrhage ? or is it traceable to the fact that the placenta is inserted over the neck of the uterus ? These are the questions to be determined, and on their solution will depend the special treat- ment indicated. If you be of opinion—judging from the antecedent as well as the accompanying circumstances of the case—that the bleed- ing is due to placenta prazvia, then I would suggest to you to pur- sue the following course: the patient should be placed on her back, with the hips slightly elevated; she should repose, not on a feather bed, but on a hard mattress; the room, if in winter, not to be above a medium temperature; if in summer, the Avindows and doors should be opened, in order that a pure and refreshing current of air may be promoted. It is most important to guard the patient against all excitement, whether of body or mind. If fear should have seized her, and the ner- vous system become in consequence much disturbed, one of the best medicines, under the circumstances, wiUbe the comforting assurance of her medical man that he will carry her safely through her tribu- lation. How often is it in the power of the accomplished physician by a dexterous use of the influence he possesses over his patient, to * Dr. Schwarz, having examined the official returns made by Hesse Cassel prac- titioners, states that during a period of 20 years, 519,328 births were reported by 150 accoucheurs, and among them 332 cases of placenta praevia, or 1 in 1564 labors; the numbers varying from 8 to 28 per annum. The mortality depends upon the degree of the presentations of the placenta, and also upon the mode of treatment; or the 332 cases reported by the Hesse practitioners, 86 died, or 1 in 3'86. These, it must be re- membered, embraced every variety of the accident, partial and complete. This cor- roborates in a remarkable manner the statistics of Prof Simpson, who shows from data furnished by lying-in hospitals and practitioners of large experience that the general mortality of the accident is 1 in 3-6, and also, with the mortality of cases enume- rated by Prof Trask (Prize essay on placenta previa, Transactions American Medi- cal Association, 1855), which was, 237 deaths in 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; thai afforded by Prof. Trask's record is 1 in 3 4. 472 THE PRINCIPLES AND PPvACTICE 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 which may be taken once in two hours, until an aperient action is produced : Sulphat. magnesiae § i. Infus. fol. Rosar. f. § viij. Ft. sol. This is a combination, Avhich I have employed with signal advan- tage in cases such as Ave are noAV 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 wine-glass of cold water. To preA^ent injury to the teeth it should be taken through a glass-tube. One point you are not to neglect—Avhen 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 followed 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 in\rolve apprehensions as to the general issue. Then, in addition to Avhat has already been suggested, it will be proper for you to institute a careful vaginal examination Avith 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 eArident that although internal flooding might possibly follow the employment of THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 473 the tampon in accidental hemorrhage, yet there is no ground for apprehension that it will ensue in placenta praevia, for the reason that ie bleeding surface is below, and the blood does not accumu- late within the cavity of the uterus, but collects between the tampon and that portion of the cervix from which 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 Avhich 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 Avhich 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—How long is the plug to be employed ? My answer 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 fcetus be still at the superior strait, and the mouth of the womb 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. But how are you to know—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 well 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 will excite action of the organ, and thus promote contractions which, of course, Avill tend to hasten the opening of the os, an object so desirable in cases such as Ave 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 a X bandage. There are several modes of introduc- ing the plug. I adopt the folloAving: the index finger of one hand being introduced into the vagina, the palmar surface upAvard, I seize with 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 otheT pieces. An efficient tampon will be the india-rubber bag, filled with ice- water (the colpeurynter). Let us now suppose that, on withdrawing the plug, it should be ascertained that the mouth of the womb is soft and dilatable, per- mitting the introduction of the hand without the fear of violence; how are you to proceed with the delivery ? I recommend, in case you should undertake the version of the foetus, to proceed as follows : Carry your hand cautiously through the vagina to the mouth of the uterus—here, of course, you come in contact with 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 with 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, without hesitation, select this as the point of entrance, and immediately introduce the hand for the purpose of bringing down the feet. But, 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 two 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 wisdom, the moment the opportunity occurs, to do that very thing which, under the contingency, is most likely to accom- plish the greatest amount of good—the prompt toithdrawal of the fcetus 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 flrst 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, will be enabled to guard against inertia of the uterus, and having accomplished the delivery of the foetus, 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. But 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 with the placenta? My advice is—to pay no sort of attention to it; bring doion the feet, deliver the child, and then, if the expxdsion 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 Avhich 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 which the placenta was 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 between spontaneous and artificial detachment. The former is the work 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, how is this mass detached, no matter where it may be situated within 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 ? But suppose, with 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 ; would there not, as a necessary consequence, in ninety-five cases out of one hundred, be more or less profuse bleeding ? TJn« 476. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. doubtedly such Avould be the result, and there is, in my judgment, a striking analogy between the two 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, how are we to explain the occurrence of profuse post-partum hemorrhage after the placenta has been expelled? Will it be argued that, in pla- centa praevia, we have one kind of bleeding surface, and in hemorrhage after the expulsion of the after-birth, another ? The great bleeding-surface, as I have 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 Aressels, was also maintained by the late Professor Hamil- ton, of Edinburgh.* It is proper, however, to remark, that the opinions with 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. Robert Lee, of London, is one of the sturdiest advocates of the doctrine that the blood proceeds from the uterine sinuses, Avhile Dr. 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, however, is very certain, that the treatment of pla- centa praevia—more especially since the suggestion of Professor Simpson of detaching the placenta as a remedial resource—has pro- voked a very bitter controversy—indeed, in some instances, the contest has assumed unmistakable evidences of what, in plain lan- guage, may be called strong personalities, a feature always to be avoided in scientific discussions. In the fierce conflict of the political arena, such episodes are more or less in keeping with 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. Barnes, 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. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 477 the serious peril of rupture of the organ—and well may it be asked cui bono? But Dr. Barnes, while 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, however, 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 well 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 with regard to the entire separation of the after-birth, and those of Dr. Barnes 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 was suggested to Dr. Simpson from a consideration of the high mortality of the operation of turning compared with that folloAving cases of sponta- 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 follow its artificial detach- ment, he suggested this as a resort in all cases of labor thus com- plicated, in which, 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, &c. To meet this objection, Prof. Trask, in his essay already alluded to, has collected all the published cases to which he had access, together with others communicated to him. He has analysed them Avith a A'iew 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 follows: '; The teachings of the best authorities are confirmed, that the period of greatest danger is between the seventh month and the completion of pregnancy. Of the presentations in the 353 cases, 113 were of the head, or the head complicated with descent of the * The Physiology and Treatment of Placenta Praevia. By Robert Barnes. 1851 478 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. funis or hand; 21 of the superior extremity; 22 of the pelvic extre- mity, and 2 of the umbilicus ; the remainder were probably, for the most part, of the head, but the proportion of unnatural presentations is very marked. "From Table I., embracing cases subjected to ordinary modes of treatment, or dying undelivered, we learn that there were 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 which the hemorrhage was very severe, among the recoveries after artifi- cial delivery, with the 12 in which it was moderate, we 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 was 1 case of moderate to 11 of severe hemorrhage, while of those delivered spontaneously there was 1 moderate to 5% severe. 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 partial presentations, and, as a consequence, less hemorrhage, and therefore a lower rate of mortality. "Adding the cases of Drs. Lever and Merriman to the cases in the table, Ave 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 Hesse-Cassel is even greater, 85 having been born living, and 251 dead, or 1 3.9 of the Avhole 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 Avhole, 59 required manual assistance, Avhile 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 plaeenta 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 Avhich we 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 expedient 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 somewhat less than the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 479 general mortality under ordinary modes of treatment, and espe- ciaUy 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 was considerably larger among these than among cases constitut- ing the first table; that the proportion of cases in which the hemorrhage was very alarming was 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 was resorted to. This circumstance is, of course, entitled to great weight in comparing the results of the two 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 Avith 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 foUowed the placenta, in more than half the cases, in ten minutes or less, while 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 powers have rallied, and, at various intervals from one-half hour up to eighteen hours, have expelled the child. " This table gives abundant evidences of the haemostatic powers of artificial detachment. Of 66 cases, in 35 hemorrhage ceased immediately and entirely, and in the remainder, with scarce an exception, it continued but a short time and in trifling degree. " Fifteen children were saved and thirty-two lost, or a trifle less than one in three saved. It is evident that unless dehvery soon follow this operation, the life of the child must almost necessarily be sacrificed. The result here given does not differ much from the results following turning and spontaneous expulsion of placenta, in which a trifle less than one in three were saved. It is quite proba- ble that, as suggested by Dr. Barnes, the detachment, in at least some of the instances in which the child was saved, had been only partially effected. " The plan of partial detachment, as recommended by Dr. Barnes, 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 allow of changes in the blood required by the child." Ergot—the secale cornutxim—is a remedy much employed by many practitioners in placenta prozvia. The Avell-known influence exercised by this agent in the production of uterine contraction has caused, I fear, a too indiscriminate resort to it. I have great confidence in ergot, under its judicious administration, but I must protest against its empirical employment. I am opposed to its use in placenta prozvia in the following conditions: 1. If the mouth of the uterus be sufficiently dilated to enable the accoucheur to have 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 womb shall have undergone a measure of dilatation. But 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 m pla- centa prazvia. 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 will 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 will be the resource. But how, in placenta praevia, with 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, which 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 AND PRACTICE OF OBSTETRICS. 481 hemorrhage, on the contrary, is in no way connected Avith placen- tal presentation, but occurs Avhen this body is in union Avith 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 follows: premature contractions of the uterus; external violence, such as falls, blows, 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, we are not to omit to mention the fascinating, but oftentimes dangerous polka and waltz. 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 woman, who, although in most other matters, a sensible and refined lady, was so wedded 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! By constant and untiring effort, I succeeded in carrying her to the eighth month of her gestation, and then was fortunate enough to deliver her of a living child. I doubt, with the sad experience of her folly, Avhether she will again, under simi- lar circumstances, be induced to " take a turn." It Avill 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. Robert Lee, of London, maintains with much positiveness, that another cause of accidental hemorrhage is a shortening 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 distinguished 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 Avhich 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 OBSTETRICS. 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 which I 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 bowels 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 with 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 two ways, 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 with cold drinks at the time of the bleeding Avill 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 fives 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 would be the conversion 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, e'usvation 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, will 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 the tincture in a wine-glass of tepid Avater thrown up as an injection. There is, however, another form of accidental flooding connected with 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 which the blood will be pouring from the utero-placental ves- sels ; in this case, however, there is no external evidence 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 pecufiar, 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 groAvs 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 what to do. UsuaUy there are no striking premonitory symptoms, and the counsel of the practitioner is not demanded until the mischief is far advanced. If, however, 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 would 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 regarded a frequent complication—it will 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 vagina, or injections of ice-water into the rectum; and it be ascertained that one of the extremities of the foetal ovoid presents, the element of hope will 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, would 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 will 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 without delay to turn the child by bringing down 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 without dilalation 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 five grain doses as circumstances may indicate. Should nausea or vomiting preclude its administration, morphia or opium, Bhould there be no contra-indication, may be substituted.* It will be perceived 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 will 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. • Onium 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 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. Gentlemen—We now 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 we 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 toxsemic influ- ence, such as uraemic 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 the 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 have 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, were cen- tric, or, in other words, the result of an influence applied directly to this nervous centre. I may, perhaps, be wrong in the remark that Marshall Hall was the first to call attention to this interesting fact, for the circumstance had been previously recorded by Whytt, Redi, Prochaska, Unzer, and H. Mayo ; but I think it must be conceded that, without 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. 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 extre- mity of one or more nerves, anil 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 known as reflex action. All nervous aberrations, of whatever grade, may very properly be divided into two classes—centric or eccentric ; and you will find 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 Eccentric 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 faeces ; 3. 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 given circumstances, are capable of evoking an attack of con- vulsions ; so that, wrhen called to a case of this serious nervous disturbance, your minds may be prepared, almost with the quick- ness of thought, to comprehend the relation of effect and cause, Avhich may at the time exist between 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, I am 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 now inquire how it is that indigestible food in the stomach is capable of producing convulsions. It is not sufficient for you to know the fact; on the contrary, you should be content—Avhen demonstration is possible— with nothing short of demonstration itself. Therefore, I now tell you, as a principle well settled, that in these cases the irritation is first produced upon the terminal branches of the pneumogastric* nerve, and is thus conveyed through that nerve to the spinal cord, constituting, as I have already stated, an interesting and striking example of eccentric influence. You are well aware, gentlemen, of my fondness for practical, bedside truths; in contrast with mere hypothesis, they constitute so many gems for the medical man. With this conviction, you will pardon me, I am sure, for intro- ducing to your attention the following instructive case, the history and sequel of which 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 was summoned in great haste to attend a young married lady, who was then in the eighth month of her pregnancy—a primipara; the messenger, her brother, told me she had just been attacked with a fit, and he desired very urgently that I Avould lose no time in hastening to the house. On * The physiologist has shown that the pneumogastric is an excitor, and, at the same time a motor and ganglionic nerve. 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, while in agreeable conversation with 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, what does this mean, or, in other words, 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 his Avife had 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 writers, which constitutes the sine qua non, the very sheet-anchor of hope in puerperal convul- sions—or would you, as I attempted to do, have taken a common sense vieAV 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 neiwe, and thus, through eccentric agency, causing the convulsion ? This was my diagnosis, and, as you "will presently learn, my therapeutics were in perfect accordance Avith it. Without loss of time, I administered tAventy 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 tho guise of quinces and plum-cake, was very soon ejected. The quantity of these substances throAvn from the stomach nearly half filled an ordinary Avashbowl. The effect was all that could be desired; I remained with the patient four hours, there was no recurrence of the convulsion, and she lapsed into a sweet 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 albumeu; there was 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. "We shall, before completing tha question of conrulsions, discuss fully the subject of albuminuria. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 489 the pleasure of presenting her with a fine boy. There was nothing whatever untoward during the labor, and her convalescence was not interrupted by any accident. Is it going too far to surmise that, without 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. But what prompted the administration of the emetic ? Why, Jie 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. limitation of the Bladder or Rectum.—It may, however, hap- pen that the true cause of the nervous paroxysm is irritation either of the rectum or bladder. An aggravated case of hemorrhoids, or a collection of faeces in the lower bowel may give rise to convulsions. In the instance of hemorrhoids, my advice to you would be, not to hesitate an instant, but at once to disgorge them by a free puncture with the lancet. No tampering, negative treatment will 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, would depend upon what might be ascertained to be the true source of the disturbance. The following case has a practical bearing on the question noAV 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 Dr. B. W. Johnston, of Long Island, to visit a lady AAdth 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 woman, and the disease was in its verj inception of a grave character; the doctor, on being called to her, very properly resorted to the lancet, and abstracted 3 xvj. of blood with decided temporary benefit; it became necessary, how ever, to repeat the bleeding in four hours ; § viij. more wer« draAvn; the patient Avas 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 emunctory, the cutaneous surface. A blister was applied to the chest, and, in twelve hours after its application, tho patient was attacked with slight convulsions. It Avas under these circumstances that I Avas requested to see her. When I visited her the intensity of the pneumonia was broken, and so far as that affection was concerned the patient was making favorable progress. But a new phase had developed itself in the guise of the convulsion, which, although slight, was still significant of portending trouble. On inquiry, I learned that there had been no indiscretion of diet, nor Avere the boAvels in any way constipated. Attention Avas next directed to the condition of the bladder, and the nurse, an intelli- gent woman, 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 water, but at each time not more than a few drops were eA'acuated, accompanied by the most painful scalding. Now, gentlemen, what do you call this more or less constant desire to micturate, with an inability to pass more than a few 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 was composed.* As soon as we had learned the existence of this vesical irritation, an important light was thrown 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 ) Extract Hyoscyam. v aa. gr. xij. Pulv. Camphor. ) Ft. massa in pil. xij dividenda.f The patient % 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. t In this case, also, the urine was examined, but there was no trace of albumen THE PRINCIPLES AND IRACTICE OF OBSTETRICS. 491 sion ; but I subsequently was informed by the doctor that she was 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 mothor. 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 renewed paroxysms of convulsion. In such cases, the obvious duty would 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 vagina f 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 what 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, aAreraging oyer ninety per cent. Then, the inquiry neces- sarily arises, why 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 who has already passed through that process, and who, consequently, becomes to a certain extent accustomed to the excite- ment, which more or less usually accompanies gestation. Again: it is a well-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 has 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, which necessarily exposes the incident-excitor nerves of that part to increased irritation. Besides, when treating of albuminuria, its causes and effects, wft shall teU you that congestion and other derangements of the kid- neys are far more frequently met with in first than in subsequent pregnancies. Another question of equal interest arises—Do convulsions mani- fest themselves, as a general rule, in middle Hfe, 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 between the seventh and ninth months.* This, too, is my OAvn experience, and I believe it to be perfectly in accordance with facts. It has been positively affirmed by some writers that convulsions cannot be developed during pregnancy, unless they are preceded by contractions of the uterus. This opinion, however, is at variance Avith the observatior 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 will depend altogether on the surrounding circum- stances. We assume, hoAvever, that the convulsions here are due to uterine irritation simply, and are not complicated with uraemia, of which we 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 timte 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 flows, the patient faints; and soon after reaction comes on, there ensues another convulsion more marked than the preceding. You have not taken away blood enough, whispers that fatal delusion—routinism ! The ligature is again applied, the orifice opened, and slowly runs the current! Syncope follows; the spark of life is again rekindled by a feeble reaction ; 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, would, if consistent, say to the disconsolate friends, " Oh! if I had seen the case at the commencement, I should undoubtedly have saAred 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 depletion being indicated in the case just cited, it may peradventure be that the resort to the lancet is the true cause of death; arid 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 anaemia ; in such an e\"ent, this very anaemic condition may be one of the essential exciting sources of the convulsion. What, then, ■f 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 which exists between 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 will be convulsive paroxysms. How 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.* Be careful, there- fore, how, without due consideration, you employ this remedy in early childhood, for its abuse will readily lead to serious conse- quences. Brown-Sequard, I have told you, has shoAvn that the cause of the convulsion folloAving excessive loss of blood is the same * Convulsions from anaemia, whether the ansemia 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 movement.* 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 prove 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 view 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 view, 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 well-established fact, that congestion of either of these important organs will, through centric influence, prove a fruitful cause of convulsions. With this proposition before you, the truth of which 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, you Avill 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 previous losses ; if, in a word, the patient be in an anaemic state, then opium conjoined Avith 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 Avhich we are now • speaking, can be regarded as appropriate only when given Avith due discrimination ; and the same remark applies 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 l'Homme et des Animaux. Tome 1, p. 201.] THE PRINCIPLES AND PRACTICE 01 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, Avhich, 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 will not only be in keeping with the philosophy of science, but the results will be Hkely to be satis- factory. In illustration of this remark, I shall now endeavor to show you under what 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, with 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 two substantial reasons: 1. The vascular 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 will 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 which 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 Bpinal 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 debilitated 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 Btates, are the very women most likely to suffer from convulsions. 496 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. This may be accomplished with 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 following draught: Infus. Sennae f. ^ iv Sulphat. Magnesiae 3 ij Mannae 3 i Tinct. Jalapae f. 3 ij. M. But, gentlemen, I must apprise you of one fact never to be lost sight of when treating convulsions: it is this—delay is oftentimes the cause of death ; and I regard it so essential, in connexion with the abstraction of blood, to have a prompt movement of the bowels, that I am in the habit of resorting to what 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 hyper catharsis, or excessive purging. I have em- ployed it repeatedly with children and adults, and I befieve it to be, under discreet administration, a safe and invaluable agent. I have on several occasions resorted to it in convulsions, and with decidedly good effect: Olei Tiglii gtt. iv Sacchar. Alb. 3 ij Mucil. Acaciae f. § i. M. a tea-spoonful every fifteen minutes, until the bowels are moved. Here, we have an important auxiliary in connexion with 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, we ha\ e an admirable remedy, which I think was first introduced to the attention of the profession, in the treatment of convulsions, by Dr. Collins, 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. But 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—which is another of the abused articles of the materia medica—with 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 which 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 Avill 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 with 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 without delay you should proceed to evoke uterine contractions. The mode of doing this, and the various plans suggested by authors, will be stated when 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 walls, 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, however, where 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, Avhich is to guide you, is precisely the same in convulsions with plethora, whether they occur during gestation or at any stage of labor. It may, however, be that the convulsive paroxysm commences soon after the inception of labor in a patient, who does not ex- hibit vascular fulness, but whose 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 fcetus. It s 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 Avhtther, under the circumstances, the convulsions are not altogether due to the unusually rapid succession of the pains. If so, I know of no remedy equal to the belladonna,* for I am quite satisfied that it possesses two important attributes, one of Avhich, at least, has, perhaps, not been sufficiently appreciated in the practice of midwifery : these attributes are the lulling of uterine contraction, a?id the promotion of dilatation of the mouth of the organ. Therefore, in the case we are noAV speaking of, I should recommend you to lubricate the os uteri freely with the belladonna ointment 3 j 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 Avith 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 les» exhaustion, it may 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 osruteri, 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 why 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, hoAvever, the dilatation have been accomplished, there can be no objection to affording the escape of the waters by rupture of the membranous bag. It must be recollected that ether is an important resource in the convulsions of laboi, as Ave have shoAvn you it is in pregnancy Avhere 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 th*> 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 the full influence of anozsthesia, and for the following reasons : 1. The very introduction of the hand into the uterus constitutes an excit- ing cause, which would almost certainly evoke the convulsive paroxysm; 2. The manipulations necessary to accomplish the delivery would 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 well down 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 organ to increased effort, and hence the marked or expulsive force which follows. \ 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 AND PRACTICE OF OBSTETRICS. upper strait, I should advise you not to apply them, version being 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 would 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 which, after an auspicious delivery of the child, convulsions 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 Avill sometimes be but the continuation of the attack prior to the delivery. I have already called your attention to the relation which sub- sists betAveen excessive losses of blood and convulsions, Avhether 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 with 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 with 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. But, 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, twitching of the muscles of the face and extremities. But it may happen that, withont any of these premonitori.es, the convulsive movement displays itself by a sudden exhibition of the symptoms, which are really pathognomonic or characteristic of the paroxysm. It is only necessary to Avitness one case of convulsions, with 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 with kindness and skill to her wants; the labor is progressing favorably, everything looks bright and promising, and, without the slightest premonition, a convulsion commences, ushered in by the following symptoms: The face becomes, as it were, sud- denly fixed, with twitchings of its muscles; the whole expression is altered; the eyes at first roll, and then become stationary, usu- ally turned upward; the pupils are dilated, and make no response to the light; the lips are drawn in various directions, and exhibit rapid movements ; general distortion of countenance, with 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 faeces; the attack is followed 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 which 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 compulsion of which Ave 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 will throw herself from the bed ; oftentimes, there is laughing alternating Avith shrieking; and what is almost always a prelude to the attack, is a sense of constriction of the oesophagus, occasioned by what 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, which uniformly follows 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 PRINCIPLED AND PRACTICE OF OBSTETRICS. 503 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 saw the patient during the stage of coma, confound this condition of things with apoplexy. But 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 Avould most probably be hemiplegia—the result of the cerebral extravasation. Again: it is Avell to bear in recollection that, even in convulsions, death will sometimes ensue from effusion of blood in the brain, constituting a veritable apoplexy, and, in such case, there will 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 with some Avriters, Avho maintain that more than one half die. It is, I think, more in keeping with facts to say that, under prompt and judicious treatment, at least 70 per cent, of the mothers are saved. Dr. Churchill states that, in 214,663 cases of labor, convulsions occurred 347 times, or 1 in about 618|. In 328 cases, 70 mothers were 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 Avhich 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 which permanent amaurosis and deafness were the results. It is stated by some authors that the great majority of women who survive the invasion of convulsions are attacked with puerperal fever. This certainly does not accord with my experience, nor can I see any other than simply a coincident relation between these two pathological phenomena. * Mania and other forms of insanity may occur after parturition, even when tha 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. Carl Braun 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; Result- 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 we have been occupied with a consideration of the eccentric causes of convulsions; I propose to-day to speak of those influences which, 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, known 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 provoke convulsions ; an anaemic state of the system, as has been already explained, may do the same thing; disease of the brain or spinal cord, whether of the substance or coverings, is also a centric cause. But, gentlemen, there is yet another centric agent capable of evoking convulsions, to which I desire especially, and somewhat in detail, to direct your attention. I allude to an impure or poisoned condition of the blood. Until within comparatively a short period, authors were 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 Hopital Sal- petriere nearly one twelfth of the insane women we received here became so afte« their dehvery." (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, Avas not employed, as it now is, to denote a very peculiar and important state of the eco- nomy. While toxozmia is the generic 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 receiver! prominent consideration.* In September, 1853, I published a paper entitled, " Thoughts on Urozmia," which Avas generally distributed among my medical friends in this city, and Avhich is incorporated in my work on the diseases of women and children.f In that paper will be found the following 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. Noav, 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 with the interest and importance of the subject, to examine the true relation of albuminuria to eclampsia, and also the points of relation between this latter and Bright's disease of the kidney. With this view I shall commence with the consideration of the causes of albuminuria. Here we find various opinions: Edouard Robin 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 will be albuminuria. This hypothesis possesses the attribute of ingenuity, but its demonstration seems to me difficult, for the obvious reason that when 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 Da Carl R. Braun, etc., etc. Translated from the German by J. Matthews Duncan, F.R.C.P.S., etc., 1858. De l'Albuminurie Puerperale et de ses Rapports avec l'Eclampsie. Par M. lb Docteur A. Imbert Godbetre. Memoire Couronne, dans la Stance Publiqas Annuelle. December 1854. \ See page 522, 506 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. albumen does occasionally exist in the urine without 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 with the explanation of Robin. It is stated by Dr. C. I. B. Williams that, per se, " albu- minuria indicates nothing more than congested kidney." I shall, on the contrary, attempt to show that other causes than simple congestion of the kidney will occasion albuminuria; and, in doing this, it will follow 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 following 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 was a favorite doctrine of the old-school-men that the blood contained certain deleterious elements, which could not continue in the system with- 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 was formerly termed the " peccant humors." The organs through Avhich 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, while the liver is engaged in the secretion of bile, etc., and the kidney water, urea, etc., we find the intestines the media through which effete matters are thrown off. These various offices are performed through what 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 we are unable to explain many of the phenomena con- nected with this fundamental law of the physical mechanism. Al- though, therefore, we are ignorant of some of the processes con- nected with glandular elaboration in a state of health, yet it does not foUow that we cannot explain many of the causes which, inter- fering Avith healthy secretion, result in morbid action. In order to apply this reasoning to the question before us, we will suppose—what 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 which 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 fcetus, together with the diseases of the embryo itself, not to speak of its excretions, some of Avhich we know enter the blood of the mother. These, then, being so many influences capable of altering the constituents of the blood, will 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 what essentially these various changes consist. For example, though it may be true that the presence of albumen in Bright'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 which 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 Segalas,* and some of a more decisive character by Dr. Brown-Sequard ;f while, 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 Brachet, J. Mulier,! and Marchand. The latter has pointed out a very important fact connected with 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, however, seems to need confirmation, as the same result has not followed 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. Bernard§ * Bulletin des Seances de l'Acad. de Med. de Paris. (Seances des 27 A6ut et 23 Beptembre, 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, however, to these demonstrations, Ave have 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 does 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, we shall, in this way, have opened to us a new field in our investigation of disease; we shall be enabled to elucidate many morbid phenomena which 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 will cause albumen to pass from the blood into the urinary secretion ; and again when the renal veins have become obliterated, in every instance in which the urine was examined, albuminuria was detected. Cases of this nature have been observed by Dance, Rayer, Duges, Velpeau, R. Lee, Cruveilhier, Stokes, Blot, 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, I think, was the first to call attention to this subject. Dr. Brown- Sequard has positively ascertained the influence of pressure upon the renal vessels, in a lady who had albumen in her urine during the ninth month of pregnancy. He placed her in such a position that the pressure was much diminished, and after a certain time the urine ceased to contain albumen. When the ordinary attitude was resumed, there was soon a reappearance of albumen in the urine. In 106 multiparas, Blot detected albuminuria in eleven instances only, while 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.J 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. X "Women in their first pregnancy present a very different condition of the abdo- minal walls from those who have already borne children. In the former, these walls 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, tAventy-seven died, five remained albu- minuric, and thirty-three were restored from two to fourteen days after delivery. The frequency of puerperal convulsions in albu- minuric women is very great. According to the same author, of 159 women laboring under albuminuria, ninety-four were attacked with convulsions. Cahenf 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 with 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 well- established observation.J As a point of diagnosis, it may be incidentally mentioned that when albuminuria in pregnant women is caused by Bright'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 primiparae 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 the renal circulation. I believe, also, there is another reason why albuminuria is observed less frequently in multipara? 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, cceterts 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 modifying 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 urasmia 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'Acad&mie Imperiale de Medecine. Tome xx. 1856. f De la Nephrite Albumineuse chez les Femmes Enceintes. These, Paris, 1847. X Blot demonstrates the fact as follows: 1. The rapidity with which albuminuria disappears after delivery in almost every case, very often in two or three hours, some- times in 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 Bright's disease, 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'Albuminuric chez les Femmes Enceintes. These, Paris, 1849.] § From a/jfiXos dull, and u\p the eye. 510 THE PRINCIPLES AND PRACTICE CF OBSTETRICS. pupil of Rayer, gives a table, showing that in 332 cases of Bright's disease, there was either amblyopia or amaurosis in 62 instances. The coexistence, therefore, of this symptom with albuminuria in the pregnant female should be regarded as grave. The opinion is now well settled, and concurred in by a great majority of writers, 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, whether 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 Bence Jones has recorded an instance of mollities ossium, in which he presents an analysis of the urine, showing that albuminous matter may exist in great quantity, Avhile the amount of urea remains per- fectly natural. Is Albuminuria always followed by Urazmia?*—That the pre- sence of albumen in the urine is not necessarily followed by uraemia is amply proved by observation ; and it is important that this fact should be well understood, for the reason that much error has arisen from the opinion entertained by certain writers, that there is a direct connexion between uraemia and albuminuria. This error is not so much owing to any inherent difficulty of the subject, as it is to that loose appreciation of facts, or, more properly speaking, to that Avant of healthy digestion of well-settled principles Avhich, 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 uraamic intoxication, but I apprehend this would be unnecessary. I shall, therefore, limit myself to tAvo 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 the term uraemia should be clearly understood. Urasmia consists in disturbed action of the two nervous 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 with 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 Bciousness; 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 othera have observed it in articular rheumatism, in inflammation of the thoracic organs, intermittent and typhus fevers, in measles, cholera, and in chronic affections of the liver. In transitory renal catarrh, such, for instance, as occurs in erysipelas nearly as often as in scarla- tina, albumen, together Avith the well-known epithelial cylinders of Bellini'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 Bright's disease.* Edouard 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 following interesting and conclusive expe- riment upon himself, and also confirmed in the person of one of his friends: He made for sometime aportion of hisordinary nourishment to consist of half a dozen eggs, and albumen, as a consequence, was soon detected in the urine.J Similar experiments have been made with similar results, by Bareswil, CI. Bernard, Brown-Sequard, and Dr. Hammond of Baltimore. There are few practitioners of careful observation, Avho will not endorse these statements. Indeed, I consider the principle to be so Avell established that the existence of albuminuria is not necessarily connected with uraemia, that further citations can scarcely be neces- sary to demonstrate the fact. Is Urea a Poison?—Urea was, I believe, first discovered in 1771, by Rouelle, who detected it in the urine. It oAves its present name, however, to Fourcroy and Vauquelin. It was obtained pure for the first time by Dr. Prout in 1817. There is an interesting circumstance connected with this production—it is the first instance known of an organic compound being artificially produced, and this was 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- raack,^" 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, Pari* 1846. p. 39. g Lumleian Lectures, in London Med. Gaz. 1849-50 [ Principles of General Pathology. *f London Journal of Medicine. 1849. Pp. 690-699. *2 Lectures on General Pathology, Amer. Edit., p. 151. 512 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. its presence in the blood will 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 way establish the fact. Among others, Prevost and Dumas, * Segalas, Tiedeman, Gmelin, Mitscherlich, CI. Bernard, Bareswil, Stannius/f and Frerichs, have extirpated the kidneys, and have never known convulsions to ensue. This, it may be urged, is only negative proof. Negative, however, as it is, it must be admitted that it is testimony not without value; and to it may be added the interesting experi- ments of Bichat, Courten, Gaspard, Vauquelin, Segalas, Stannius, Bernard, Brown-Sequard, Frerichs,J and others, who, after inject- ing into the veins urea and urine, never in a single instance observed a case of convulsions. Again: Bright, Christison, Rees, and Frerichs have cited cases in which 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 which he detected the greatest amount he had ever observed, there was no approach to uraemic disturbance. Vauquelin and Segalas, so far from regard- ing urea as a poison, have proposed to administer it as a diuretic. Some recent experimenters, however, especially Dr. Hammond and Mr. Gallois, affirm that they have observed convulsions in rabbits after the injection of urea into the veins. But there is no proof that it was the urea itself which 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 which 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 urozmia is exclusively due to the transformation of urea into the carbonate of ammonia. The modus in quo, however, of this transformation is not clear; there is no proof as to the manner in which it is accomplished; but the major point, viz. dependence * Annales 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. SI3 ofurozmia on tJ,e 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. Brown-Sequard has published the fol loAving facts in Tessier's dissertation Sur PUremie, 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. Bernard and Bareswil 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 with cholera. Christison, Jakehs, and others, have recognised, under certain cir- cumstances, an ammoniacal odor in the blood. Until, hoAvever, the exposition of the peculiar vieAvs 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 two following propositions he has proved beyond a doubt: 1. That in every case ofurozmic intoxication, a change of urea into carbonate of ammonia takes place ; 2. That the symptoms which characterize urozmia can all be produced by the injection of carbonate of ammonia into the blood. After citing 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 which he had injected urea; these animals remained quiet and awake as long as the expired air was not impregnated with the ammonia; but the moment the lat- ter was 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, which 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 which, to the present time, have eluded observation; and, in their recogni- tion, Ave may find additional causes for the production of toxaemia. It has, indeed, been suggested that, in Bright's disease, the accu- * Many facts have recently been developed in France, proving that the phe- nomena of uraemia must be due to some kind of poisoning. It has been shown by Piberet, Tessier, Picard, Rilliet, and Barthez, that in patients who have died from uraemia, there is no organic lesion of the nervous centres. 33 514 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. mulaion of oxalic acid in the blood will develop the symptoms of urasmic intoxication. I may here remark that Braun 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 foetal blood. Treatment of Urozmia.*—-This necessarily involves two objects : 1. The immediate restoration of the principal eliminators of the system, such as those of the kidney, skin, and bowels, Avith a vieAV of diminishing, through these outlets, the quantity of urea and noxious elements, Avhich 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 water, urea, and salts. The various remedies, therefore, known to increase the cutaneous secretion should be employed in cases of uraemic poison- ing. With a view 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. Anozsthetics in Urozmia.—Chloroform and sulphuric ether have been repeatedly employed in these cases with 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 oxit of the body, preATents 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 preArenting this decom- position.! * Dr. Maclagan, of Edinburgh, has drawn attention to the value of the colchicum autumnale in ursemic 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, Avhile 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 diuretioa 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, Avhich 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'Academie Imperiale de MMecine. 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 the 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 the 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 ? Gentleiien—Your attention having been directed to the various causes of manual interference for the termination of delivery, you are now prepared for the discussion of the question—in what way is manual labor to be accomplished ? Before, however, entering upon the particulars of this interesting subject, it will be proper to make one or two preliminary observations touching version, or, as it is sometimes termed—turning. This operation consists in bring- ing down to the superior strait one or other of the obstetric extremities of the foetus, 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 which we shall more particularly speak hereafter, an attempt is also made to bring the head down. Cephalic Version.—In the earliest periods of our science this was the only kind of version adopted; indeed, Hippocrates and his contemporaries speak of no other, turning by the feet being in no way 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 was 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 GuiHemeau, yet it is but just to say that Franco preceded them both in the suggestion.* GuiHemeau was the instrument in the seventeenth century of spreading the new view, and it was 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 he 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 own times.* Let us now proceed to discuss the general question of manual labor under the following heads^ an recourse must be had to the blunt hook, by placing it in the groin of the limb, which is posterior, and making downward 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 will be compression more or less serious of the fcetus, to which may be added undue pressure of the umbilical cord, and not unfrequently premature detachment of th'e 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 foetus 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 always more endangered when 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 wHl 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 wfil 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 with 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, which corresponds with the heels (Fig. 11) 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 with 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 fcetus in its long axis, so as to bring the pos- terior plane of the chHd's body in apposition with one or other of the acetabula; if, for instance, the toes are toward the left cotyloid ca- vity, the back of the fcetus 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, when 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 fcetus is the same as in presentation of the feet. The indications are also identical as in footling cases; if there be malposi- tion, it must be corrected ; and if the labor suffer from complication, delivery is to be accomplished. For this Fiq. 78. 552 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. purpose, the hand should be introduced which corresponds by its palmar surface with the anterior surfaces of the chHd (Fig. 78), and the knees being brought down, the same principles are to guide you as in a foot presentation. It may, however, be that there will be unusual difficulty in extricating the knees with the hand; in this case, the fillet may be advantageously employed, which, being placed in the ham of the leg which is posterior, downward and backward tractions are to be made untH the knees are 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, which, being carefully inserted into the ham of the posterior limb, will enable you by proper extractive force to bring down 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 with inertia of the uterus. You will occa- sionally meet with cases in practice in which, under breech pre- sentations—and the same thing may occur when the vertex or any of the other extremities of the ovoid present—the uterus, after vigorous effort, ceases for some time 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, with this abstract view, recourse is too frequently had to certain special remedies, which are known 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 what I mean, I shaU 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 who 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 will occasion it. Again: excessive plethora may be ranked among its causes. If this view of the subject be correct, it is very evident that one of the fundamental prerequisites for judicious treat- ment will be to distinguish the particular constitutional circumstance to which the inaction of the organ is to be referred. In the case of inertia from previous disease, or any exhausting influences, the remedy will consist in the administration of stimulants together with generous and renovating 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 foHow- ing : increase in the volume of the uterus from an excessive quantity of liquor amnii, Avhich, 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 Avant 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 in 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 wiU be at once to rupture the membranes, and, by the escape of the liquor amnii, liberate the uterus from the paralysis to which it has been subjected by the excessive distending force. The same course, also, must be pursued when, 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 reliefs I should not, under the circumstances, hesitate to incise the cervix; and, in having recourse to this expedient, I would 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 wearying 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 two-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 debHity of the uterus consequent upon a want 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 "% iv. of boiling water; let it infuse for twenty 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 wiU rarely happen that it will not have the desired effect after a few doses are administered. In this latter character of inertia, I have found repeated drinks of ice water, taken in small quantity, to be of signal service in promoting uterine contraction; warm tea or gruel wiU occasionally have the same effect. LECTURE XXXVII. Manual Delivery continued—Trunk or Transverse Presentations, including the Abdomen, Chest, Back, and Sides of the Fcetus—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. Gentlemen—Our third division of manual labor embraces trunk or transverse presentations together with those of the arm and shoulder.* It is quite obvious that when 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 between 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 following heads: 1. Presentation of the abdomen; 2. Presentation of the chest; 3. Presentation of the back; 4. Presentation of the sides of the foetus, including the shoulder and hips. It is proper here to remark, that I shaU 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.! . Presentation of the Abdomen.—h\ this presentation, which is extremely rare, the chHd 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 fcetus are, when found at the superior strait, simply varieties of the shoulder presentation. + This is the classification suggested by Halmagrand, and others, and I adopt it becauso 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 avHI 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 will readily discover in directing his finger from right to left, with which side of the pelvis correspond the borders of the false ribs, the crests of the Hia, and the organs of generation. First Position.—Here the head is in relation Avith the left Hiac 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 down, and converted into the second position of the feet. The delivery to be terminated as if it were originally a footling case. Second Position.—This position is precisely the reverse of the preceding, the head corresponding with 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, however, 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 down be attached by a fiUet, and retained in position, while the hand is again introduced for the purpose of seeking for the other extremity which, when grasped, is to be placed by tho Bide of the foot held by the fillet. Presentation ,of the Thorax.—When the thorax presents, it wHl be readfiy recognised by the ribs and sternum, as, in the presenta- tion of the abdomen, the anterior surface of the chfid's body ia THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 557 doAvnward, and the dorsal plane is upAvard. 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, without 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 with the pelvis, the necessity will 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 when 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 Hiac 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 chHd 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, with 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 with the two scapulas. These various points will also enable you to ascertain the particular position. First Position.—The head is in correspondence with the left, and the feet with the right iliac fossa. The left hand is to be introduced in a state of supination, and the fcetus 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 Hiac 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 wHl 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 with 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 fcetus is to be elevated, and after pursuing the anterior surface of the body, which 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 Shoulder.—In calling attention to shoulder presentations, it will be proper to divide them into two classes: 1. Where simply the shoulder presents; 2. Where, together Avith the shoulder, the arm and hand protrude. As we proceed, it avHI 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 will be needed in distinguishing the shoulder, for it may be confounded with the elbow, the breech, hips, or knee. The true distinction, the one which makes it certain that it is a shoulder presentation, consists in recognising with the finger the scapula, clavicle, and the upper ribs, which may be done with a proper degree of caution. First Position of the Right Shoulder.—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 backward. 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 below; 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 with the practice inculcated by our predecessors. In this presen- tation, delivery was 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 were resorted to ; one incul- cated the practice of tAvisting off the arm, and terminating the deli- very by bringing down the feet; another suggested amputation; a third recommended to diminish the volume of the arm by means of scarifications and incisions. Deventer, with the hope of causing the fcetuf to withdraw the arm into the uterus, directed the hand to be pinched or pricked Avith a pin ; for the same purpose ice was employed. Need I tell you, also, that, ignorant of the principles on which rests the mechanism of labor, the absurd and reckless prac- tice was maintained by some of making tractions on the protruded arm, under the conviction that the body of the chHd could thus be delivered! 560 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. But all these were the suggestions of men who had not suffi ciently studied in the school of nature; they neither comprehended her resources when undisturbed by contravening influences, nor did they appreciate the ability of science to aid her in the moment of want. Now, however, through the advances which 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 with safety to both mother and fcetus. There are, how- ever, it is well to remember, certain conditions connected with this form of presentation, which wiU 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 will be greatly increased.* First Position of the Right Shoulder 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 avHI 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 right shoulder, the pelvis of the fcetus 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 width, and twehe inches in length) around the wrist 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 (which will take place as the feet are brought down) 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 Avith more or less tumefaction, giving rise tc the belief that the child is dead, thus inducing the practitioner to a resort to instru- ments to dissect the foetus 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 OBSTETRICS, 561 Fig. 80. 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 with 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 with 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.—Having now spoken of the general principles which are to guide the practitioner in cases of shoulder 86 Fig. 8L 562 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. presentations, either with or without protrusion of the arm, it is proper that I should allude to two other questions in connexion with this subject, viz. evisceration in cases in which version is found impracticable, and spontaneous evolution. Evisceration of the fcetus will engage attention in a future lecture, when treating of instrumental delivery; on the present occasion I propose to make a few 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 which 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 with an instance of Avhat 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, however, that while they intended no vio- lence to truth, their opinion was 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, however, a very general con- currence of opinion on one point, viz. its extreme rarity. It is mentioned by Dr. Riecke that it was 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 was 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 Avriters Avere unquestionably impressed with the idea of the great mobility of the foetus in utero, and it was 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 Kovus ei * 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 shown 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 were replaced by the breech of the child. Douglass,* on the con- trary, demonstrated the fallacy of Denman's opinion by proving that the fcetus, without 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 upward 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 svith 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 fcetus be relatively small, or the pelvis more than ordinarily capacious ; and it is an interesting fact to note that, in several instances in which this movement has been cited, by authors, the fcetus 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 Fcetus, 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 down into the pelvic cavity, in the event of nature being unable to accomplish the movement. It may, however, happen that you will 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 avHI 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 foetus, the womb intervening between it and the finger. In examining very cautiously the surface of the tumor, I was unable to discover the os tincae. 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 foetal head, and carrying it towards the posterior part of the pelvis, I felt the os tincae, which 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 Dehvery—Instruments divided into Blunt and Cutting—B unt Instru- ments—What are they?—The Fillet and its Uses—The Blunt Hook and Yectis; 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 Instruments—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. Gentlemex—We shall noAV consider the second branch of preter- natural labor, viz. Instrumental Delivery—and here, permit me to say, we 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 involve 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 he 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 dehvery 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 E., 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 tincae; 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 I 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 Fillet; 2. The Blunt Hook; 3. The Lever or Vectis; 4. The Forceps. 1. The Fillet.—This is simply a piece of ribbon or linen, one inch in width and twelve in length. It may be applied under the following circumstances: (a) In a breech presentation Avhere, in con- sequence either 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 with the finger to the bend of one of the thighs, so as 'to encircle the groin, the two ends of the fillet are then seized by the accoucheur, and, Avith well-directed traction, it becomes a ready means of bringing down the breech, (b) In cases in which the trunk is expelled, and there is unusual delay in the descent of the shoulders, the fillet being placed under the axilla Avill 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 fcetal 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 tincae. 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 Medecine 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 ityuries 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 child. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 567 fiUet should be placed around the wrist, for reasons already explained when treating of this form of presentation. 2. The Blunt Hook.—This instrument is employed for most of the purposes for which the fillet is used, viz. to bring doAvn 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 carefully carried to the particular part of the foetus on which the blunt hook is to be applied, the instrument, previously Avarmed and oHed, is made gently to glide along the hand, which acts as a dire© Fig. 82. tor, and when the point is reached, either the bend of the thigh (Fig. 82), 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 downward traction exercised. In this way, the foetus will be brought down without injury to it or the parent, and the deli\ery promptly terminated. As soon as the part reaches the vulva, the instrument should be withdrawn, and the delivery, if necessary, terminated by the hand. 3. The Lever or Vectis.—This instrument has been variously estimated by different writers on midwifery; some claiming for it merits of a high order, Avhile others repudiate its use altogether. It has been urged that the lever 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, Avhen the occiput is extended backward, the lever will 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 Forceps and Lever.—I do not deem it necessary to institute any special contrast between 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 leATer was 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 what occurs in the private practice of certain medical gentlemen, who 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 know- ledge of the laws by which nature is regulated in the parturient effort; and, secondly, he is cognizant that, when 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. 1. The Forceps.—I shall not occupy your time Avith the early history of this instrument, nor Avith 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 forceps are concerned, is not only a vast armory, but has really become an institution in itself; and, indeed, it may be asked, Avith some degree of propriety, Avhether the interests of humanity Avould 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 Employed? 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 midAvifery 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 with good heart and unmeasured confidence to what he deems the scene of conquest; but too often, alas! it proves a scene of harrowing agony to the unhappy pa- tient. One would almost think that nature had become emasculated of her power, and that Avhat Avere once considered her OAvn 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 own consummate ordinances—but an act to be carried out according to the peculiar caprices of the accoucheur. ' Nature, gentlemen, is ahvays the same so far as her OAvn fundamental laws give her an identity; she is noAV in this particular what she was at the commencement of the world, whether 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, however, 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 in view 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. safety 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 comriction that, in this particular, he has faithfully discharged .his duty to those who, in the hour of tribulation, looked to him for assistance. You, who have attended the obstetric clinic, Avhere you enjoy such abundant opportunity of witnessing 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 well as by words, I shall take the liberty of refreshing your recollection with a brief abstract in reference to the melancholy case of a married woman, who was brought before you not a long time since, in whom there was com- plete occlusion of the meatus urinarius, with partial adhesion of the walls 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 work on the Diseases of Women and Children: \ Mrs. R., aged 22 years, married, complains of inabHity to pass her Avater in the natural way, and says it runs from her nearly all the time through the front passage. " How long, madam, have you been married ?" " Just tAventy-six months, sir." "'Were you a healthy woman before your marriage ?" " Yes, sir ; I never had a day's sickness, thank God!" " You have had a child, have you not?" "Yes, sir." "When was it born?" "Fifteen months ago, sir." " How long Avere you in labor ?" " Three days, sir." " Was your labor severe ?" " No, sir, but it was lingering." " Had you any one to attend you ?" " Yes, sir, there were two doctors with 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 the forceps in a manner not endorsed by the experience of the lying-in room. So far, thereforOj 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. f 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 m inflammation and ulceration. From these latter causes will sometimes arise a recto vaginal fistula, more frequently, I think, than from the use of the instrument. X Page 346. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 571 poor little thing was aU bruised, and its head was a good deal injured." " Why so, madam ?" " The doctors did it, sir, with the instrument." " Then, you were delivered with instruments, were you ?" " Yes, sir, indeed I Avas, and a poor sufferer have I been ever since !" " No matter, my good woman, do not deplore the past; you have been cruelly wronged, but we will endeavor to do something for you ; at all events, we will make you more com- fortable." " Thank you, sir." " Before your delivery, had you any trouble with your water ?" " None in the world, sir." " How long after the birth of your child did you experience trouble in this way ?'' " Since the birth of my child, sir, my water has always troubled me. It runs from me, and 1 cannot help it!" " Did you call the attention of the doctors to thia circumstance ?" " No, sir, for they never came near me after I was delivered." "Then, madam, they did not do their duty." " Indeed, they did not, sir.'' " How long was it after the birth of your chHd that you left your bed ?" " I could not go about, sir, for nearly six months." " Have you had your courses since your confinement ?" " Only once, sir, about two months ago, and I thought I would have died from the forcing pain I had." " Did the usual quantity pass from you ?" " No, sir, very little, indeed." This case, gentlemen, exhibits another of the many instances of professional cruelty more or less frequently occurring in this popu- lous city; and it is, indeed, needful that something should be done to arrest the reckless temerity of men calling themselves physi- cians, who, if we are to judge them by their acts, place a very insignificant estimate on human life. But the melancholy feature of the whole business is, that these assaults on health and life are made under the protection of a diploma, and, therefore, are per- fectly within the record! No! a diploma, though it may serve the purposes of the holder, is insufficient to justify the moral wrong of the sufferings, the details of which have just been narrated. A diploma without knowledge is a curse to its possessor, and a fearful instrument of destruction to the community. With knowledge, too, must be conjoined a refined morality based upon that Christian principle—" Do unto others as you would wish others do unto you !" This poor woman, whose health was her only capital, whose daily bread was the product of her dafiy labor, has become involved, either through ignorance or unpardonable carelessness, in a compli- cation of maladies which, even if measurably relieved, will cause her more or less distress during her entire existence. The first question, which naturally presents itself to the mind in viewing the serious afflictions of the patient, is this: What has produced this state of things, and could it by a proper exercise of judgment have been avoided ? She was delivered with instruments, and to their unskilful and unnecessary employment are to be referred aU her 572 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. present difficulties. There is no evidence before us that the use of instruments was at aU indicated. The patient observed that " her labor was not severe," it was " only lingering." She, then, has fallen a victim to that " hot haste," Avhich unfortunately too often prevails in the lying-in chamber, or to that undying fondness, Avhich some men cherish for operative midwifery. Let this case be a lesson to you; think of it in your hours of meditation, and may it prove a shield to those who confide their lives to your custody. In the eye of Heaven, murder loses nothing of its atrocity because concealed from the ken of human observation; so it is with the dark deeds of our profession. The diploma may afford a mantle, so far as earthly jurisdiction is concerned, but the time of reckoning will come with appalling retribution ! You are, however, gentlemen, not to misunderstand me; I con- demn only the abuse of the forceps, and desire to admonish you that while in it you have, when properly employed, a means of accomplishing great good, yet, in reckless and unskilful hands, it is indeed an instrument of fearful destruction. On the one hand, it will enable you to save the lives of both mother and child, and rescue them from the dread consequences of embryotomy. On the other, it will oftentimes lead to the death of parent and offspring ; or if, peradventure, the former should survive, she will have entailed upon her troubles to which death itself is frequently preferable— such, for instance, as vesico-vaginal, urethro-vaginal, recto-vaginal fistulas, rupture of the uterus, and other lacerations of the soft parts, often the sad consequences in the practice of those gentle- men, who are in the habit of resorting to instrumental delivery without cause or justification. Prior to the introduction of the forceps in operative midwifery it was the usual practice, in all cases of difficult parturition in which the hand was unable to overcome the obstacle, to destroy the child and bring it aAvay piecemeal by means of hooks, etc. Therefore, while I most cordially admit that I regard the forceps, under proper employment, as one of the undoubted boons, which science has placed within the reach of the conscientious and skilful accoucheur, yet it would be an interesting inquiry—if the statistics could be fairly gathered—whether, in consequence of its reckless use, the good derived from the employment of this instrument has not been more than counterbalanced by the evil it has inflicted. It is a maxim of the assassin that " dead men tell no tales ;" is it not equaUy true that those practitioners, who destroy their patients by the rude and unjustifiable use of instruments, are very much dis- posed to allow their deeds of blood to accompany their victims to the grave, where, amid the silence of death, they may find shelter from the public gaze! Hence, the true difficulty of arriving at reliable statistics on this point. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 578 I trust I may be pardoned for the plain and emphatic manner in which I Avrite on this important question; but I feel that I have a sacred duty to discharge to you, and also to those, who, after you shall have left this University, will look to you for counsel and aid in the time of their anguish. But a short while since, at the request of one of those truly good women, " a sister of mercy," I visited in a miserable hovel a poor creature, who had been attended in her confinement by a medical man, who found it necessary to call to his aid two of his professional friends. The woman had been in labor only six hours, when it Avas deemed necessary to resort to the forceps; she was delivered of a dead child with the right os parietale crushed, and the corresponding eye forced out of the socket! The unhappy mother had only been delivered four hours when I saw her; she was at that time vomiting, her face pale and haggard, with a pulse extremely rapid. I requested the physi- cians to be sent for, but they could not be found! On an examina- tion, I detected a rupture of the neck of the uterus,* and the poor creature was soon released from her sufferings, having expired just fourteen hours from the time her labor commenced !f What better * I may refer the reader to the prize essay on Rupture of the Womb, by Prof. James D. Trask, M.D., for some extremely interesting facts. His monograph is the most complete we have on the subject. His observations are based on over four hundred cases, which he has variously collected. The paper will be found in the American Journal of Medical Science for January and April, 1848. The following extract touching the results of treatment in this formidable complication will be read with interest: We formerly showed that the average duration of life, after rupture, with those delivered, was twenty-two hours; and that of the undelivered, but nine hours. By adding to these the new cases, we find that, of those delivered, fifty-four per cent. survived beyond twenty-four hours; while of those dying undelivered, twenty seven per cent, survived beyond the same period. Relative success of different modes of Treatment when the Head and the whole or pari of the Body has escaped into the Peritoneal Cavity. SUMMARY OF ALL THB CASES. Gastrotomy saved, 16, lost, 4, or 20 per cent. lost. Turning, er 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 woman'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, why 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 very important complication. Yes, gentlemen, this argument, I admit, was not without force, and great force, too, before the introduction into the lying-in room of that sterling boon to suffering woman— 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 which, 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 *vith 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 when death ensues soon after the operation—say two or three days—it is in consequence of the grave concussion sus- tained by the nervous system, as is evinced by the symptoms, which, under these circumstances, so speedily develop themselves, 638 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. such, for example, as a general sinking of the forces, A'omiting and hiccough. In these cases, I repeat, in which death so rapidly follows 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 Cesarean Section.—Before describing the manner in which—when 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 Avoman is dead ; and the practice is founded upon the wrell-known fact that the fcetus 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, twenty, 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 Avas mistaken for death. It is important, for the assured safety of the chHd, 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 ATery general assent of the pro- fession. I allude to the extraordinary case of the Princess of Schwartzenberg, Avhose 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-law, the Austrian ambassador. During that night of festivity there was an appalling conflagration which, together with 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, while 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 chHd 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 Cesarean 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 quaepregnans mortua sit, humari anteqxtam partus ei excidatur ; qxii contra fecerit, spem animantis cum gravida peremisse videtur. In recognition of the propriety of this ancient law, and Avith the AieAV 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, who 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 Avhich an incision had been made into the abdomen for the purpose of extracting a child from its supposed dead parent, when it was subsequently shoAvn 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 aU 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, which occurred to him, and about which, 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 tressaillement accom- pagne de grincement des dents et de remiXment des levres !\ How the Operation should be Performed.\—I have already said, with 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; and I now state without qualification—that it is the duty of the accoucheur to ascertain at an early period of the labor Avhether 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 with 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. \ Prof. Fordyce Barker reports an interesting case of Caesarean section in the American Medical Times, Jan. 26th, 1861. 640 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 woman 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 without the knowledge of the patient ? The answer 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, with the lower limbs slightly flexed; at least two assistants will be needed, well supplied with soft, delicate sponges. Things being thus pre- pared, the question presents itself—In Avhat way is the incision to be made ? One author recommends the oblique, another the trans- verse, while 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 wounding 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 will 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 toward the pubes. This first incision will lay open the abdominal cavity, which, of course, will 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 with 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 will be so situated as to be included in the incision made into the uterine wall—it would 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 elylrotomy, and is performed as follows: The incision commencing near the 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 force 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 after 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 fcetus and the walls of the uterus; on the contrary, should the membranous sac be entire, there Avill 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. 41 642 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. occurred—in the following manner : Should the head be near the 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, withdraw it first; if aoy other surface of the fcetus 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 world, 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 two 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 with 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 withdraAval of the after-birth, to remove any coagula of blood from the uterine cavity. But suppose nature does not promptly detach the placenta, how long would 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 would, I think, be imprudent to wait 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 followed by inertia of the womb—a circumstance quite unlikely to occur—a small piece of ice momentarily applied to the lips of the opening avHI 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 with the finger; soon after the extraction of the after-birth, the wound contracts, the incision made into its Avail is reduced to one or two inches, and in this way all hemorrhage is arrested. For the purpose of closing the wound 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 wound 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 Avhole should be covered with a piece of linen spread Avith simple cerate ; over this should be placed a compress supported by a circular bandage. [t 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 Since the publication of the second edition of this volume, I have read with much pleasure an excellent essay on the " Statistics of the Caasarean Operation," by M. Philan-Dufeillay,J and it affords me no little satisfaction to find that his views are entirely coincident with my own.§ This author remarks, that "the method usually followed of simply comparing the deaths with the reco- veries after the operation, must lead to false deductions. In nume- rous cases, the deaths cannot be ascribed to the operation, but to antecedent conditions of the patient; which, in many instances, may be controlled." He presents a table of 88 cases, collected since 1845, in which the caesarean section has been performed ; " of these, 50 recovered; of the remaining 38, the causes of death Avere, in six, some antecedent disease ; two died of puerperal fever, the operations having been performed in hospitals. In the 30 remaining cases, the deaths must be imputed, in part, at least, to the unsuccessful attempts made to deliver by the natural passages." M. Philan- Dufeillay then speaks of the influence of the duration of labor over the result: " In 29 successful cases, the natural powers were pre- served in 24; in 20, the duration of the labor Avas under 24 hours; in 19 fatal cases, the forces were failing or exhausted in 18; and in 11 cases, the labor continued beyond 24 hours.'' He concludes that the caasarean operation, performed under favorable conditions, gives nearly 75 per cent, of recoveries. * Although, as 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. f 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 Caesarean section and symphyseotomy what he terms the resectio 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 osseous deposits. He records four experiments on dogs, in which this deposit of bony matter followed the enucleation. [Ann. Univ '858 % Arch. Gen. de Med., 1861. § See page 632 of this volume. LECTURE XLII. 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 justifying 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— Omphalotripsy—Meaning of the Term—When to be employed. Gentlemen—Having disposed of the subject of the abdominal Cesarean section, it is now proper that I should describe to you the vaginal Cesarean operation, sometimes called vaginal-hystero- tomy. This operation may be necessary without any deformity of the pelvis, or any disproportion between 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 fibro-cartilaginous change. Again: it may some- times happen that the cervix of the organ is so completely malposed, 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 whole force of the parturient effort is lost; 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 will also be hazarded from long-continued and undue pressure. It is, therefore, when 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 Btated : 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 Cozsarean operation twice, 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 with 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., who had been in labor for twenty-four hours. On arriving at the house, I learned the following particulars from the medical gentlemen : Mrs. M. was the mother of two chHdren, and had been suffering severely, for the last fourteen hours, from strong expulsive pains, which, 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 Avere 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 crowds 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 was much struck with this language, especially as I had already been informed that she had previously borne two living children. At the request of the medical gentlemen, I proceeded to make an exami- nation per vaginam, and must confess that I was startled at what I discovered, expecting every instant, from the intensity of the con- tractions of the uterus, that this organ would be ruptured in some portion of its extent. I could distinctly feel a solid, resisting tumor at the superior strait, through the Avails of the uterus; but Icoxdd detect no os tincae. In carrying my finger upward and backAvard toward the cul-de-sac of the vagina, I could trace two bridles, extending from this portion of the vagina to a point of the uterus, which Avas quite rough and slightly elevated ; the roughness was 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- ing in the womb. In passing my finger with great care from the bridles to the rough surface, and exploring the condition of the parts, with an anxious desire to afford the distressed patient prompt and effectual relief, I distinctly felt cicatrices, of which this rough surface was one. • New York Journal of Medicine. March, 1843. 646 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Here, then, was a condition of things produced by injury done to the soft parts at some previous period, resulting in the formation of cicatrices and bridles, and likewise in the closure of the mouth of the womb. At this stage of the examination, I knew nothing of the previous history of the patient more than I have already stated, and the first question I addressed to her was this: Have you ever had any difficulty in your previous confinements ? Have you ever been delivered with instruments ? She distinctly replied that her previous labors had been of short duration, and that she had never been delivered with instruments, nor had she sustained any injury in consequence of her confinements. Dr. Vermeule informed me that this was literally true, for he had attended her on those occasions. This information somewhat puzzled me, for it was not in keeping with what any one might have conjectured, taking into view her actual condition, which was undoubtedly the result of direct injury done to the parts. I then suggested to Drs. Vermeule and Holden the propriety of questioning the patient still more closely, with the hope of eliciting something satisfactory as to the cause of her present difficulty; remarking, at the same time, that it Avould be absolutely necessary to have recourse to an operation for the purpose of delivering her. On assuring her that she was in a most perilous situation, and, at the same time, promising to do all in our power to relieve her, she voluntarily made the following confession: About six weeks after becoming pregnant, she called on the notorious Madame Restell, who, learning her situation, gave her some powders with directions for use; these powders, it appears, did not produce the desired effect. She returned again to this woman, and asked her if there were no other way to make her miscarry. " Yes," says Madame Restell, " I can probe you; but I must have my price for this operation." " What do you probe with ?" " A piece of whale- bone." "Well," observed the patient, "I cannot afford to pay your price, and I will probe myself.'' She returned home, and used the whalebone several times; it produced considerable pain, followed by discharge of blood. The Avhole secret was now dis- closed. Injuries inflicted on the mouth of the uterus by these violent attempts had resulted in the circumstances detailed above. It was evident, from the nature of this poor woman's sufferings and the expulsive character of her pains, that prompt artificial delivery was indicated. As the result of the case was doubtful, it was important to have the concurrent testimony of other medical gentlemen, and as it embodied great professional interest, I requested my friends, Dr. Detmold, and the late Drs. Washington and Doane, to see it. They reached the house without delay, and after examining minutely into aU the facts, it was agreed that a bHateral section of THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 647 the mouth of the womb should be made. Accordingly, Avithout loss of time, I performed the operation in the folloAving manner: The patient was brought to the edge of the bed, and placed on her back. The index finger of my left hand Avas introduced into the vagina, as far as the roughness, which I supposed to be the original seat of the os tincae ; then a probe-pointed bistoury, the blade of Avhich had been previously covered with a band of linen to within about four lines of its extremity, Avas carried along my finger until the point reached the rough surface. I succeeded in introducing the point of the instrument into the centre of this surface, and then made an incision of the left lateral portion of the os, and, before AAdthdrawing the bistoury, I made the same kind of incision on the right side. I then withdrew the instrument, and in about five minutes it was evident that the head of the child made progress; the mouth of the womb dilated almost immediately, and the con- tractions were of the most expulsive character. There seemed, however, to be some ground for apprehension that the mouth of the uterus would not yield with sufficient readiness, and I made an incision of the posterior lip through its centre, extending the inci- sion to Avithin a fine of the peritoneal cavity. In ten minutes from this time, Mrs. M. was delivered of a strong, full-grown child, whose boisterous cries were heard with astonishment by the mother, and Avith sincere gratification by her medical friends. The expres- sion of that woman's gratitude, in thus being preserved from what she and her friends supposed to be inevitable death, Avas an ample compensation for the anxiety experienced by those, who were the humble instruments of affording her relief. This patient recovered rapidly, and did not, during the whole of her convalescence, present one unpleasant symptom. It is now ten weeks since the operation, and she and her infant are in the enjoyment of excellent health. I omitted to mention that the urethra Avas preternaturally dilated. I introduced my finger as far as the bladder without any conscious- ness on the part of the patient, such was the degree of its enlarge- ment. About ten days after the operation, the late Dr. Forry visited the patient with me, and heard from her own lips the narrative of her case, so far as her visit to Madame Restell is concerned, and which I have already stated. On Saturday, January 20, Dr. Forry again accompanied me on a visit, and a vaginal examination was made. The mouth of the womb was open, and permitted the intro- duction of the end of the forefinger; the two bridles were distinctly felt, extending from the upper and posterior portion of the vagina to the posterior lip of the os tincae, which they seemed firmly to grasp. In a professional point of view, this case is not without interest. It is evident that, without the operation, the patient must have 648 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sunk. She had been in labor precisely tAventy-nine hours Avhen 1 made the section of her womb, and for twenty hours previously the contractions were most energetic, possessing all the character- istics of true expulsive pains. But yet, Avith all this suffering, not the slightest change had been effected in the parts. If nature, therefore, had been competent to overcome the resistance, sufficient time was aUowed for this purpose. Longer delay would undoubt- edly have placed the lives of both mother and child in extreme peril; for, from the reiterated but unavailing efforts of the Avomb, there was reason to anticipate rupture of this viscus, Avhich would most probably have compromised the life of the mother; while, at the same time, the child was exposed to congestion from constant pressure by the contractile force of the uterus. The second case is as folloAvs:* On Saturday, November 6, 1847, at 6 a.m., Dr. Alexander Clinton was summoned to attend Mrs. L., aged thirty-six years, in labor with her first child. Dr. C. had been for some time the family physician of Mrs. L., and had attended her in repeated and severe attacks of nephritis. On arriving at the house he found Mrs. L. in labor, the pains being decided, and occurring with regularity at intervals of fifteen and twenty min- utes. In his examination per vaginam, the doctor was unable to detect the os tincae; he very cautiously explored the vagina and presenting portion of the womb with his finger, and, after several fruitless attempts to find the mouth of the uterus, he came to the conclusion that the difficulty of reaching the os was owing to mal- position of the organ, probably retroversion of the cervix. Accord- ingly, he waited until evening, Avhen the pains increasing in vio- lence, and assuming an expulsive character, he examined his patient, but without better success. He then proposed a consultation, the patient having been in labor fourteen hours. My colleague, Pro- fessor Mott, Avas sent for. On hearing the particulars of the case, he made a vaginal examination, and, after repeated attempts, failed in finding the mouth of the womb. Professor M. suggested that possibly some change might occur during the night in the position of the parts, which Avould enable him to reach the os uteri, and left the house with the promise that he would return in the morning. Dr. Clinton continued with his patient during the night, and the pains recurred regularly with more or less force. He made several examinations in the night, but could feel nothing except a globular surface. In the morning, Nov. 1, at ten o'clock, Professor Mott returned. The pains were then much more violent, and the patient suffered severely. He again attempted by examination to reach the mouth of the womb, and again failed. To use his own language, " I have * American Journal of Medical Sciences. 1847. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 649 Been a great many obstetric cases, and have attended almost every variety of parturition, but it is the first time, after thirty-six hours' labor, that I could not feel the os tincae." The case was now assum- ing a dangerous phase; the pains Avere frequent and expulsive, with an obliterated mouth of the uterus. The fear, therefore, Avas rupture of this organ, and death of the patient, Avith but little chance for the life of the child. The husband and friends were informed of the precarious situation of the patient. Drs. Mott and Clinton decided to have additional consultation, and at the request of these gentlemen I met them at one o'clock on Sunday, the patient having been in more or less active labor for forty hours. On examining her I could not feel the slightest trace of the os tincae, and I became satisfied, after a thorough exploration, that it was entirely obliterated. Under these circumstances, the death of the mother being inevitable Avithout an operation, it was proposed to lay the womb open through the vagina, and at the request of the gentlemen, I proceeded to perform the operation as follows: With a probe-pointed bistoury covered to Avithin a few lines of its extremity with linen, and taking my finger as a guide, I made a bilateral section of the neck of the womb, extending the incision to within a line or two of the peritoneal cavity. The head of the child Avas immediately felt through the opening. The pains con- tinued with violence, but there Avas no progress in the delivery; the neck of the uterus was extremely hard and resisting, and pre- sented to the touch, after the incision, a cartilaginous feel. Dr. Mott and myself then left the patient in charge of Dr. Clinton, and returned again at six in the evening. At this time, although the pains had been severe, the head had not descended, nor had any impression been made on the opening. I then made an incision through the posterior lip; the patient was not in a condition to sustain bloodletting, and a Aveak solution of tartar-emetic was administered with a view, if possible, of producing relaxation. Dr. Clinton remained with his patient, and promised, if anything occurred during the night, to inform us of it. We Avere both sent for at two o'clock. Dr. Mott having arrived before me, and finding the patient suffering severely from violent and expulsive pains, all of which produced little or no change in the position of the child's head, enlarged the incision which I had pre- viously made in the posterior lip of the cervix. We remained until seven o'clock in the morning, when we left. The patient being much fatigued, a Dover's powder was ordered, which procured a comfortable sleep, and temporary immunity from suffering. We called again at eleven o'clock. The opening had somewhat dHated, and the head could be more distinctly felt, but it had not begun to engage in the pelvis. There was much heat about the parts, and the scalp was corrugated. The pains continued with 650 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. regularity, losing nothing in violence, and at six o'clock in the even- ing of Monday the patient's strength, which had been cautiouslj guarded, was evidently giving way, and her pulse rose to one hun- dred and forty! In a word, the symptoms were most alarming. The question now presented itself—What was to be done ? After mature deliberation, being essentially conservative in the Avhole management of the case, Ave determined to make an attempt to deliver with the forceps, certainly not an easy thing to do Avith the head of the fcetus at the superior strait, not having begun to engage in the pelvis, and the mouth of the womb rigid and un- yielding. The forceps, however, after a full view of all the cir. cumstances, presented to us the most feasible means of effecting delivery. At the request of Drs. Mott and Clinton, I applied the instru- ment, and was fortunate enough, without much loss of time, in locking it. The head was situated diagonally at the upper strait, with flexion but partially made. At first, I directed my traction downward and backward, the handle of the forceps forming an acute angle with the axis of the inferior strait of the pelvis; and when I succeeded in flexing the chin of the child upon the sternum, I then rotated the handle of the instrument for the purpose of giving the demi-spiral movement to the head. In this way, after very great effort, I succeeded in bringing the head to the inferior strait, and with powerful, but well-guided tractions, drew it more than one half into the world. At this stage of the operation, my arms and hands were nearly paralysed, such was the force necessary to overcome the difficulty. I requested Dr. Mott, Avho was by my side, to relieve me, and after no inconsiderable effort he succeeded in bringing the head into the world; our gratification was in no way diminished by the fact that the child was alive, an event cer- tainly not to be expected. As strange as it may appear, the only inconvenience experienced by the mother after delivery was an inability to pass her Avater; this continued for about two weeks, rendering it necessary to intro- duce the catheter twice daily for the purpose of emptying the bladder. The mother and child are in the enjoyment of excellent health. It may, perhaps, be thought by some that the patient should have been delivered sooner, and that we subjected her to serious and unnecessary hazard in delaying delivery by forceps. This reasoning might possibly be sustained on general principles; but I think it will be conceded that, in this individual case, we were not only jus- tified in the delay, but the result proved the wisdom of the course we pursued. In my opinion, nothing, under the peculiar circum- stances of the case, could have warranted an attempt at artificial delivery, save an approach to exhaustion on the part of the mother THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 651 or the occurrence of some accident placing life in imminent peril The position of the fcetal head, and the condition of the mouth of the womb, were such as to render extremely probable the failure of any attempt at delivery. The obvious indication, therefore, was to trust to nature as long as she Avas capable of acting, and for the accoucheur to proceed to artificial delivery the moment the general system exhibited unequivocal evidence of prostration. It may be asked Avhether this was primary or secondary closure of the os tincm. That it Avas secondary is manifest from tAvo cir- cumstances : 1. The patient always menstruated regularly previous to her pregnancy; and secondly, to suppose that she could have become impregnated with an imperforate os tincm, is to suppose what, under the circumstances, may be called an absurdity. There are cases, however, recorded in which sexual intercourse was had through the female urethra, folloAved by impregnation, but in these examples there was a communication between the bladder and uterus. In the present instance, there existed no such communi- cation. The only rational explanation of the closure of the womb in this patient is, that it was the result of inflammation of the os uteri. Embryotomy.—The term embryotomy means literally the cutting up of the child for the purpose of diminishing its bulk, so that it may be brought away in fragments. It may be of two kinds: 1. Where it becomes necessary simply to lessen the volume of the head, either by affording an outlet to the brain (cephalotomy), or removing the bones of the cranium piecemeal (craniotomy), or by means of the cephalotribe—an instrument of which we shall speak presently—crushing the head; 2. Where it is essential to extract the entire child in portions, thus involving more or less the section of the whole fcetal mass. It can scarcely be necessary for me to remind you that the only justification which can be alleged for this operation, is such a dis- proportion between the maternal organs and fcetus as to render it physically impossible that the latter can be made to pass, either through the natural effort, by the aid of the forceps, or version, sup- posing, of course, the woman to have arrived at the full period of her gestation. I have already remarked that it is not safe, so far as the mother is concerned, to attempt the extraction of a child by embryotomy if the antero-posterior diameter be less than from 2 to 2 J inches, unless, perhaps, in case of the child being dead, and more or less advanced in decomposition. Again: you have been told, that, as a general principle, although there are some exceptional instances, a living child cannot be delivered with a pelvic diameter under 3£ inches. If this be so—and I am quite confident that I am strictly within the record—the question arises, if the child be alive, and the diameter should even measure 2£ inches, or if it should THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be more than 2£ but less than 3£,* Avhat is the course to be pur- sued ? My own principle of action, under these circumstances, would be a preference for the Caesarean section over the mutilation of the child, and for the reasons detailed in the previous lecture; and, moreover, if I be correct in my argument in that lecture, an early resort to the Caesarean section with the aid of anaesthesia Avould so far diminish its dangers in contrast with embryotomy, as absolutely to render it, of the two expedients, but little more fatal to the mother, Avhile, instead of the necessary destruction of all the children, a very large portion of them would be saved; for you are not to forget that, under the most unfavorable circumstances, only 1 in every 3 J of the children is lost in the Caesarean operation. If, however, it be ascer- tained that the child is dead, then the circumstances of the case entirely change ; for the cardinal argument, I contend, in favor of the Caesarean operation is to prevent the horrid destruction of fcetal existence, whHe at the same time the danger to the mother is but slightly enhanced. So that the child being dead, with a diameter even less than two inches, I should unquestionably have recourse to embryotomy; for it would be only under the most desperate cir- cumstances, that, knowing the chHd to be sacrificed, the Cassarean operation could be selected as an alternative; and yet I must con- fess that if the antero-posterior diameter did not measure l£ inches, the Caesarean section would present, in my judgment, a better chance to the mother than embryotomy. You see, therefore, that if the antero-posterior diameter should not afford a space of one and one halff inches—even admitting the * It would be proper if the diameter were three and one-eighth inches, or even slightly under, to attempt delivery by the forceps, for it is barely possible that suc- cess might attend the effort. Should it, however, fail, as I am sure it would in the vast majority of cases, put the instrument aside, and have recourse (the child being alive) to the Caesarean section. f The celebrated case of Elizabeth Sherwood, so repeatedly referred to by writers on midwifery, has, I am confident, been productive of bad practice, and I am dis- posed to think that, more especially in Great Britain, it has been regarded as ample authority for a resort to the perforator. So impressed am I with this conviction, and anxious as I am that the true facts of the case shall be properly appreciated, I do not consider an apology necessary for quoting it in extenso, as originally published by Dr. William Osborn, in whose practice the case occurred: " Elizabeth Sherwood was forty-two inches in height, and so deformed as never to be able to stand erect for one minute without a crutch under each arm. At the age of twenty-seven years she became with child. Early on Sunday morning, November 19, 1776, she complained of having been in pain the two preceding days and nights. I examined her per vaginam that evening with great attention. On the introduction of the finger, I perceived a tumor, equal in size, and not very unlike in the feel, to a child's head. It was, however, instantly discovered that this tumor was formed by the basis of the os sacrum, and last lumbar vertebra, which, projecting into the cavity of the pelvis at the brim, barely left room for one finger to pass between il and the symphysis pubis, so that the space from bone to bone at that part, could not THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 653 child to be dead—embryotomy is not to be resorted to, but the alternative is the Caesarean operation. If, on the contrary, this^ diameter should yield slightly over one and one half inches, then with all the risk incurred by the mother from the operation, with a exceed three quarters of an inch. On the left side of the projection, quite to the ileum. which was about two inches and a half in length, the space was certainly not wider, and by some, who examined her afterward, it was thought to be narrower. On the right side, the aperture was rather more than two inches in length from the protu- berance to the ileum, and as it admitted the points of three fingers (lying over each other) in the widest part, it might at the utmost be about one inch and three quarters from the hind to the fore-part; but it became gradually narrower, both toward the ileum and toward the projection. " The membranes were not yet broken, but with some difficulty I felt the child's head through them, situated very high above the projection. The abdomen was hard and tender; as she seemed much fatigued for want of rest, fifteen drops of tinct. opii were given, by which some sleep was procured between the pains. The mem- branes broke some time after I left her, and there was the usual quantity of liquor amnii. The next morning, being hot and thirsty, and her pulse very quick, ten ounces of blood were taken from her arm ; and the bandage accidentally slipping off soon after her arm was tied up, she might perhaps lose as much more before it was discovered. No alteration whatever had taken place either in the os uteri, which was still but little dilated, though soft and flabby, or in the position of the child's head. In so extraordinary and singular a case, I naturally wished for the advice and assistance of my professional friends. I met in consultation that evening Drs. Bromfield, Denman, Walker, and Mr. Watson. Every gentleman present imme- diately satisfied himself by examination per vaginam, of the dimensions of the pelvis, some thinking it rather narrower, but none wider than the dimensions stated above We weighed, with great deliberation, every circumstance by which our future conduct in this case ought to be regulated; particularly we used our best endeavors to determine the state of the child in utero; and whether, if the Ccesarean operation should be per- formed, which we had in contemplation to do for some time, there would be a certainty of preserving one life at least. We were rather disposed to believe that the child was dead. It was, therefore, agreed that an attempt at least, ought to be made to deliver the poor creature, by opening the child's head, and extracting it with the crotchet. "I commenced the operation about eleven o'clock that night. Even the first pari of the operation was attended with considerable difficulty and some danger. The os uteri was but little dilated, and awkwardly situated in the centre, and most contracted pari of the brim. The child's head lay loose above the brim and scarce within reach of the finger. I desired an assistant to compress the abdomen with sufficient force to keep the head in contact with the brim of the pelvis, so as to prevent it receding from the scissors. I introduced them with the utmost caution through the os uteri; and after repeated trials, at length succeeded in fixing the point into the sagittal suture; I very soon, with great facility, penetrated the cavity of the head, and with a common spoon extracted a quantity of the brain; breaking down the parietal bones, made an opening sufficient for the free discharge of what remained. In this state we left her; although fatigued with this part of the operation, no opiate was given, as I wished to have the full effect of the labor-pains. In this expectation I was disappointed, for, not- withstanding she was prevented from sleeping all night by the frequency and violence of the pains, in the morning I was not sensible of the smallest alteration in the position of the child's head. During the whole day the pains were neither so strong nor so frequent as they had been; her pulse was extremely quick, but tolerably strong; the discharge from the vagina was very considerable in quantity, and most abominably fetid. Drs. Bromfield, Denman, and Hunter saw her in the crurse of the day; sht 654 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. less space than tAvo and one eighth inches, I should not hesitate to mutilate the child—being first satisfied of its death—for in this case, the compensating argument in favor of the Caesarean section—the safety of the child—does not obtain. was examined, besides, by more than thirty students in midwifery, which she willingly permitted at my request, from a representation of the singularity of her case and the utility which might result from its being more generally known. " Toward the evening, the pains considerably increased, and as I wished to benefit from the full effect of them, no opiate was given; she, therefore, had no sleep; and the pains continued through the whole night. When I first saw her the next morning, her strength was greatly reduced; her pulse beat one hundred and forty strokes in a minute, notwithstanding every precaution had been used to guard against fever, par- ticularly by forbidding all strong liquors, and_ by keeping the ward unusually cooL Her spirits, however, were good, and her resolution unabated. Upon examination, a small portion of the head was found squeezed into the pelvis. " Our intention, by delaying the extraction of the child six and thirty hours after opening the head, was to allow the uterus opportunity to force the head as low and as much within reach of the crotchet as the nature of the case admitted; and after- ward to induce as great a degree of putrefaction as possible in the child's body, by which means it would become soft and compressible, and afford the least possible resistance in its extraction. These two purposes appeared to me most completely accomplished, and there was no advantage from further delay. On the contrary, I was fearful that so large a mass of putrid matter as a child at full term, with placenta, etc., remaining in the uterus longer than was absolutely necessary, might expose her to the future dan- ger of a putrid fever, if she should escape all material injury from the inevitable violence and consequent danger of the operation. " I determined to begin to make an attempt to extract the child; I call it an attempt, for I was far from being satisfied in my own mind of its practicability. Adverting to the very small space of only If inches at the utmost, and in the widest part, and that only on one side of the projecting sacrum, while the space between it and the symphysis on the other side barely amounted to three quarters of an inch, I trust I am justified in my feelings and expression. "About 10 o'clock on Wednesday morning (the patient having been in labor since the previous Friday), I began the operation of extraction. The os uteri situated as before described, in the most contracted part of the brim, where the space was inca- pable of permitting the introduction of the curved point of the crotchet, without great difficulty and danger, I first endeavored to draw the os uteri with my finger into the widest part of the brim, and to dilate it as much as possible. Both these results were accomplished. I then introduced the crotchet through the perforation into the head, and by repeated efforts destroyed almost the whole of the parietal and frontal bones; as the bones became loose and detached, they were extracted with a small forceps, to prevent as much as possible the laceration of the vagina. "The great bulk of the head, formed by the basis of the skull, still, however, re- mained above the brim of the pelvis, and it was impossible to enter without either diminishing the volume, or changing the position; the former was the obvious method, for it was a continuation of the same process, and I trusted would be equally easy in the execution. I was, however, most egregiously mistaken and disappointed, being repeatedly foiled in every endeavor to break the solid bones of the base of the cranium, the instrument, at first, invariably slipping. At last, however, by changing the position of the instrument, I fixed the point, / believe, into the great foramen, and by that means became master of the most powerful purchase that the nature of the case admitted. Of this I availed myself to the utmost extent, steadily increasing my force, till it arrived to that degree of violence which nothing could justify but the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 655 The question of whether the child be alive or dead, is one of great significance, and is, in my judgment, Avith the reservations just stated, the turning point on which must rest the final decision—■ Caesarean section or embryotomy. Therefore, it is right that Ave extreme necessity of the case, and the absolute inability, in repeated trials, of succeed- ing by gentler means. But even this force was to no purpose, for I made no impression on that solid bone, nor had it in the least ad vanced by all my exertions. " I became fearful of renewing the same force in the same way, and abandoned the first idea of breaking the bones of the cranium, and determined to try the second, of endeavoring to change the position. I once more examined, as accurately as the mangled state of the head would admit, how it presented. From the information thus procured, the second method appeared to me a forlorn hope; however, there was no other resource. I therefore again introduced the crotchet, fixed it in the great foramen, and got possession of my former purchase,-and succeeded, together Avith the two fingers of my left hand, in changing the position of the head, and thus diminishing its volume. Continuing my exertions with the crotchet, I soon perceived the head to advance into the pelvis. " Every difficulty was now removed, and, by a perseverance in the same means for a short time, the remaining part of the head was brought out of the os externum. After waiting a few minutes, a napkin was put round the neck of the child, and given to an assistant. I then introduced the crotchet, and, first opening the thorax, fixed it firmly in the sternum. By our united force, strongly exerted for about a quarter of an hour, the shoulders were brought down; and, lastly, after opening the abdomen, the whole body was extracted in the most putrid and dissolved state; but it appeared to be a moderately sized child at full term. The placenta came away without much trouble. The operation continued for about three hours; and the poor creature, although in strong labor three days, and her bodily strength much exhausted by violent and unavailing pains, yet she supported the whole business with surprising fortitude, and suffered much less than might reasonably have been expected either from the length of the labor or the extreme violence in the delivery. She went to Bleep soon after the operation, passed a good night, complained of very little pain, etc.; she recovered so fast, that she sat up the seventh day, acknowledging, with great gratitude, that she was then as well, in all respects, as in any former period of her life. " As far as I know, this woman's pelvis was the smallest, through which a child at full time, and of the ordinary size, however lessened by art, has ever been extracted; and it was in contemplation in this very case, to perform the Catsarean operation, if we could have been satisfied of the life of the child, upon the presumption of the impossi- bility of bringing it, under the circumstances of age and size, through the natural passages. I hope the event of the case may prove the means of frequently preventing that fatal operation (the Cesarean section) in future." [Essays on the Practice of Midwifery, By Wm. Osborn, p. 240-257.] I think I have rendered a substantial service by the insertion of this case here; it is no garbled statement; on the contrary, it is in ipsissimis verbis of Dr. Osborn him- Belf, just as it was distilled from his own pen. The underlinings are my own, and I intend them as a sort of commentary upon the details. Dr. Osborn, in his day, occupied no mean position; his opinion was one of weight in 'all matters pertinent to obstetric science; and hence the case of Elizabeth Sherwood, from the circum- stance mainly of its having occurred in the practice of so distinguished a man, has not only become a part of history, but is regarded too frequently as an authority wny embryotomy should be preferred to the Caesarean section. But how different the influence of this case on the professional mind, if the unhappy woman had died 656 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Bhould examine the evidence, which may enable us to determine if the child in utero be living or not. Authors differ as to the nature and value of this evidence ; some supposing that the question is one of easy decision, while others again, and certainly with good reason, regard it as a point, under certain circumstances, of much embar- rassment. Evidences of the Child's Death in Utero.—The folloAving are enumerated as among the ordinary proofs that the child has ceased to live: 1. The discharge of meconium per vaginam; 2. A flaccid condition of the cranial bones, overlapping each other ; 3. A Avant of elasticity in the scalp under the force of uterine contraction; 4. Cessation of fcetal movements; 5. Failure to detect the pulsa- tions of the fcetal heart, or those of the umbilical cord ; 6. Fetid discharges from the vagina, together with the passage of small detached pieces of epidermis from the presenting portions of the fcetus. Let us briefly consider the true import of these signs. Every practitioner of ordinary observation knoAvs that the discharge of the meconium through the vagina of the mother is, per se, no evi- dence at all that the child is dead; for it may occur consistently with the life and full health of the fcetus. In breech presentations, for example, it is one of the usual accompaniments of this form of birth; and I have known it to take place in an ordinary head pre- sentation, and the child born alive. The flaccidity of the cranial bones, together with their over- lapping, is one of the uniform circumstances attending hydrocepha- lus ; and hydrocephalus, although a deplorable complication, is no proof that the child does not live. A want of elasticity in the scalp, under the force of uterine effort, needs a Avord of comment. As a general rule, when the labor is developed, and the head pressed more or less against the Avails of the pelvis, there Avill be recognised corresponding with the orifice of the uterus an elastic tumor formed by the scalp of the child's head. This tumor is the result of the contractions of the uterus under her accumulated sufferings I I now ask the reader to peruse every word of this statement with unbroken attention; and then I ask him whether, from the irresistible evidence furnished by the details of the statement, the fact of Elizabeth Sherwood having survived the operation is not a circumstance which would not be likely to occur once in ten thousand times ; and whether her recovery is not fully entitled to be classed among the miraculous, hair-breadth escapes from death ? Therefore, if this be so, it should be discarded from the books and the eulogiums of the lecture halls, as a guide for practice. It has exercised a singularly unhappy influence over the minds of some clever men; and has been, without due considera- tion, adopted as an evidence of the extreme deformity through which a child can be brought into the world by embiyotomy, without compromising the safety of th« mother. The only value of the evidence is, it proves simply what is universally admitted—that every rule has its exception. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 657 together with the resistance encountered by the head in its descent. It is of no consequence, for it in no Avay involves the safety of the child. But in another aspect, it is of much interest. The tumor cannot form if the child be dead at the commencement of the labor, and if, after its formation, the fcetus should die, the tumor becomes soft and flaccid. Again: even Avhen the child continues to live, the tumor will occasionally lose its elastic tension, in consequence of an extravasation of blood under the scalp, constituting a species of cephalhematoma, or bloody tumor, and this is apt to occur Avhen the head of the child encounters an exaggerated pressure, either as the result simply of strong uterine force, or conjointly with a con- traction of the pelvis. It may, also, happen that the child will be born alive and healthy without the slightest approach to the forma- tion of the tumor. As to the cessation of the fcetal movements, it is Avell known that some women never feel the chHd move during the whole period of pregnancy; others again, after having experienced the sensation for a certain period, fail to do so afterward, and yet bring forth living children. The pulsations of the fcetal heart may or may not be detected; in the former instance, there can be no doubt that the chHd is alive; whUe in the latter, it does not necessarily folloAV that life is extinct. Fcetid discharges from the Aragina, together with the passage of small detached fragments of epidermis, indicating the decomposi- tion of the fcetus, constitute very strong evidence that the child is dead; and yet there are cases recorded in which these phenomena have been recognised, and the child alive. Such instances, how- ever, must be regarded as extremely rare exceptions to a very gene- ral rule. One of the most remarkable is that mentioned by Baudelocque* as having occurred in his OAvn practice: He was called to a poor woman Avho had been in labor two days ; there was emitted from the vagina an insupportable foetor, commingled with fluids of the same character. The head of the child was at the upper strait, and the scalp soft and loose ; the epidermis and hair fell off with the mere pressure of the finger; there had been no movement of the fcetus for the preceding twenty-four hours; the mother's pulse was feeble and quick; the tongue, gums, and lips were black, and she exhaled a cadaverous foetor. These evidences —strong, indeed—of the child's death determined Baudelocque to resort to the crotchet; he held the instrument in his hand, but as he Avas about to introduce it, suddenly changed his mind, and decided to substitute for it the forceps, although convinced that the chHd was dead. It was a most happy substitution, as the * L'Art des Accouchemens, vol. ii., p. 229. 42 658 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. sequel revealed, for he delivered the mother of a living child I The foetid discharges, etc., were the result of a gangrenous slough on the summit of the head, which, however, only involved the thickness of the integuments. So, you see, gentlemen, all these phenomena, denoting the de- composition of the fcetus, may ensue, and yet the child be alive. But remember, as I have just remarked, such examples are to be regarded as altogether exceptional, and out of the ordinary record. The absence of pulsations in the cord does not, of necessity, imply the death of the fcetus ; for I have already cited the authority of Dr. Arneth, of Vienna,* who mentions four cases under his im- mediate notice in which no pulsations had been detected for half an hour previous to delivery, and in each instance the child was born living. Procidentia of the cord, its coldness, and absence of pulsation, together with its incipient putrefaction, may be regarded as among the very decided proofs that the child is dead. The decision of this question is one of no ordinary import, and it, therefore, is the duty of the accoucheur to exercise a full mea- sure of discretion, in order that he may reach the truth ; and, above all, let him be cautious not to suffer himself to be led to a hasty conclusion from the mere love of bringing the child into the Avorld piecemeal. Whether it be really a love for this kind of thing, or an indifference to the shedding of innocent blood, I will not undertake to determine; but of one fact I am quite confident—the perforator and crotchet are oftentimes employed in this metropolis with a recklessness altogether startling to those, who suffer conscience to have its share of influence in the doings of the lying-in chamber. Culpable Indifference to Professional Obligation.—Not long since I was visited by a young medical gentleman, who had been in practice but a short period. In the course of conversation the subject of operative midwifery was introduced. He remarked that he had enjoyed the best opportunities of becoming familiar with the use of instruments, for his preceptor had performed the opera- tion of embryotomy on an average sixteen times a year!!! To you, gentlemen, such an announcement may appear like romance; but I have myself witnessed in this city scenes of blood sufficient to satisfy my mind that it is not an exaggerated picture; and I will take the liberty of citing one case among several others now fresh in my memory, to show you that I do not speak without cause, when I protest against the unholy acts of men, who were intended neither by Heaven nor education to assume the sacred duties of the parturient room. The particulars of the following case I have recorded in my * See Lecture xxxL THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 659 Translation of Chailly's Midwifery: " Two years since, I was re- quested to visit a poor woman who resided a few miles from this city; she had previously borne tAvo living children, and her con- finements had not been attended by any unusual circumstance. On arriving at the house, there was presented to my view a scene which I never can efface from memory. It Avas a spectacle at which the heart sickened; it was humiliating to my professional pride, and I could not but experience feelings of deep mortification. The un- fortunate sufferer had been in labor 26 hours, when tAvo medical gentlemen, for reasons which I trust were satisfactory to them- selves and their consciences, decided to resort to the perforator. This instrument of death was accordingly thrust into the brain of a living child; the labor, however, did not advance, and they pro- ceeded to remove the fcetus piecemeal. After four hours of des- perate toH—and I ask where could have been their feelings of humanity—they succeeded in bringing away the entire fcetus in a mangled condition, with the exception of the head which Avas still in the womb. The friends of the poor creature—for, destitute as she was, she was not without friends in this her hour of tribulation —her friends, I repeat, became alarmed—their confidence was lost, and the serious apprehensions entertained for her safety, induced them to call in additional aid. I was sent for, and on hearing the particulars of the case, so far as the messenger could communicate them, I hastened to the house, accompanied by my former pupils, Drs. Busteed and Burtzell. " The patient was pale and exhausted—her countenance was that of a dying woman—she was almost pulseless, with cold extremi- ties, and the perspiration of death on her! In her death agony she supplicated me to save her, and said, Avith a feeling which none but a mother can cherish, that she was willing to undergo any additional suffering, if she could only be spared to her children. Poor creature! her measure of anguish was indeed full; and had she known that she was about being removed from her children by the atrocious butchery of men to whom she had entrusted her life, she would not have made the appeal she did. In approaching the bed of the dying woman, and on attempting to make a vaginal examination, to ascertain the condition of the womb, the head of the fcetus being still in its cavity, having been separated from the trunk, you may well imagine my feelings on finding a mass of small intestines protruding from the vagina, and lying between the thighs! " The operators, not content with slaughtering the infant, had ruptured the uterus, through which the intestines escaped, and thus abandoned the woman! She lay in this condition three hours be- fore I saw her, the doctors having left the house, stating nothing more could be donel Verily, death does terminate all human effort. The question may now be asked—Why was embryotomy had 660 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. recourse to in this case ? I never could ascertain. There must have been a secret reason for it—the burning love, perhaps, Avhich tome men have for the eclat of bloody deeds. There was no deformity of the pelvis ; the head of the fcetus was of the usual size; and, as far as I could learn, it was an ordinary labor. The doctors judged it advisable to do something; they decided to turn and deliver by the feet. They accordingly proceeded, and, mistaking a hand for a foot, pulled it into the vagina. They were then foiled, and, in order to complete the delivery, commenced cutting up the fcetus, and extracting it piecemeal. Thus were two lives wantonly sacrificed. The patient died in about two hours after I arrived ; half an hour before she expired she observed—' My poor child was alive, for 1 felt it move when the doctors were tearing it from me /' Such language, uttered under such circumstances, was indeed graphic and eloquent in condemnation of those who had been participa- tors in this cruel tragedy." The melancholy case which I have just cited, harrowing as it is, unfortunately is not alone; its counterparts have not only been witnessed in the lying-in room, but the archives of the profession record many such. Giraud* says, "I have on several occasions been present when embryotomy was performed by the most dis- tinguished practitioners, and the mothers have died immediately after the operation. In two instances, I myself assisted in extracting the foetus by fragments, and the mothers sank a few hours after- ward ; in one, the intestines passed through a laceration of the uterus, and projected from the vagina; in the other, the vagina and posterior Avail of the uterus were frightfully lacerated!" Mode of Performing the Operation of Embryotomy.—It must be kept in memory that this operation may be judged expedient by the accoucheur under several different circumstances ; for example, when there is such an abridgment in the diameters of the maternal organs as to render it physically impossible for the child, without mutilation, to pass ; where the maternal organs are normal in their dimensions, but the excessive size of the child constitutes the diffi- culty, as is illustrated in hydrocephalus; where there is no actual disproportion in the respective size of the child or organs, but where the obstacle consists in malposition of the fcetus, which cannot be rectified either by the hand or through the agency of an instru- ment, and which, therefore, may call for the dismemberment of the child. Trusting that you will not fail to keep in view the line of argument which I have endeavored to lay before you, as to the justification of embryotomy, I shall now proceed to point out the mode of procedure usually adopted, after you have decided that the operation is a feasible and proper resource. * Journal de Medicine. Par MM. Corvisart, Leroux, and Boyer. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 661 The patient is placed on her back, and brought to the edge of the bed, occupying precisely the same position, already described, when delivery is to be accompHshed either by version or the for- ceps. The bladder and rectum being previously evacuated, two fingers of one hand are to be introduced as far as the head of the chHd, to serve as a guide for the perforator or pierce-crane; if possible, the instrument should be made to enter the cranium through either the anterior or posterior fontanelle; or, if this can not be done, any other portion may be selected, endeavoring, how- ever, to avoid penetrating the sutures. As soon as the instrument has entered, the handles should be separated, so as to facilitate as much as possible the complete breaking up of the brain. If it be necessary, a small spoon may be employed for the purpose of bringing away the cerebral mass ; and, if you are operating on a living child, aUow me, in mercy, to beseech you to be thorough in your work of death, and see that the medulla oblongata is de- stroyed, in order that you may be spared the sad scene of witnessing the sobs of the poor infant after it has been brought into the Avorld, mangled and mutilated! If, after the discharge of the brain, and the col- lapse of the cranial bones, the head should not ad- vance, then recourse may be had to the guard-crot- chet, which may be in- serted into the foramen magnum occipitale, the socket of one of the eyes, or behind the mas- toid process. In addi- tion, should it be found necessary, the bone for- ceps may be employed for the purpose of remo- ving the bones of the head in fragments. As a general rule, when the head has passed, the trunk will follow without much difficulty; if how- ever there be an obsta- 662 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. cle to its exit, the perforator may be introduced into the chest and abdomen, for the purpose of evisceration, thus diminishing the general bulk of the fcetus. Instances will occasionally occur, in which, after the delivery of the trunk of the child (without any pelvic deformity) the head becomes arrested at the superior stiait, and the accoucheur is unable from malposition, or some other cause, to bring it into the cavity of the pelvis. Under these circumstances the perforator and crotchet may again be indicated. In hydrocephalus,* provided there be evidence that the child is alive, I should caution you not hastily to decide on opening the cranium (Fig. 96) for the purpose of affording escape to the accu- mulated fluid, for, if the pelvis be natural, or even slightly con- tracted, it is possible that the efforts of the uterus may suffice to accomplish the expulsion of the fcetus, and this, too, consistently with its safety. Therefore, my advice is—exercise a constant vigi- lance ; sustain as far as may be, the courage and hopes of yoxcr patient, and do not have recourse to the perfo- rator until you are satisfied of the inability of nature to terminate the labor, and that further delay would prove perilous to the mother. In a shoulder or arm presentation, it may happen that version cannot be performed; in such an event, it would be of little avail to attempt to amputate the arm, for this would in no way facilitate the delivery. It Avould be far better practice to introduce the curved instrument, with an internal cutting border (Fig. 97), for the purpose of separating the head from the trunk, as was originally suggested by Celsus; or, if this cannot be done, a pair of long scissors may be carried up, as Dubois recommends, in the foUowing manner: The finger to be cautiously introduced with a view of ascertaining the position of the neck; as soon as this is done, the finger should be hooked round the neck to force it as near as possible to the upper strait, and then the scissors, carried up along the finger, wiU enable the accoucheur to complete the work of decolla- tion. When this has been effected, traction should be made on the shoulder or arm which presents, and in this *?!». 97. way the trunk will be brought down. The head, which * It would seem that, in hydrocephalus, rupture of the uterus is not an unusual accompaniment. Dr. Thomas Keith has collected 74 cases of intra-uterine hydroce- phalus, and in 16 of these, the uterus became ruptured during labor. It has there- fore been suggested in hydrocephalus, especially if the labor be prolonged, instead of resorting to the perforator, and consequently destroying the child, to introduce a small trocar for the purpose of evacuating the fluid, which does not necessarily involve the safety of the fcetus. [Simpson's Obstetric Works, vol. i., p. 654.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 663 of course remains within the uterus, is to be removed, as described in a previous lecture. There is still another alternative in these cases of arm or shoulder presentation, in Avhich version is found impracticable; it is this—passing the finger along the arm or shoulder, as a guide to the axHla, the latter is penetrated by the perforator, and the chest eviscerated; this being accomplished, the delivery of the child, by making a lever of the arm, wHl not be difficult. Cephalotripsy.—It is proper, before concluding this lecture, that I should direct attention to an alternative which, in the judgment of some distinguished and experienced accoucheurs, may with great advantage to the mother, be substituted for the crotchet and other instruments, employed for the extraction of the fcetus, after its cranium has been opened by the perforator. I aUude to cepha- lotripsy, which consists in crushing the child's head by what is caUed the cephalotribe or embryotomy forceps, and thus extracting it through the maternal organs. It has been well remarked that the true dangers to the mother in craniotomy are in no way to be referred to the mere act of perforation, but arise altogether from the subsequent use of the crotchet, bone forceps, etc., which are employed for the purpose of completing the delivery. There is much truth in this observation, and in order to overcome these undeniable objections to the crotchet, etc., A. Baudelocque, Jr., some years since constructed an instrument, known as the embry- otomy forceps or cephalotribe. It has, since its first introduction to the attention of the profession, undergone several modifications by different accoucheurs, among whom may be named Cazeaux (Fig. 98), and Scanzoni. The cephalotribe of the latter is a good instrument, and will be found to answer very efficiently all the pur- poses for which it is intended. It is an error, however, to suppose that the ce- phalotribe can do away with the perfora- tor ; on the contrary, the true excellence of the instrument is developed only after the cranium has been previously emptied of the cerebral mass. It has been demonstrated by nume- rous experiments made on dead fcetus- es by Hershent, that, if the instrument be applied to the head previous to the evacuation of its contents by the perfo- Fio. 98. rator, the diameter in accordance with which it is grasped wHl be diminished, whHe the other dimensions of the head become increased. If, on the other hand, the cranium 664 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. be perforated and freed of the brain, and then crushed by means of the cephalotribe (Fig. 99), it is less voluminous, and the diame- ters much more contracted.* But the advantages of the instrument are not limited to the head of the child; it may be employed with benefit, if the fcetus be dead, in difficult breech presentations; also, for the purpose of diminishing the volume of the thorax, should it be necessary after Fig. 99. the escape of the inferior extremities; and, in some instances, in transverse positions of the trunk, when version cannot be effected in consequence of the impossibility of introducing the hand into the cavity of the uterus. One of the essential prerequisites for the use of the cephalotribe is a sufficient space in the pelvic canal to admit the passage of the fcetus after it has been crushed. If, there- fore, there were not a space of at least two inches, the instrument could not be employed with any hope of success. * Scanzoni LECTURE XLIII. The Induction of Premature Artificial Delivery—Premature Artificial Delivery- How divided—When is the Fcetus 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 Fcetal 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 Kluge and 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-Sequard; its influence on contraction of non-striated muscular fibres—Induction of Abortion—Is it ever justifiable! Gentlemen—In the two preceding lectures we have discussed the question of operative midwifery under two important aspects: 1. Whether the mother shall be subjected to a perilous alternative for the purpose of dividing the chances of life between herself and offspring; 2. Whether the child shall be mutilated, and brought into the Avorld piecemeal, thus sparing the mother the hazards of an operation performed on her own person. But I desire you distinctly to recollect that the discussion of this question had reference to the female, Avho should not only have arrived at the completion of her pregnancy, but who was actually in labor at the time at which your opinion was to be determined as to the choice of one or other of these expedients. In the examination of this subject, and in the pursuit of truth, we were necessarily compelled to narrate facts and circumstances well calculated to sicken the heart, and draAv largely on your sympathy. To-day we have a more agreeable duty to per- form ; for it is my purpose to present to your consideration an alter- native, which will oftentimes not only do away with the necessity of the Caesarean section and embryotomy, but will prove the means of greatly diminishing the destruction of human life. I allude to the induction of premature artificial delivery—one of the most precious boons which science has yet bequeathed to suffering woman. Premature artificial delivery may be properly divided into two 666 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. branches: 1. When the fcetus is viable, or, in other words, has attained a degree of intra-uterine development, Avhich will enable it to enjoy an independent or external existence ; 2. Previously to the viability of the fcetus. These two divisions of the subject I shall now proceed to examine, giving to each, as far as I may be enabled to do so, its respective value and indications. Premature Artificial Delivery when the Fcetus is Viable.—It is now very generally admitted that a fcetus at the end of the sixth month of gestation is capable of living independently of its parent; and there are not a few examples of fcetal viabHity at an earlier period than the completion of the sixth month.* It is an interest- ing circumstance to note that the first suggestion of the alternative of premature artificial delivery originated in the fact observed by accoucheurs, that women, who had previously been subjected to the use of cutting instruments, in consequence of pelvic deformities obstructing the passage of a living child at full term, had been delivered without a resort to these instruments, and with safety to themselves and offspring, when taken accidentally in labor at the seventh or eighth month of gestation. The earliest historical record touching this operation we find in the following language of Dr. Denman :f " A consultation of the most eminent men in London at that time (1756), was held to consider the moral rectitude and advantages which might be expected from this practice, and it met with their general approbation." England, therefore, is not only entitled to the honor of having decided the morality and utility of the expedient, but to one of her medical men, Dr. Macauley, is due the credit of having been the first to have recourse to it, and with success to both mother and child. Soon after this, it became a recognised alternative in Great Britain. It was also adopted in Germany, Holland, and other countries, but, strange to say, it was repudiated in France as a "cruel and inhuman" operation, and it was not until 1831 that it was resorted to in that nation for the first time by Stoltz, of Stras- bourg, saving both mother and child. Since that period, it has met with general favor in France, and has been repeatedly performed. * When discussing the interesting subject of premature and protracted gestation, it was stated that France had enacted a law granting to a child born six months, or one hundred and eighty days after marriage, all its social and legal rights; and this law, wise in itself, though often subject to abuse, is predicated on the fact that children are sometimes sufficiently developed at this early period of pregnancy to enable them to live. The law originated in the desire to protect the honor of the parent and the privileges of the child, in these instances of premature delivery; but it cannot be regarded as a guide to the induction of premature artificial labor, for the reason that the viability of the fcetus at the sixth month is to be considered au exceptional circumstance, whereas, at the seventh month, it assumes more the cha* racter of the rule. f Introduction to Practical Midwifery, p. 396. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 667 In Our own country, it is also in favor. In a word, under justifying circumstances premature artificial delivery now holds a high place among the alternatives of the lying-in room; for it must be remem- bered that the object of the operation is not merely to diminish the dangers to the mother, but also to save the life of the child. Let us examine what it is that gives faculty to the passage of a living child at the seventh and eighth months, which cannot possi bly be brought into the world alive at the full period of utero-ges- tation. In order to determine this question, and decide what the pelvic capacity must be to allow the expulsion of a viable foetus, it will be proper to ascertain the diameters of the head at the differ- ent periods of pregnancy. When the head begins to engage, it is its biparietal or transverse diameter which traverses the antero- posterior of the pelvis, and consequently it is very important to have an accurate idea of the dimensions of the biparietal diameter. The following tables of M. Figueira and Ritgen, which have been presented by Dr. Churchill,* are important, and elucidate fully this question: Age of Foetus. Biparietal Diameter. Occipito-Frontal Diameter. Occipito-bregmati* Diameter. 1 months. 7* « 8 " Si " 9 " 2 inches 9 lines. 3 inches. 3 inches 1 line. 3 inches 2 lines. 3 inches 4 fines. 3 inches 8 lines. 3 inches 9 lines. 3 inches 10 lines. 4 inches. 4 inches. 2 inches 10 lines. 3 inches. 3 inches 1 line. 3 inches 2 lines. 3 inches 4 lines. According to Ritgen, premature artificial delivery may be induced at the 29th week, when the antero-posterior diameter of pelvis is 2 inches T fines. 30th " " " " 2 " 8 " 31st " " " " 2 " 9 " 35th " " " " 2 " 10 " 36th " " " " 2 " 11 " 37th " " " " 3 " Allowing for the overlapping of the parietal bones, and the con- sequent diminution of the biparietal measurement of the fcetal head, it would appear that the extremes indicating the operation, all other things being equal, wHl be 2| and a fraction less than 3£ inches, and, indeed, it might become a question, if the antero-pos- terior diameter measured even 3 J inches, whether premature dehvery would not present a better chance of life to both mother and chHd; for you are to remember that although we have stated that, as a general rule, a contraction of 3£ inches is the smaHest space through * Theory and Practice of Midwifery, fourth London edition, 1860, p. 296. 668 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. which a living chHd can be made to pass at full term, yet its exit, if accomplished under this condition of things, would be attended by more or less peril. Some writers* have urged, as an objection to the operation in a primipara, the difficulty of arriving at an accurate idea of .the true size of the pelvis; they allege the insufficiency of the pelvimeter to reach this fact, and maintain that the real dimensions can only be approximated. I must confess I am unable to appreciate the strength of this objection; for it matters not whether the accouch- eur can come within one or more lines of the actual extent of the antero-posterior diameter; what he desires is simply to approxi- mate a knowledge of the physical condition of the pelvis, so that, with aU the accessible facts before him, he may, assisted by other counsel, decide whether or not the contraction is such as to render it morally certain that a living child cannot pass at the full term of pregnancy. This cardinal fact being ascertained, then the ques- tion legitimately presses—What is the general character of the deformity? Is it such as to preclude the birth of a viable child ? If not, there should exist no doubt as to the course to be pursued. If, however, the contraction be so marked, as to demonstrate the impossibility of the exit of a seven months' child, then the next alternative presents itself for consideration—t^Jie induction of abor- tion, which latter point wHl be fully examined before the close of this lecture. While, for argument's sake, I am willing to accord a due degree of force to the objection, that the pelvimeter is oftentimes insuffi- cient to allow us to judge of the real dimensions of the pelvis, yet I believe the experienced accoucheur will be enabled, under ordinary circumstances, by the introduction of the finger—the pelvimeter, in my opinion, par excellence in the exploration of the pelvis of a married woman—to ascertain whether the deformity is of a charac- ter to justify a resort to the operation now under discussion. Be it, however, as it may, the objections urged in reference to the primipara do not exist in the multipara; for, in the latter, we have a positive demonstration, not only of the existence, but the actual amount of the pelvic deformity. For example, suppose the case of a female, whose pelvis is so contracted that, having gone to the * Dr. Merriman has no doubt exercised more than ordinary influence in tho emphatic language he employs against recourse to premature artificial delivery in a primipara. With all respect for his name and authority, I cannot think he is right. The following are his words: " The practice should never be adopted till experience has decidedly proved that the mother is incapable of bearing a full-grown fcetus alive." [Medico-Chirurgical Transactions of London, vol. iii., p. 144.] If this opinion be recognised to the letter, it must, of necessity, to a greater or less extent, lead to dis- astrous results. It seems to me cruel, to say the least, that the tenure of an infant's eafety should be the previous destruction of its little relative before its transit into the world. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 669 full period of gestation, she has been subjected one or more times either to the Caesarean section or to embryotomy, for the reason that a living chHd could not be made to pass per vias naturales. Here, then, is the certain evidence of past experience—a proved fact—not a question of mere speculative opinion. It is, in truth, what is termed in law, the strongest and most irrefragable species of testimony. In a case, therefore, like this, there is no basis for a conflict of thought; the sacred obligation is imposed on the accoucheur, if the space be adequate to the passage of a viable foe- tus, to induce premature action of the uterus, in order that both mother and child may be liberated from the perils of embryotomy or the Caesarean section, should the mother be permitted to go on to her full term. But, gentlemen, there are other conditions than a deformed pel- vis, in which the operation of premature artificial dehvery may very legitimately be regarded as a justifiable alternative; although in reference to some of them there has, and still continues to exist a marked difference of sentiment. For example, there are some women who, from disease of the placenta or other influences, are in the habit of bringing into the world dead offspring, the physical appearances showing that death occurred a short time before the completion of pregnancy. In cases like these, it has been proposed to have recourse to premature artificial delivery, for the purpose of saving the children ; and again, the same alternative has been sug gested in instances in which the volume of the foetuses, in several successive labors, has been such as to render their passage through the maternal organs, although presenting their normal proportions, physically impossible. Certain serious diseases of the gravid woman are also enumerated among the causes justifying this expedient— such as dropsy of the cavities, placing in more or less peril the life of the mother; aneurism and strangulated hernia, procidentia, or retroversio uteri, complicating gestation; the presence of abdomi- nal tumors exercising an undue pressure on the uterus and other organs; an intra-uterine, or intra-pelvic growth, curtailing the dimensions of the pelvis to such a degree as to prevent the passage of a living child at maturity; contractions of the soft parts ;* pro- * The following is an interesting case of contraction of the soft parts in which I performed, on two different occasions, the operatfon of premature artificial delivery with entire success to both mother and children. The lady was a native of Canada. Her husband, some months after marriage, took her to South America, where she was delivered of a child. He stated to me that she had been suffered to continue In labor five days; and, after experiencing the most agonizing pains, she was spon- taneously, in the absence of her physicians, delivered of a putrid foetus of immense size. In two months after her delivery she began to walk about the room, and although weak, was otherwise in tolerable health. The first intimation she had of anything wrong, was excessive pain in any attempt at sexual intercourse; this proved to be impossible. In the course of a few weeks they sailed for New York; as 670 THE PRINCIPLES AND PRACTICE OF OBSTErRICS. fuse uterine hemorrhage, whether accidental or unavoidable, befcte the completion of pregnancy, seriously compromising the safety of the mother; convulsions and excessive vomiting. The various conditions I have just cited are to be weighed with due attention, and can only be considered as just motives for the operation after they have received the sanction of a calm and dis- Boon as they arrived, my late lamented and distinguished friend, Dr. Bushe, was consulted in reference to the case. At this time his health was so infirm as to dis- qualify him for professional duty. He sent a note to me by her husband, requesting that I would take this lady under my charge. On visiting her, and making an exa- mination, I found the entire vulva in a state of adhesion, allowing only a small open- ing for the meatus urinarius. After hearing an account of her labor, this condition of things was easily explained. From the protracted and severe pressure of the head of the foetus against the walls of the vagina, inflammation ensued, resulting in sloughing and consequent adhesion of the vaginal parietes. The indication in this case was obvious—the vagina nee ded restoration. Accord- ingly, I commenced an incision just below the meatus urinarius, and extended it about an inch downward ; the knife soon came in contact with cicatrices so resist- ing, that it appeared almost as if I was cutting on iron. The incision being com- pleted, I introduced a small sponge covered with oiled silk, and retained it in situ with the T bandage. Occasionally withdrawing the sponge, and renewing it, I found the vagina yielded slowly to this sort of pressure. With the aid of a small- sized rectum bougie, carefully introduced twice a week, and, after being withdrawn, replaced by the sponge, the vagina, in the course of a month, permitted the intro- duction of the finger. Then I had an opportunity of ascertaining its condition. It was filled with hard and unyielding cicatrices in the form of rings. Having suc- ceeded in dilating the vagina to this extent, I recommended my patient to continue the sponge, and occasionally to introduce a larger-sized bougie. In about three months afterward I was visited by her husband, who seemed somewhat chagrined; he stated that it pained him to say that his wife thought she was again pregnant. This I found really to be the case, though it is manifest from what has been said, that sexual intercourse must have been attended with great difficulty. With this, however, I had nothing to do; the mischief had been done, and it was my duty to provide in the best possible manner for the patient's safety. The sponge and bougie, gradually increasing the size of both, were continued, and the vagina seemed to yield slightly to this equable pressure. The patient having nearly reached the end of the seventh month of her gestation I deemed it prudent to hold a consultation as to the propriety of resorting to prema- ture delivery, feeling in my own mind that, although contractions of the soft parts do sometimes yield sufficiently to the combined influences of pregnancy and labor, yet, in her situation, it would, to say the least, be hazardous to the child to allow her to proceed to the full term. On proposing a consultation to the husband, he was anxious that a particular friend of his, Dr. Richardson, of Havana, then on a visit to this city, should be called in. This was accordingly done, and after a full »nsideration of all the circumstances, it was deemed prudent to bring on premature delivery. This I did, and delivered the lady of a healthy, living daughter. She egain became pregnant, and went to the city of Baltimore, where she was delivered at full term, with the forceps, of a dead child, after a labor of six days' duration. In consequence of the contraction of the soft parts, the vagina was lacerated. About three years from her last labor, I was again consulted. She was pregnant, and, at the seventh month, I resorted to premature artificial delivery, the soft parts not being La a condition to justify delay until the completion of gestation. In this instance, too, the child was alive and healthy. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 671 passionate judgment. In reference to convulsions, as a cause for the adoption of artificial delivery, it is to be remarked that the pregnant woman may be attacked with almost any grade of con- vulsive disorder; and if this latter, either under the form of cata- lepsy, hysteria, chorea, epilepsy, or the true puerperal eclampsia, should prove rebellious to remedies, and, more especially, if the convulsion be traced to irritation of the uterus, and the life of the mother placed in peril, I should not hesitate to liberate the organ from the irritation by promoting its premature action. Excessive Vomiting as a Motive for Premature Delivery.—The subject of excessive vomiting in pregnancy, involving the life of the mother, has recently attracted much attention. In 1852 there was a remarkable discussion in the French Academy of Medicine, embracing more particularly the question—Is it ever justifiable to induce abortion in cases of excessive vomiting? The discussion grew out of a report submitted to the Academy by M. Cazeaux, and there was much conflict of opinion on the subject, the ultimate decision being one of a mixed character. It is conceded that preg- nant women have occasionally died from the effects of vomiting ; there are some striking instances recorded, and I am quite sure the unrecorded experience of practitioners could furnish many more examples. Without entering into a prolix discussion whether abor- tion is ever justifiable in these cases, it seems to me to be more a question of sound judgment than one of controversy; and, in this as in all other instances, in which doubts may arise as to the proper course to be pursued in the treatment of disease, it is the para- mount duty of the medical man to fortify himself in every possible way by an appeal to judicious and experienced counsel, together with a searching review of all the surrounding circumstances of each individual case. In this way, with no preconceived opinion to sustain, with no prejudice to cloud his judgment, no false light to lead him into error, the sound physician will, I think, be enabled in these con- tingencies to arrive at a just decision; and, at all events, whatever he may do under the influence of such antecedents, will have been done with good and justifiable intent, and therefore will deserve, and must receive, the sanction of all right-thinking men. I can- not, for myself, recognise any difference between the decision of this question and multitudes of others more or less constantly pre- senting themselves to the practitioner while engaged in his daily rounds of duty. Where is the physician who has not, at times, been almost be- wildered in his desire to decide the nice question—further depletion or stimulation, in a case, for example, of pneumonia, pleurisy, or typhus, knowing, at the same time, that on the correctness of hia decision must depend the life of the patient! In a case like this, 672 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. after the proper exercise of his judgment, looking merely at the safety of the invalid, whatever that judgment may indicate, or whatever the issue may be, I hold that the medical man has dis- charged his duty. So, gentlemen, is it in symptomatic vomiting, endangering, if not checked, the safety of the mother. Look scrupulously at all the circumstances, and if, with the aid of ripe counsel, you should be impressed with the conviction that the best if not the only alternative is in premature delivery—then, in my opinion, you would deserve rebuke if you withheld this means of relief; for, after all, the question to be determined is the simple but grave one—life or death—and the decision has nothing to rest upon but human judgment. The two chief arguments employed by those, who oppose the induction of premature delivery for the cause under consideration, are: 1. That, in some instances, pregnant women, who have been supposed to have been almost in a moribund state from the ex- haustion of vomiting, have recovered and brought forth living chHdren; 2. That the physician is not justified in the performance of an operation, which necessarily leads to the death of the chHd. I do not perceive much force in this reasoning except in the abstract; and, when taken in connexion with all the circumstances presented by each case, it loses, in my view, aU strength as a guide in prac- tice. To the first argument, therefore, I reply—that if a woman, apparently moribund from long-continued and excessive vomiting, should recover and reach the full period of her gestation, it is a rare exception to a general rule, and, as an exception, utterly worthless as a precedent. Again: it is well known that women have died from the effects of this disturbance, who would in all probability have survived, if premature delivery had been resorted to. The second argument, it seems to me, is readily disposed of. The chances of saving the life of the mother, in these cases, are very much enhanced; and, without the operation, should the mother die, the life of the child is also sacrificed. But, I repeat, the whole question resolves itself into one of expediency, the word expediency in this case meaning—the interpretation which science, conscience, and a high morality may place on the necessity for action. In connexion with this subject, it may not be uninteresting to cite the following instance in which it became necessary to induce premature action of the uterus in a patient affected with hydatids of that organ: I was requested to visit a lady in consultation with Dr. Whiting, of this city. Several medical gentlemen had, previ- ously to my visit, seen and prescribed for the patient. When I saw her, in company with Dr. Whiting, she was apparently near dissolution. Her prostration was extreme; the countenance almost hippocratic; and, indeed, her friends had abandoned all hope of recovery. The particulars of the case are these: She was the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 673 mother of one child, seventeen months old; about four weeks previously to my visiting her, she had occasionally been troubled with nausea and vomiting, and for the last two wTeeks had vomited more or less constantly. Nothing could be retained on her stomach, the vomiting having resisted every remedy which had been administered. It was under these circumstances that I was called to her. The medical gentlemen, who had previously visited her, had ordered cups, leeches, and blisters, over the region of the stomach, with various other remedies; but all without the slightest appreciable effect. The vomiting was still unchecked, and her death hourly expected. In examining critically the case, I came to the conclusion that the vomiting was merely a symptom of trouble elsewhere, and that no remedy addressed to the stomach would be of the least avafi in rescuing her from the imminent peril in which she was placed. On applying my hand to the abdomen, I found the uterus enlarged, occupying the hypogastric region. The alarm- ing situation of the patient precluded delay; if her life were to be saved, everything admonished us that it was to be done by instan- taneous measures. My opinion was, that the vomiting was alto- gether sympathetic, occasioned by irritation of the uterus. I therefore suggested the propriety of endeavoring to bring about contraction of the organ, in order that its contents might be ex- pelled. This view was concurred in by Dr. Whiting. Accordingly, with the doctor's full approbation, and at his request, desperate and almost hopeless as the case was, I at once introduced a female catheter into the uterus; in a short time strong contractions ensued, and a large mass of hydatids was thrown off. Almost immediately, as if by enchantment, the vomiting ceased. The patient, after a tedious convalescence from her extreme prostration, recovered, and is now in the enjoyment of robust health. Let this case impress on you the importance of tracing effects to causes ; and bear in recol- lection this cardinal truth—that the practitioner who prescribes for mere symptoms will oftentimes find himself surrounded by obscurity, which will necessarily frustrate the successful treatment of disease.* Statistics of the Operation—-It will be seen that no comparison can be instituted between the results, to both mother and child, of premature artificial delivery, and those obtained from the Caesarean section and embryotomy. The mortality of the two latter alterna- tives has already been detailed; and we shall now, in contrast, present a brief schedule of the former. Prof. Hamilton* had re- * Dr. Churchill records an interesting example in which he produced premature delivery at the sixth month, in a young woman pregnant with her third child, in consequence of excessive vomiting; he says, he "never saw such agony in any case" from the effects of vomiting. The mother "was delivered of a dead foetus, recovered rapidly, and has since borne a child at full term."—Churchill's System of Midwifery, p. 282. \ Practical Observations, 1840. P. 285. 674 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. course to premature artificial delivery forty-six times, and forty-two of the children were born alive; on one of his patients he per- formed the operation ten times. Dr. Ramsbotham,* under some very discouraging circumstances, induced labor prematurely sixty- two times, and more than one half of the children were saved. Dr. Merriman,f in his own immediate practice, and in consultation, has met with thirty-three cases in which the operation was performed, and nearly a third of the children saved. Dr. Robert Lee J had recourse to premature artificial delivery twelve times in one woman with complete success. In two hundred and eighty cases collected by M. Figueira, one hundred and sixty-six chHdren were saved, and only six mothers died. In the sixty-two cases occurring in the practice of Dr. Ramsbotham, more than one half of the children were saved, and not one mother lost. Kilian, up to 1831, had gathered from various sources one hundred and sixty-one opera- tions, the results of which were one hundred and fifteen living children, and eight mothers lost. It is, however, stated that five of these eight died from causes altogether unconnected with the delivery. It will be thus perceived that, in premature artificial labor, considerably more than one half of the children are rescued, with the insignificant mortality of one in fifty of the mothers ! Ad- mitting, therefore, that this operation should be had recourse to under circumstances fully justifying it, it cannot, I think, but be regarded as one of the brilliant substantial triumphs of science, opening to the contemplation of the conscientious accoucheur a gratifying and cheerful vista, and, at the same time, closing up an avenue, which has proved so destructive to human life. The Various Modes of Operating for the Induction of Prema* ture Artificial Delivery.—These may be enumerated as follows: 1. The perforation of the membranes, for the purpose of affording escape to the liquor amnii; 2. The administration of ergot; 3. The dilatation of the os uteri by means of prepared sponge, known as the method of Kluge and Bruninghausen; 4. The method of Kiwisch, consisting of vaginal injections; 5. The vaginal tampon ; 6. Cohen's method, consisting of injections into the cavity of the uterus; 1. The injection of carbonic acid into the vagina; 8. Gal- * Dr. Ramsbotham observes, "It occurred to me between the years 1823 and 1834, to be compelled to induce labor prematurely forty times. This may seem perhaps, a very large number; and, in explanation, I may state that the extensive Charity whicn has supplied the principal part of these cases, embraces the district of Spitalfields and Bethnal Green, which, I believe, contains more females with de- formed pelves than are to be met with over the same quantity of square acres in any other part of the kingdom. In most of the patients, also, the operation has been repeated, and some have undergone it five and six times."—Ramsbotham's System of Obstetrics, Keating's edition, p. 315. f Merriman on Difficult Parturition, p. 172. X Medical Gazette, Feb. 7, 1851, p. 245. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 675 vanism as suggested by Dr. Radford. I now propose briefly to examine each of these propositions. Perforation of the Membranes.—The first suggestion, that of perforating the membranes, is undoubtedly the most reliable so far as the mere production of uterine contraction is involved ; but it has certain counterbalancing inconveniences. It is known in Germany as the method of Scheele, although it is recorded that Macauley had recourse to this very expedient in the operation, which he was the first to perform in England for the induction of premature delivery. The true objections to the perforation of the membranes are—that the escape of the liquor amnii* necessarily brings the walls of the uterus more or less in contact with the surface of the foetus, thus incurring the hazard, through undue pressure on the cord, of destroying the child by an interruption of the placento-foetal circu- lation ; again: the employment of a sharp instrument, with the object of perforation, will be likely to produce injury to the uterus; and it is also to be remembered that the presentation of the pelvic and other portions of the foetus than the head, is far more frequently met with in premature than in full term births ;f and this latter fact would consequently enhance the dangers to the child,J in the event of its becoming necessary to perform version after the exit of the amniotic fluid. Paul Dubois§ states that in the Maternite of Paris, during 1829 and the three succeeding years, of one hundred and * In order to obviate the objection that, in perforation of the membranes, the liquor amnii escapes in full quantity, Meissner, of Leipsic, has contrived a mode of opening them so that he can control the amount of fluid discharged. This he accom- plishes by penetrating the membranes at a distance remote from the os uteri, by means of a long curved trocar embraced in its canula. He first introduces the canula alone between the posterior surface of the membranes and internal wall of the uterus, and being assured that the upper extremity is turned toward the sac of waters, the trocar is then introduced through the canula, and made to penetrate the membranes; as soon as this is done, the extremity of the canula is carried into the opening made by the trocar, and the latter is immediately withdrawn. In this way, Meissner says he can draw off sufficient fluid to cause the uterus to contract, without endangering the life of the child by the loss of the entire quantity. It does seem to me, that the idea has at least plausibility to recommend it; but the carrying it out practically—though no doubt feasible in the skilful hands of its author—would prove a most difficult operation, and apt, also, to endanger the lives of both mother and child, in consequence of injuries inflicted upon them. Therefore, while men- tioning the operation of Meissner as a part of obstetric history, it is my duty to cau- tion the practitioner as to its too hasty adoption. At the same time, it is but just to remark that Meissner has recorded fourteen cases in which this plan has been adopted with safety to both mother and child. \ See Lecture hi. t This only applies to those cases in which the child presents crosswise; for, I have very emphatically stated that, all things being equal, delivery can be accom- plished consistently with the safety of parent and offspring, in either a breech, knee, or foot presentation. § Mem. de r Academic Roy. de Med., vol. il, p. 271. 676 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. twenty-one foetuses born before the completion of seven months, fifty-one presented the pelvis, and five the shoulder. This expe- rience is amply confirmed by all good observers. In the thirty-three cases in the practice of Dr. Merriman, fifteen presented preterna- turally, and in the forty-one quoted by Dr. Ramsbotham, fourteen were preternatural. It may be mentioned here, that Stoltz recom- mends in cases of premature artificial delivery—if it be previously ascertained the foetus occupies an irregular position—before bringing on labor, that an attempt should be made, through external abdo- minal version, to change the presentation to one of the head. To this there can be no objection in any cross-presentation of the foetus; but, as has been already stated, it should be limited to this latter presentation, and not had recourse to when either of the pelvic extremities is at the superior strait. Administration of Ergot.—The second method—the adminis- tration of ergot—is to my mind extremely objectionable, although in the advocacy of its use under these circumstances by Dr. Rams- botham it certainly has the sanction of high authority. This author first administers ergot, say four or five doses, at intervals of four to six hours, and then ruptures the membranes. Paul Dubois, also, commends the employment of this drug in these cases. The pro- miscuous administration of ergot, for the induction of premature artificial delivery, must occasionally be attended with serious con- sequences to both mother and child. For, in the first place, the justification of the operation is founded partly on the fact that there is such a contraction in the bony or soft structures of the mother— or such an excess of development in the foetus—as seriously to endanger her life and that of her child, if she be permitted to pass on to her full term. Now, if one of the obstetric extremities of the foetus should not present at the superior strait—and this cannot always be ascertained before the dilatation of the uterine orifice—to administer ergot would be to ensure the death of the child, and incur the hazard of grave lacerations to the mother. In all cases, therefore, be it remembered, in which the child may present crosswise, or in any other position so as to cause a disproportion between it and the parts through which it has to pass, ergot is certainly contra-indicated. Dilatation of Os Uteri by Prepared Sponge.—The dilatation of the os uteri by the prepared sponge, as suggested by Bruning- hausen and Kluge, is, likewise, not without its objections. For instance, it may be found extremely difficult, in consequence either of resistance or malposition of the os, to introduce the sponge, and the abortive efforts made to accomplish the object may induce more or less irritation of the parts. It must, however, be conceded that it possesses a very marked advantage over the process of perforating the membranes, and allowing the liquor amnii to escape, for, in this case, as we have remarked, the safety of the child is more or less THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 677 compromised. The manner of performing the operation is as fol- lows : Take a piece of prepared sponge, about three inches in length, conoidal in shape and properly pointed, with a string attached to the outer extremity so that it may, when needed, be withdrawn. Instead of employing the speculum for the purpose of introducing it—an unnecessary annoyance and exposure of the patient—it wHl suffice to carry the index finger of one hand as far as the os uteri, and grasping the sponge with a narrow forceps it should be made to glide along the finger, which wHl act as a guide; in this way, it is introduced into the mouth of the organ, care being exercised not to penetrate too far, for fear of rupturing the membranes; and it is then to be secured by the tampon. The sponge thus arranged may be permitted to remain unchanged, should the uterus not be brought into action, for ten or twenty hours; at the end of this time it should be withdrawn, and for the purpose of removing irritation, the vagina thoroughly injected with tepid water. The first sponge is then to be substituted by one slightly larger, if it be found neces- sary. If, however, after two or three days' trial, the contractions of the uterus be not provoked—an unusual circumstance—it must be laid aside, and some other expedient had recourse to. The modus operandi of this method is quite apparent, the sponge absorbs the moisture, always in more or less quantity about the os uteri; as a consequence, it enlarges, acting as an irritant on the incident excitor nerves of the vaginal-cervix, and thus, through reflex movement, brings on the needed contractions. Method of Kiwisch.—The method of Kiwisch, of Wurtzburg, known as the water-douche, was introduced to the attention of the profession in 1846, and is, perhaps, under ordinary circumstances, the safest and most reliable of all the plans yet proposed for the induction of premature dehvery. It consists in throwing a stream of water against the os uteri continuously for ten or fifteen minutes; and, to render the action of the stream more certain, the fluid should be alternately cold and warm. The suggestion of Kiwisch has met with very general favor; its modus operandi is, also, through reflex action. One of the advantages of the method is that it does not subject the patient to the necessity of keeping her bed, nor is it accompanied by the inconveniences of the other means already alluded to. The injection of the water may be repeated once in three or four hours until contractions of the organ are induced. Vaginal Tampon.—The vaginal tampon has been suggested by Scheller, as a means of inducing artificial delivery. It is well known* that the pressure of the tampon against the os uteri will, in many cases, provoke action of the organ ; and consequently it has been proposed as a suitable agent. It is, however, apt to occasion more or less suffering to the patient, and is now generally aban- * See Lecture xxxL 678 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. doned, for the more substantial reason that it is superseded by more efficacious means. Method of Cohen.—Next, there is the method of Cohen, which consists, through the agency of a curved tube, in throwing fluid into the cavity of the uterus itself. This plan has its advocates, but it seems to me is not so efficient as the proposal of Kiwisch. Injection of Carbonic Acid.—I should not omit to mention the use of carbonic acid as a means of inducing premature action of the uterus. Dr. Brown-Sequard was the first to direct attention to its influence in causing contractions of non-striated muscular fibres. His observations on this subject will be found in the Memoirs of the Society of Biology, 1849 and '50, and also in his work entitled, " Experimental Researches applied to Physiology and Pathology'," 1853, p. 117. Scanzoni, Simpson, C. and J. Braun, led by "the experiments of Dr. Sequard, have employed this agent with complete success in several instances, not only as a means of provoking early contractions of the uterus, but also in inertia of the organ. The gas is injected into the vagina, and is quickly followed by marked results. Galvanism.—Galvanism was suggested by Dr. Radford, of Man- chester, in 1844, and he employed it with success in four cases of contracted pelvis; so also have Dr. Barnes and others been fortu- nate with this agent. Induction of Abortion*—Is it ever Justifiable?—It now remains for us to examine the important question—is abortion, under any circumstances, a justifiable alternative ? This question has been much controverted, and it is one on which the sentiment of the profession is not concurrent. In order that the special points in the discussion may be fully appreciated, they may be advanta- geously presented under the two foUowing heads: 1st. When the maternal passages are so contracted—no matter from what cause— as to render it certain that a viable foetus cannot be made to pass. 2. When the maternal passages are normal, but the mother's life is involved in alarming peril by the occurrence of some serious com- plication, such as convulsions, hemorrhage, or excessive vomiting. It is manifest that the moral part of the question turns upon the simple interrogatory—is the embryo in the earlier states of its existence a living being ? All correct physiology demonstrates that it becomes in truth, at the very moment of fecundation, imbued with vitality—the contact of the sperm cell and germ cell consti- tuting the act of the breathing of life. Jorg, of Leipsic, I believe, alone claims the doubtful merit of describing the human foetus as * It i3 not of course intended here to discuss the general question of criminal abor- tion, which has become, both at home and abroad, a monstrous crime, owing in great measure to the laxity with which the laws on the subject are enforced. I may refef the reader to an instructive paper entitled " Criminal Abortion in America," by Hora cio R. Storer, M.D., 1860. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 679 " only a higher species of intestinal worm, not endowed with a human soul, nor entitled to human attributes." With his infidel notions on this point he might have added—nor is the shedding of its blood of any more moment than the slaughtering of the calf! Besides the proofs of physiology, we have the testimony of the early fathers of the Catholic church ; that church has always main- tained, with an unwavering consistency, so characteristic of its canons, that the destruction of the foetus in the womb of its parent, at any period from the first moment of conception, is a crime equal in turpitude to murder* Assuming, therefore, as an incontrovertible fact that the human embryo is in reality a living being, the suggestion naturaUy arises— are we justified, and, if so, under what circumstances, in depriving it of its life ? It is quite certain that the only plea for such an alternative is the safety of the mother; and as to the force of this plea there has always existed a difference of opinion. Here, then, we have the naked question—a woman is pregnant, carrying within her a living being—her pelvis is so abridged that it will be phy- sically impossible to afford exit to a viable foetus, and, consequently, if she proceed to her full term, the only chance of rescue will be the Caesarean section or embryotomy. Now, I repeat, what, under these circumstances, is the duty of the conscientious accoucheur, who is not actuated by a thirst for innocent blood, but who is most anx- ious to discharge with fidelity the sacred obligations which his pro- fession imposes upon him ? I cannot undertake to determine this question for others—it is one which must be left to conscience and a sincere desire, as far as may be, to do what is right. But, in no event, should a decision be arrived at without first invoking the aid of wise counsels, and duly considering all the surroundings of the case. On the other hand, suppose the instance of a pregnant woman, with a perfectly normal condition of the maternal organs, but who has not yet attained that period of gestation at which the child is viable—and she should suffer from some serious complication which would subject her, according to all human evidence, if not deli- vered, to the loss of her lHe—what, in this contingency, is the course to be pursued ? Here, in my judgment, the morale of the case is greatly changed; for should the mother sink, in consequence of not being delivered, her child, also, must of necessity be sacri- ficed. Therefore, under these circumstances, if my convictions as to the danger to the mother were beyond a peradventure, I should not hesitate to induce abortion upon the broad ground that, with- out the operation two lives would certainly be sacrificed, while, with it, it is more than probable that one would be saved. * For an elaborate discussion of this whole question, see the Dublin Review for April and Oct. 1858. LECTURE XLIV. Puerperal Fever—Synonyms; its Fatality most Fearful—What is Puerperal Fever ? —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 confined 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. Ameth'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. Gentlemen—I propose to-day to offer some general remarks on a disease, connected more or less directly with child-birth, than which there is, perhaps, no malady to which the female is liable that has called forth more discrepant opinions, or enlisted in its discus- sion abler and more accomplished minds. Writers in the profes- sion of the very highest order of intellect have been engaged in the study of this question—and in defiance of the marked ability with which it has been examined, the result still is that we are without a united verdict. I allude to what is generally known as puerperal fever. This affection has been described under a variety of names, such as—Febris puerperalis, febris puerperarum, perito- nitis, morbus puerperarum, metritis puerperalis, uterine phlebitis, child-bed fever, etc. When it prevails in its epidemic form, it is fully entitled to be denominated the scourge of the lying-in room, Its mortality even now, with all the advances of modern scientific investigation, is appalling, although it has undergone a comparative diminution from former periods of its history. Indeed, at one time, a recovery from this fearful malady was the exception, whHe the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 681 rule was death !* It, therefore, is a subject well worthy of inve* tigation; to the accoucheur it is one of the deepest interest. I shall not attempt a history of this destructive affection, nor shall I venture to impose upon you an array of the conflicting tes- timony which has been presented touching its nature. I prefer rather, as briefly as may be consistent with the importance of the subject, to discuss it under the following heads: 1st, What is puer- peral fever ? 2d, What its divisions? 3d, Is it contagious? 4th, Its caxises. 5th, Its symptoms. 6th, Its lesions. 7th, Its diagnosis. 8ih,*Its prognosis. 9th, Its treatment. What is Puerperal Fever ?—The earlier writers regarded every form of fever occurring at the time of child-birth as puerperal, and hence their views were extremely vague. No less precise and satis- factory are some of the modern teachings on this vexed question. We are told by one school that puerperal fever is an essential or specific disease—by another, that it is simply a local inflammation of a sthenic or active grade—again it is maintained that the phleg^ masia is asthenic, assuming at its very inception a low typhoid type. In the opinion of some, it is in close alliance with hospital gangrene, while others hold that it partakes more or less of an ery- sipelatous inflammation. A prominent hypothesis, sustained with no little ability by Dr. Robert Lee, would seem to refer the true source of the malady to uterine phlebitis; and so I might proceed to enumerate other individual opinions as to the real nature of the disorder under discussion, but such an enumeration would be with- out profit, and, therefore, I omit it. It does really appear to me that, in the multiplied hypotheses which have been presented in the attempted exposition of the essential nature of puerperal fever, there has been a sad confounding of terms. For example, simple peritonitis, metritis, etc., purely accidental, and, if you choose, spo- radic, totally unconnected with epidemic or typhoid influence, and liable to occur from cold, or the exercise of any other ordinary agency, have too often been regarded as the very types of puerpe- ral fever; and their inception, together with their progress and phenomena, looked upon as the reliable exponents of the epidemic puerperal disease, which is, as we shall attempt to demonstrate, an entirely different pathological derangement. It is to be remem- bered that both the pregnant, parturient, and non-pregnant female may be attacked with peritonitis or metritis, precisely as the male may be invaded by pure inflammation of the peritoneum. Here, * It is recorded by M. Malouin, in his account "of the epidemic at Paris, in 1746, that scarcely one woman recovered. Prof. Young, describing the disease as it occurred in the Royal Infirmary, Edinburgh, 1773. says: "It began about the end of February, when almost every woman, as soon as she was delivered, or perhaps twenty-four hours after, was seized with it, and all of them died, though every method was used to cure the disorder." 682 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. then, there is nothing specific—nothing essential. It is, if I may so term it, an inflammation under ordinary circumstances, and is to be treated on ordinary antiphlogistic principles. In this form of peritoneal inflammation, I repeat, we are not to seek for any speci- fic or mysterious something, which has produced the affection. But it is a vastly different thing when true epidemic puerperal fever prevails—a fever usually characterized by depression of the vital forces, and exhibiting many of the phenomena of a typhoid affec- tion. With the distinction just made, the question now1 before us, naked and deprived of aU collateral and adventitious issues, is— What is Puerperal Fever ? Is it in its origin a local disease—a phlegma- sia—and are the constitutional disturbances simply effects ? Or is its starting-point in the constitution, and the local lesions merely results ? The whole matter is, it seems to me, narrowed down to these two inquiries; and let us briefly examine them. Those who maintain that the origin of the disorder is traceable to a local phlegmasia have, with some slight show of reason, based their opinion on the circumstance that, in almost aU the fatal cases of puerperal fever, autopsical examination has revealed the evi- dences of inflammation of the peritoneum, the uterus, its veins, or some of its appendages; and, therefore, they associate the relation of cause and effect. No one will attempt to deny, with our pre- sent knowledge of pathology, that the lesions named are, more or less, accompaniments of the puerperal affection; and it will also be admitted, that the lesions are by no means confined to these struc- tures. Some of the ablest pathologists, aud among others Rokitan- sky, have demonstrated that the mucous lining of the alimentary canal and of the respiratory organs, the pleura, and the articula- tions themselves, wHl not unfrequently afford evidence of change of structure, under the form of exudations, congestion, or purulent secretions. But admitting the lesions to exist—and the fact can- not be controverted—do they prove that the source of puerperal fever is in the primary inflammation of some one or more of these structures ? I think not; and the hypothesis develops, in my judgment, the frequent faUacy of the post hoc propter hoc doctrine. To my mind, one of the most powerful—indeed, it is irresistible— arguments against the local origin of puerperal fever, is, that occa- sionally, in certain marked and fatal cases of this disease, the patho- logist has been unable to recognise the slightest appreciable trace of inflammation in any of the viscera designated as the starting- point of the malady. This fact has been well pointed out in the researches of Dr. Ferguson, Tessier,* Tardieu,f Depaul,J and * Tessier, De la Diathese Purulente, p. 312. 1838. f Tardieu, Journal des Connaissances Medico-Chirurgicales, 1841, p. 233. X Depaul, Bulletin de lAcademie de Medecine, t. xxiii., p. 395. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 683 others. This being so, it is difficult to conceive with what degi ee of "consistency the theory can be sustained, for certainly one affir- mative is worth a thousand negatives. Other arguments might be adduced, such as the occurrence of peritonitis, metritis, etc., in the parturient female, unaccompanied by any of the constitutional dis- turbances ordinarily characteristic of puerperal fever ; but the accu- mulation of further proof I do not deem necessary, and I have np hesitation in avowing that, as far as I can understand it, the entire weight of proof is adverse to the hypothesis. If, therefore, puerperal fever be not traceable to a local phleg- masia, what is its true source ? A number of able observers have referred the origin of the affection to a peculiar altered condition of the blood—to a poison introduced into this fluid—in a word, they maintain that it is a veritable toxaemia, and in this view I fully concur. In my opinion, the whole chain of evidence on this point is in demonstration of the sentiment of Dr. Ferguson, that " the phenomena of puerperal fever originate in a vitiation of the fluids, and that the various forms of puerperal fever depend on this one cause of vitiated blood, and are readily deducible from it.''* But you may very naturally ask, What is this poison, and how does it reach the blood ? The real essence of the contaminating element it may not be so easy to explain; it is one of those mysterious, subtile somethings which is more or less frequently met with, exhi- biting varied pathological phenomena, and oftentimes resulting, with remarkable promptitude, in the extinction of life. You may call it, after some of the older writers, a ferment or a morbific mat- ter, but this in no way facfiitates the solution of the inquiry—what is this poison ? Toxaemia, or blood-poisoning, is a generic term, and exhibits seve- ral varieties: in one instance it results in scarlet fever, in another in small-pox, in another in measles, in another in puerperal fever. Here, by some of the schools, I shall be charged with advocating humoral pathology, which has too generally been regarded as a doc- trine long since exploded. I have only to say in reply, that I always endeavor to advocate truth, and do not believe in restrict- ing our science to any exclusive dogmas—" Je prends le bien oil je le trouve." Indeed, if time permitted, it would be an agreeable task to exa- mine somewhat in detail whether the doctrine of humoral pathology is altogether a phantom, without a shade of scientific basis, as some of the schools maintain. The examination might, perhaps, result in the conviction that some of the finest displays of modern science, under the ministrations of organic chemistry, have not only ren- dered plausible, but have absolutely demonstrated, the truth of the doctrine of "peccant humors," as taught by the early fathers, * Ferguson on Puerperal Fever. 684 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Hippocrates himself inculcated that fever was but the offspring of accumulated morbid matter in the blood, which, after a certain number of days, through a process of fermentation, was thrown off either by hemorrhage, alvine evacuations, the perspiratory surface, or through the development of some of the exanthemata. It does seem to me that the doctrine of fermentation finds a clever advo- cate in the distinguished cultivator of organic chemistry in our day —Liebig. His explanation of the morbid phenomena consequent on blood-poisoning is strongly kindred to the ancient theory. It is important to note that, when blood-poisoning exists, its effects are not always identical; there are marked grades of seve- rity, and this is abundantly exemplified in scarlet fever. In some instances this latter affection assumes an extremely mild form—the scarlatina simplex—in other cases it proves the terror of the house- hold, seizing its victim in the fuU bloom of health, and terminating life in two or three hours—the scarlatina maligna. In puerperal fever, also, there wHl be observed a modification in the action of the poison, the disease being at times comparatively light, and again exhibiting a fearful virulence.* If we cannot explain the essence of the poison, yet observation proves that its influence on the economy may be very materially affected by certain conditions, such as the state of the atmosphere, the locality, etc. The testimony is ample showing a connexion between puerperal fever and erysipelas. The two diseases may prevail simultaneously in the same neighborhood ; or if erysipelas alone prevail, a third party may communicate, from a patient affected with it, puerperal fever to a woman recently delivered.! On the other hand, well-authenticated instances are recorded of husbands and nurses, in attendance on women dead of puerperal fever, having been attacked with erysipelas ; and Dr. RigbyJ states that in an epidemic which prevailed in the General Lying-in Hos- pital, London, the child of every female in whom the disease proved fatal died of erysipelas in a few hours.J * Diseases produced by blood poisoning have one especial characteristic—they are usually sudden in their invasion, and after running a fearful course for an inde- finite period, as suddenly disappear. This is within the experience of all vigilant practitioners. We recognise the fact constantly in yellow fever, cholera, typhus fever, measles, scarlet fever, puerperal fever, &c, all of which are due to the opera- tion of a morbid poison. In a pathological sense, the seat of lesion in the various affections resulting from a toxsemic influence is not without interest. In scarlatina and measles, for instance, the development is on the cutaneous surface; in typhoid fever the glands of the small intestines are more or less involved, while in cholera it is the general gastro-intestinal mucous surface. In puerperal fever the serous sur- faces, and more especially the peritoneum, are usually affected. f In constitutional erysipelas, whether affecting the male or the non-pregnanl female, a not unusual lesion will be inflammation of the peritoneum. X Rigby's Mid., p. 392. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 685 Although, as a general rule, puerperal fever attacks the parturient female,* yet it should be recollected that it is not exclusively confined to this class of patients. Young women, married and non- pregnant women, the new-born child,f and the foetus in utero, even when the mother has no symptoms of the disease, are all liable to the affection; instances are recorded of its existence under these circumstances ; and what may surprise you still more, it has been shown that, in some cases, the male, if subjected to the peculiar poison known to generate the disease, will become sick, and exhibit lesions more or less in accordance with those found in women affected with puerperal fever. While it is proper to mention these exceptional cases, the important fact is, that in the great majority of instances, the disease attacks the parturient female—and I am inclined to adopt the explanation of the circumstance given by Trousseau, in the recent discussion of this question in the French Academy of Medicine—he says the lying-in female exhibits a pecu- liar morbid opportunity, and presents a remarkable pathological aptitude for the malady. Both in sporadic and epidemic puerperal fever, the special poison generating the disease may originate in the person of the parturient woman, and be conveyed into her blood through the absorption of putrid coagula, portions of placenta, &c.; but there are other modes by which the poison may be communicated, to which we shall refer under the head of contagion. What are the Divisions of Puerperal Fever ?—It has already been remarked that there are two distinct varieties of this disease— one known as the sporadic, the other assuming the epidemic form. The characteristic of-the former is that it is an isolated affection, and does not extend; while the epidemic variety is not limited to one or two cases, but involves districts and neighborhoods, oftentimes proving frightfully destructive. Some authors have made other distinctions, which do not appear to have much practical impor- tance—such as inflammatory puerperal fever; bilious or mucous puerperal fever ; typhoid puerperal fever, etc. * The following is the language of Tarnier, and I quite agree with him in opinion : "In ordinary medical phraseology, the term puerperal state is understood to mean the particular condition presented by the recently delivered woman. This definition is entirely too limited. I adopt the division recently proposed by M. Monncret, viz. The first period of the puerperal state commences with conception; the second comprehends the puerperal state of all authors, that of the newly deli- vered female; the third period includes the entire term of lactation. To these three divisions I shall add a fourth—that of menstruation. In menstruation, in gestation, and in parturition, 1 can see but a series of inseparable facts, which tend to the same object—the reproduction of the species." [De la Fievre Puerperale, observe a l'Hos- pice do la Maternite par Stephane Tarnier. Paris, 1858.] f Puerperal fever in the recently delivered female, the fcetus, and the new-born child. By M. Lorain. Paris, 1856. 686 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Is Puerperal Fever Contagious ?—The views on this point are far from being concurrent; and one of the. most emphatic advocates of the non-contagious character of the affection is our distinguished countryman, Prof. Meigs of Philadelphia; he is also sustained by Prof. Hodge, the able Prof, of Midwifery in the University of Pa. It is somewhat singular that these two gentlemen, ripe observers, and engaged as they have been in extensive practice, should so positively maintain an opinion in opposition, it seems, to me, to evidence which, if thoroughly examined, is irresistible.* I do not deem it necessary to cite particular examples in which puerperal fever has been conveyed through the principle of contagion—they are so numerous, and so free from all doubt—in a wrord, they are so conclusive that I cannot conceive how they can be regarded otherwise than completely demonstrative of the point at issue. I have already remarked that puerperal fever may, under certain circumstances, originate with the patient herself. She may, so to speak, inoculate herself with the noxious element through absorp- tion of putrid coagula, or portions of the placenta remaining in the uterus; or she may derive the affection from the passage of some of the products of inflammation into her blood ; or the translation of the disease may be by contagion through the intervention of a third party; and again, the inoculation may be traceable to the hand of the accoucheur carrying the poison into the system during his vaginal explorations. The question of the possibility of trans- mission of puerperal fever by the physician has received fresh support within a few years from some German investigators.f * Dr. Holmes, of Boston, has discussed this question of contagion most elabo- rately, and I refer the reader to his admirable paper. ■j- In an interesting paper by Dr. Arneth, of Vienna, we have the following state- ment: Dr. Semmelweiss, assistant to the Prof, of Midwifery, was struck with the difference as to the prevalence of puerperal fever in fhe two clinics of the hospital; in one of these clinics, the pupils are midwives; in the other, medical students. The latter were, almost without exception, in the constant habit of assisting at autopsies, of which there were eight or ten nearly every day. The dissections were sometimes made by the students; or at least they handled the pathological preparations, and carefully examined them. Moreover, the assistant was accustomed to lecture on the obstetric operations which were performed on dead bodies. After such investiga- tions on the cadaver and such practice, it was not rare for the students to proceed immediately to the wards of the lying-in hospital, and examine the pregnant and parturient women. The pupils of the other clinic, being midwives, did not take any share in the occupations just alluded to ; and even the assistant of that clinic had comparatively but seldom to do with post-mortem examinations, as it was not a part of his duty to instruct midwives in pathology or in operative midwifery. Having convinced himself that the great prevalence of the disease in his wards was caused by the inoculation of the female genitals, Dr. Semmelweiss entertained the hope of being able to diminish the frightful mortality. He finally deduced from his researches these conclusions—Any fluid matter in a state of putrefaction, com- municated by linen, by a catheter, by a sponge, by small particles of the placenta, or even by the ambient atmosphere impregnated with the foul substances, may pro> THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 687 It is now, I believe, very generally admitted that the laws of contagion can only operate when the disease thus communicated is the product of an animal poison ; and it is also, in my judgment, clearly established, that puerperal fever is rightfully classed among the zymotic diseases, or those whose existence depends on the presence of a noxious animal material. Since the publication of Dr. Arneth's paper, German physicians have made experiments on animals, which have given the following results: 1st. Any kind of putrefied animal matter introduced into the vagina of a parturient female may engender a malady bearing a strong resemblance to puerperal fever, and frequently foUowed by death ; 2d. A very small quantity of the fluid in the vagina of a woman or of an animal, attacked with puerperal fever, being introduced into the vagina of a parturient animal causes puerperal fever, or at least a disease very much like it. With the above results, it might very consistently be asked, why every woman after parturition, is not affected with puerperal fever; it would, at first view, seem that this should be so, for there is in more or less quantity, putrefied animal matter in, the uterus or ragina of every recently delivered female. Let us, for a moment, pause, and examine this point. In the first place, it seems quite duce puerperal fever. Mere washing of the hands with soap and water is not suffi- cient, and Dr. S. has found it necessary to make use of a solution of chloride of lime. In the course of the month of May, 1847, it was arranged that no one should examine any woman in the clinic without previously having washed his hands with the solution, and made use of a nail-brush. Even in June, it was impossible not to remark the influence of this precaution. Out of more than three hundred women confined in that month, only six died; in July, three out of about the same num- ber ; in August, three; in September, twelve; October, eleven; November, eleven; December, eight; whereas in April, fifty-seven, and in May thirty-six cases had ended fatally. In the year 1848, the mortality among the puerperal women deli- vered by male pupils was one in eighty-four; while in the second clinic, among the women delivered by midwives, it was one in seventy-six. Since the year 1827, the rate of mortality in the hospital had never been so diminished. Analogous results have been obtained by the same means at Kiel. According to the reports of the lying-in houses in the whole Empire of Austria, in none of those institutions in which midwives have been the only pupils has puer- peral fever made its appearance as an epidemic; but it prevailed obstinately in Pavia, where they were in the habit of dissecting (in one of the rooms of the lying- in hospital) bodies of the children who died in the hospital. While in search of the true cause of the prevalence of puerperal fever, and before the necessity of washing the hands with chloride of lime was appreciated, a pregnant woman was admitted into the hospital affected with cancer of the uterus. Aa several days elapsed before her confinement, and as the case was highly interesting, all were anxious to examine her. The consequence was most deplorable. Fourteen mothers who had been confined at the same time with this woman, and who had been examined by the same students, exhibited symptoms of puerperal fever, and three of them died, although the disease had not been prevailing immediately before, nor did any other case occur except these fourteen. [Braithwaite's Retrospect, part 23d, p. 492.] 688 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. certain that the mere contact of putrefied material with the walls of the cavities of the female genitals is not sufficient for the absorp- tion of the deleterious principles; and secondly, there must be some openings in the blood-vessels, through which the matter will pass into the blood, and thence be conveyed to the general circulation. Therefore, even if exposed to her own decomposed matter, or mat- ter from dead bodies, the consequent development of puerperal fever will depend upon the condition that there are openings of some of the blood-vessels through which resorption may be accomplished. An interesting question now arises—Is a woman, with the con- ditions named, more liable to contract puerperal fever from the pas- sage into the blood of her own decayed matter, or of matter trans- ferred to her from another female, or from any dead body ? The solution of the inquiry will not be difficult with the two following propositions, which I believe have the sanction of science: 1st. The matter found in dead bodies is more putrefied, and, therefore, more poisonous, than that contained in the uterus and vagina; 2d. It is well known that we become accustomed to poisons generated or having long existed in our own system, or produced from decom- posed substances coming from our own body. In proof, we may invoke what has been established in regard to syphilization; we may also refer to vaccine, and to an interesting fact connected with the fibrin of the blood. As to syphilization—If an individual had for some time a venereal ulcer, so that the system has become impregnated, the pus of this ulcer cannot, under inoculation, pro- duce a similar one in that individual, but let the pus be.infused into the system of another, and the result will be the appearance of a syphilitic ulcer. In vaccination, when the body has become charged with the virus of vaccine, this virus will fail to produce its primitive effects under a second inoculation. In regard to the fibrin of the blood—it is proved that the blood of an animal of one species will generally act as a poison on an animal of another species; and this is on account of the fibrin of the blood, according to Dieffenbach, Bischoff, and Dr. Brown-Sequard, who have shown that no poison- ous element exists in defibrinated blood. It would seem, therefore, to follow that the poisonous power of fibrin, or of a substance eliminated with it during defibrinization, varies in different animals, and that each species is accustomed to the poison contained in its own blood, but is intolerant of the action of the poison in the blood of another species. It may here be remarked that it is the duty of the medical man, when in attendance on women attacked with puerperal fever, no matter what his views may be as to the contagiousness of the disease, to use every precaution against the possibility of translating the affection through his own person. In this precaution nothing will be lost, and much may be gained. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 689 Causes.—It is not easy to assign any special class of influences or causes capable of producing puerperal fever, for in this affection, as in epidemic diseases generally, there has always existed an intan- gible something, which has not failed to embarrass scientific investi- gation. There are, however, certain influences which are generally admitted to predispose to the disease—and among them may be mentioned the following: mental emotions of a depressing nature, difficult and protracted labors, yet I have known puerperal fever to follow very rapid deliveries; women with their first children are more liable to the affection than those who have borne one or more, cold and humid seasons seem to favor the development of the dis- ease, although, in some instances, very destructive epidemics have prevailed in the warm months ;* inadequate nourishment, a neglect of the laws of hygiene, an impure atmosphere, etc., are so many causes, which may be enumerated as predisposing to the malady. In one word, all influences which, from their depressing tendency, are calculated to lower the forces of the economy may be regarded as predisposing more or less to the disease. Symptoms.—In order that there may be no confusion in reference to the usual symptoms of this affection, and as there is some differ- ence in those of the two varieties—the sporadic and epidemic—I shall first direct attention to the symptoms indicative of the sporadic form of the disease. Here, I would wish to impress on you the recollection of the important fact that, as a general rule, before there is the slightest shade of suspicion that puerperal fever is at hand, the very first abnormal condition of the patient will be an accelerated pulse; be vigilant, therefore, when the pulse becomes quickened after delivery; for although it may not be followed by peritonitis, yet it portends no good. The disease ordinarily com- mences its development from thirty to forty-eight hours after partu- rition ; next to the quickened pulse, one of the earliest phenomena— it is a very rare exception for it not to precede the other symptoms ■—will be a rigor, of more or less force, and it may be partial or general. Succeeding the rigor, will be exquisite tenderness over the abdominal surface, involving a section, or a large portion of that region; foUowing the chill, there will be a heated and dry skin, and an increase in the rapidity of the pulse, ranging from 120 to 160, and upward. There is nothing uniform in the appearance of the tongue; sometimes dry and extremely red ; again, it is coated and * The researches of M. Laserre give the annexed results: In 27 epidemics in the Maternite of Paris, from 1830 to 1841, 16 occurred during the months of Jan., Feb., March, Oct., Nov., and Dec. Of the whole number of labors in the same institution within the same period, from 1830 to 1841, he presents the following tables: In 18,108 accouchements during the six cold months, there were 868 deaths, or 1 in 20, while in 15,986 accouchements during the six warm months there were 465 deaths, or 1 in 34. [Recherches Cliniques sur la fievre puerpprale.] 44 690 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. Biimy; distressing thirst is one of the ordinary accompaniments of this disease; the respiration is rapid and short. Nausea and vomit- ing not unfrequently ensue ; the lochial discharge usually becomes suppressed, as also the milk secretion; but these in some cases will go on without interruption. Although the skin is generally dry and hot at first, as the disease advances it becomes moist and clammy. There is a notable change in the countenance—it is expressive of great anguish, and sunken, with a circumscribed lividity around the eyes. The bowels are confined at first, but afterwards diarrhoea not unfrequently sets in; the urinary secretion is high-coloured and defective in quantity. There is, in the progress of the affection, a marked distension of the abdomen—and this may arise from a flatulent condition of the intestines, or from a sero-purulent effusion which is one of the ordinary attendants on the disease, more espe- cially when it proves fatal. Commonly, when the effusion takes place there is a cessation of pain, which oftentimes deludes the friends into false hope; for, under the circumstances, the absence of pain is but one of the preludes to death—the other fatal symp- toms consisting in the extreme rapidity of the pulse, which becomes weaker and fluttering, with cold extremities; the patient lapses into unconsciousness; there is a low unintelligible muttering, toge- ther with subsultus tendinum; the tongue is parched and exhibits a brownish color, with vomiting of a dark offensive nature. These are the closing phenomena, and are soon followed by death. There is one striking peculiarity as to the position of the patient in this affection, and I regard it as quite characteristic—the patient remains on her back, with her knees drawn up, and she assumes this position for the reason that she seeks, as it were instinctively, to relieve the abdomen from pressure, the slightest adding greatly to her distress. This attitude not only relaxes the abdominal walls, but in a measure protects the patient from the weight of the bed- clothes. On the other hand, a spontaneous change of position on the side, for instance, should be hailed as a most favorable indi- cation. In the epidemic form of the disorder the symptoms are somewhat modified; as a general rule there is increased rapidity of the pulse; and from the violence of the poison, a depressed condition of the forces is noticeable at the very invasion of the malady ; the disten- sion of the abdomen is mucli earlier developed, and the disease is more rapidly fatal, sometimes destroying the patient in twenty-four or thirty hours. In some instances, it is worthy of remark that there is an absence of pain on pressure, although the subsequent autopsy may disclose the existence of peritonitis. Lesions.—There is nothing uniform in the anatomical lesions accompanying this affection, although it may be stated that evi- dence of peritoneal inflammation is the most constantly met with, THE PRINCIPLE'S AND PRACTICE OF OBSTETRICS. 691 and it is no doubt for this reason that the disease has received the designation of puerperal peritonitis. When this lesion is observed it will be found almost always that the peritonitis is general, and not limited to one portion of the membrane; the sac will usually contain more or less sero-purulent effusion; and in this particular there is a marked difference between simple and puerperal peri- tonitis—in the former there are adhesions through pseudo-mem- branous formations, because in simple peritoneal inflammation, instead of a sero-purulent affection there is the presence of plastic lymph, the tendency of which is to produce these adhesions. In the uterus and its appendages there will also be exhibited various changes; uterine phlebitis is among the most uniform attendants upon the disease ; the abdominal viscera undergo morbid changes, exhibiting more or less abundantly purulent collections, and these collections wiU sometimes involve the various articulations. There is one peculiar feature usually characterizing the pathology of puer- peral fever—it is a softening of the tissues, and this will oftentimes be observed in the structures of the uterus, ovaries, peritoneal covering, liver, spleen, and other organs. In some instances there is no cognizable alteration of the peri- toneum, and strange to say M. Charrier* records the history of an epidemic puerperal fever in which lesions of the pleura were sub- stituted for those of the peritoneal sac. It is worthy of note that sometimes in its severest forms, and when most rapidly fatal, the only apparent changes are those exhi- bited by the blood ; but in what these changes actually consist it is not so easy to determine. It is darker, and loses much of its coagulable properties. According to Prof. Vogel,f it contains lactic acid, sometimes carbonate of ammonia, and again hydro-sulphate of ammonia, its globules do not redden on exposure to the atmosphere, and, therefore, the act of respiration is defective ; the globules are in part decomposed, and dissolved in the serum. Diagnosis.—Where puerperal fever prevails as an epidemic, there can be no embarrassment in the diagnosis; the lines of the affection are so well defined that the observant physician wHl rea- dily appreciate its existence. Not so, however, in the sporadic form of the disorder; for here it may be mistaken for metritis, but this is of no material consequence, as the therapeutic management in either case would be the same. It may, however, be stated that in metritis the pain on pressure is more circumscribed, and the volume of the uterus itself much increased, the patient bearing pres- sure well untH some portion of the organ is touched; whereas in peritonitis, the affected surface being more diffused, pressure on almost any point of the abdominal region would be followed by * De la fievre puerperale, epidemic en 1854. f Virchow. 692 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. more or less suffering. You are not to understand that pain in peritonitis is simply the offspring of pressure by the hand; on the contrary, the patient without either change of position or pressure wiU experience much agony, which at intervals will be increased by the passage of flatus from one portion to another of the intestine. There is some tact required in the manual exploration—too much force should not be used, for this, without any compensating good, only aggravates the condition of the patient. Let the medical man keep his eyes, as he cautiously presses the abdomen, on the coun- tenance of the invalid, and he wHl quickly discover whether or not he inflicts suffering. When speaking of the attentions needed by the recently delivered woman, the general phenomena of after-pains were fully discussed, so that by reference to what was then said it would be an act of unpar- donable carelessness to mistake them for peritonitis. It is barely possible that some confusion might exist in discriminating between puerperal inflammation and tympanites intestinalis, which not unfre- quently follows child-birth, and which has already been mentioned as one of the ordinary accompaniments of puerperal fever. In simple tympanites, however, the pulse will be but slightly accele- rated ; no sunken, dejected condition of the countenance; and gentle pressure with frictions will diminish the pain. Tympanites, also, may be distinguished from effusion by percussion ; the former, tympanites, revealing a resonant sound, while the latter, effusion, would disclose the evidences of fluctuation. Prognosis.—It need scarcely be remarked, after what has been said touching the nature of the disease, that epidemic puerperal fever is one of the most fatal disorders of the lying-in room; our prognosis, therefore, should always be guarded, and no false hopes encouraged. Even in its sporadic type, the malady, although much less fatal, is full of danger. During the progress of the malady, the experienced observer wiU be enabled to foresee with prophetic truth its fatal termination by the presence of certain significant indications. I have, as has already been remarked, an abiding faith in the pulse; if it should not exceed 120 beats in the minute, this may be regarded as most favorable; but how different if it reach, and continue at that rate, from 140 to 160 ! A cessation of pain, without any diminution in the throes of the heart, accompanied with an anxious and drawn countenance—fades hippocratica ; an oppressed respiration, showing imperfect decarbonization of the blood; involuntary intestinal discharges, the cadaveric odor, &c, may justly be regarded as the precursors of dissolution. Treatment.—The treatment of puerperal fever may very appro- priately be divided into prophylactic and remedial. Prophylactic Treatment.—In a disease so fearfully destructive, it can require no argument to show the vital importance of pre- THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 693 ventive measures, if these can be proved to arrest the develop- ment of the malady. Without referring to • other proofs, I shaU content myself with alluding to the remarkable results obtained in the Dublin Lying-in Hospital, under the mastership of Dr. Collins. For the four years previous to the adoption of his sanitary mea- sures, the entire relative number of deaths in the hospital during the prevalence of puerperal fever, was 1 in 52; but from 1829 to 1833, under the system of purification, the disease almost entirely disappeared, and the mortality diminished to 1 in 190, 181, 187, 178, the average deaths in the aggregate being 1 in 184 cases. His preventive measures were as follows: The wards of the hospital were closed, during the process of purification, against the admis- sion of patients; they were then filled, in rotation, with chlorine gas in a very condensed form, for the space of forty-eight hours, during which time the windows, doors, and fire-places were kept shut, so as to prevent, as much as possible, the escape of the gas. The floors and wood-work were covered with the chloride of lime, mixed with water to the consistence of cream, which was not removed for forty-eight hours or more. The wood-work was then painted, and the walls and ceilings washed with fresh lime; the blankets, &c. scoured, and stoved in a temperature from 120° to 130°. In addition, the strictest attention was always paid to the proper ventilation of the wards. The beds were composed of straw, and never used a second time without washing the covers, and a renewal of the straw. Dr. Colfins states that from the time of the adoption of this mode of purification until the termination of his mastership in 1833, not one patient died of puerperal fever* The above results are not without interest, and they would seem very broadly to indicate the efficacy of chlorine as an element in destroying the poison of the disease. Dr. Collins further remarks that, in every instance of the death of a patient, if the most remote symptoms oi fever had been pre- sent, besides scouring every article connected with the bedding, the wood-work and floor was washed with a solution of chloride of lime, and the entire ward whitewashed. This was readHy effected, as the sick were invariably placed in a small ward, apart from the healthy. To this latter precaution, he observes, too much attention cannot be paid, as the instant separation is of vast importance to both. . The suggestion of Dr. Collins in reference to the separation of the sick from the healthy is, in my opinion, a sine qua non to the arrest of epidemic puerperal fever as it prevails in hospital practice. In the crowded wards of the hospital, the poison becomes concen- trated, and this circumstance, I believe, is one of the chief reasons * Practical Treatise on Midwifery, p. 388. 694 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. of the fearful spread of the affection in lying-in establishments. Here, then, is a subject worthy the attention of the philanthropist —let the laws of hygiene in reference to the health of the numerous poor, who seek shelter in our public institutions at the time of their accouchement, receive merited attention—let these laws be rigidly and humanely enforced, and the fearful outlet to life, through epi- demic puerperal fever, will be measurably closed. We are firm in our conviction, that if the poor were attended at their own homes —defective as they may be in ordinary comforts—instead of being exposed to the infection of crowded wards, the bills of mortality would be greatly diminished. There is a wonderful charm in pure air in all cases of disease, but more especiaUy as regards convales- cence from the puerperal state. Although puerperal epidemic fever usually exhibits its most devastating effects in lying-in hospitals, yet it should be known that these disastrous results are not always confined to this class of asylums. In 1819, the epidemic prevailed at the same time in Vienna, Prague, Dresden, Wurtzbourg, Bamberg, in several small cities of Italy, at Lyons, Paris, Dublin, Glasgow, Stockholm, and Petersburgh. It is also very remarkable that the epidemic has extended even to the females of some of the domestic animals— to sluts, for example, in the disease observed in London in 1787 and 1788; and to cows during the epidemic which occurred in several parts of Scotland in 1821.* Remedial Treatment^—In regard to the remedial management of the disease, much difference of sentiment has existed, and the discrepancy is mainly due to the conflicting opinions which have prevailed touching the pathology of the disorder. On the one hand, we are directed to depend on prompt and full depletory measures—while, again, the stimulating method is considered as presenting the only hope. There is too much generalization in this kind of therapeutics, and neither the one nor the other plan can be resorted to without a proper discrimination. Let it be care- fully treasured in memory, that there is no specific for this disease. In my judgment, the treatment of puerperal fever should not be restricted to the opinions of the respective schoolmen, but, as in other pathological conditions of the system, we should be governed by the special indications which may exist at the time. The lancet, and other of the antiphlogistic agents, are oftentimes necessary in pneumonia, erysipelas, &c, but there are numerous cases in which * Danyau, Bulletin de TAcademie de Medecine, t. xxiii. Paris, 1858. f There is one point in the treatment, not only of puerperal fever, but, as a rule of all puerperal diseases, which should claim in a special manner the attention of the accoucheur, and it is to forbid the patient suckling her child. This duty, so natu- ral and obligatory under ordinary circumstances, cannot be discharged with impu- nity while laboring under affections incident to the puerperal state. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 695 these measures would prove quickly fatal; the same remark applies to puerperal fever, and this imposes the importance of discussing the question of treatment in reference to the particular form of the disease which may present itself. We have, even in its epi- demic garb, what may be termed inflammatory puerperal fever; and, again, the disorder will exhibit itself with all the phenomena of depression, simulating, at the very inception, the type of a low typhoid affection. If this be so—and its demonstration will be clearly recognised at the bedside—it follows as a fundamental prin- ciple in therapeutics that the treatment of the two grades of the malady cannot be identical. In inflammatory puerperal fever— the nature of which will be defined by the symptoms—prompt depletory measures are certainly indicated. But, in order that these measures may result in benefit, remember that they are to be resorted to opportunely—the blow is to be struck simultaneously with the advent of the enemy—no delay can be tolerated here, and the only hope of rescue is in the sudden arrest of the disease. Therefore, the prompt abstraction of blood is called for ; take from the arm from twelve to thirty ounces of blood, depending of course on the urgency of the case, and in order that there may be nothing equivocal in the impression made on the system, bleed from a large orifice, let there be a bold and full stream; in one word, make your patient faint; syncope will more readHy be accomplished by placing the patient in the sitting position during the abstraction of blood. Is the bleeding to be repeated ? Yes, if the indications justify it. But the repetition must not be delayed. Not more than three or four hours should elapse ; at this time, one, two, or more dozen leeches may be applied to the abdomen, resting with the judgment of the practitioner, and the bleeding promoted by warm fomentations. The next indication wHl be a free action on the bowels ; in ordei that there may be no unnecessary delay in the effect of the medi- cine, give immediately the good old searching compound: IJ. Submur. Hydrarg. gr. x. Pulv. Jalapse gr. xv. " Antimonial. gr. ij. M. Let this be followed in two hours with the annexed draught: $. Sulphat. Magnesise 3 ij- Infus. Sennse f. 1 iv. Mannse 3 i- Tinct. Jalapse f. 3 i. M. If free purgation be not accomplished, I should have recourse to Croton oH, which is a favorite remedy with me in these cases; ft 696 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. acts promptly and thoroughly, producing full serous discharges; it stimulates the intestinal mucous surface, thus causing a powerful derivative influence, which necessarily diminishes the engorged con- dition of the vessels of the inflamed peritoneum. IjL OleiTiglii gtt. iv. Sacchar. Alb. 3 ii. Mucil. Acaciae f. § ij. M. A teaspoonful every half hour until free catharsis follows. When the bowels have been properly evacuated, it is essential to attend to that important emunctory—the skin; and with the combined view of diaphoretic action, and calming nervous irrita- bfiity, one of the following powders may be administered every two or three hours: IJ. Pulv. Doveri gr. xxiv. " Ipecac gr. vi. Divide in chartulas xij. The diet should consist, until the inflammatory stage has subsided, rigidly of dHuents ; a free use of the nitrate of potash, either in gruel or water, 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 somewhat broken; instead, however, 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 two 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 have 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, whether 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 DubHn, and many able practitioners have endorsed his views. There can be no doubt of the efficacy of this medicine in relieving the tym- panites, which is so usual an accompaniment of the affection. Half an ounce of the turpentine, with the same quantity of castor oil, every six or eight hours, will be found often effective in removing the intestinal flatus; and frequently it wHl 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 water. 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! how often are our best-directed efforts made negative by the inexorable demands of the mercHess foe. The sulphate of quinine, although by no means a new 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 bowels. 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 when lesion of the peritoneal covering exists. As far as I know, the administration of large doses of opium in peritonitis, altogether unconnected with child-bearing, was 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 was in 1822 ; it was the case of a woman in whom the inflammation set in after the operation of tapping for dropsy. Dr. Graves says, "the case seemed so hopeless,.and the agony the patient was suffering so intense, that I was induced to order opium for her in very large doses; she also got wine; to my great astonishment she recovered."! 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 what had been administered by injection.^ 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 with 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. X Clinical Lectures on the Practice of Medicine. Vol. ii., p. 244. § 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 foUowing as an evidence of the extraordinary extent to which 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, with the respiratory move- ment reduced to 12, and, as a general rule, the pulse below 100, with 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.m., 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 5, gr. v.; at 6, gr. viii.; at 8, gr. x.; at 9, gr. xij.; at 11, sol. morph. sulph. (16 gr. to f § i) 3 iss.; at 12, 3i.; 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 11 P.M., sol. 3 ij-; at 2£, 3 ij.; at 3£ opium, opium gr. xxiv.; at 5, gr. xij.; at 6|, sol. 3 ijss.; at 7£, 3ij.; 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 3£, opium gr. xx.; at 4, sol. 3 ijss.; at 5, 3 iii.; at 6, 3 iijss.; at 6J, 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 the 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 (106) grains of opium. In the second 24 hours, she took opium gr. cxlviii., and sulph. morph. lxxxj., 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, 54 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 controUing the disease." * Remarks on puerperal fever, New Tork Academy of Medicine, Oct. 1851. LECTURE XLV. FUerperal Mania; its Pathology—Is it a Phrenitis, or is it essentially a Diseass 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 Pract^pe—Duration of Puerperal Mania—Is Permanent Aberration of Mind Probable in this Disease ?—Treatment —Marshall Hall and Blood-letting—Opiates—Their Importance—Moral Treat- ment. Gentlemen—Puerperal Mania will occupy our attention to-day; it is one of those affections incident to the puerperal woman, which always to a greater or less extent has its melancholy surroundings. Imagine, for instance, a young mother, who has a few 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, the wants of her new-born infant, whose very condition of dependence makes it an object of additional interest. Indeed, the affection very naturally throws a gloom over the house- hold, and is a subject well worthy 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 follow weaning. Instances have been recorded of its having occurred in very sensitive women 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; whHe 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 with 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 witnessed, 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 which is to impair to a greater or less extent its equilibrium, and thus dispose it to nume- rous derangements, one of the phases of which may be mania, or • melancholia. I do not mean to be understood that mere exhaustion will necessarily occasion mania; but what I do believe is this, that there is a peculiar specific sensitiveness in the sexual organs of the female during the puerperal period, which, 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 we 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 larbor, 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 want of proper discrimination in the results of necroscopical researches—for in- stance, it is well shown by these researches that, in what may be designated general insanity, evidences of inflammation of the brain and its membranes, may be regarded as the rule. But, according to the b.est observers, among whom may be mentioned Esquirol,* such is not the fact in the examination of those, who have died of puerperal mania. At what Period of the Puerperal State is Mania most apt to Occur ?—Although puerperal mania will occasionally exhibit itself during pregnancy, and after weaning, yet it is generally con- ceded that it is most liable to become developed a few days after delivery, and in the progress of advanced lactation. The following tables by Esquirol are not without interest: In 1811, 1812, 1813, 1814, there were eleven hundred and nineteen insane women admit- ted into the Salpetriere, of whom ninety-two were affected with puerperal insanity; of these, 16 were attaoked 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 weaning. 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 women in the Salpetriere, there were 52 cases of puerperal mania, and Dr. Haslam reports 84 cases among 1644 women admitted at Bethlem. Is Puerperal Mania liable to Recur in a Subsequent Birth.— This is certainly an interesting inquiry—for when a female has ouco 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. Gooch, is quite emphatic on this point. He says: " I have attended many patients, who 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 own personal experience. I once attended the wife of a clergyman from the South in her third labor; she had previously borne two living chfi- dren, and in each of her confinements had been attacked with puer- peral mania. The lafror 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, whom I have confined five times. In the two first confinements nothing remarkable occurred. In the third, two 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 two other cases, which have occurred to me in consultation, one with Dr. White of this city, the otherj with Dr. Brown, of Little Falls, in which both patients became affected with puerperal mania in two consecutive deliveries. It may be that these cases will be regarded as coinci- dences, and do not bear the relation of cause and effect. However this may be, it seems to me that with the predisposition necessarily induced by a previous attack, together with the constant dread of a recurrence of the malady, the nervous system will 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. X In this case, too, there was hereditary predisposition, for the mother of the patient had suffered from puerperal mama 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, whether 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 writers as an excitant to puerperal mania, but I do not think it entitled to much prominence; if it were so, the disease would assuredly be apt to develop itself frequently in women who, from want of proper feeling or other circumstances, do not suckle their children ; this, however, is shown not to be the case. I am disposed to think that some of the instances of mania, which have been referred to weaning, are due to the exhaustion consequent upon protracted lactation rendering the weaning 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 what 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 wakeful, throwing herself about the bed, and some- times sighing. This state of watchfulness, I cannot too emphati- cally remark, should always be regarded with 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 bowels, 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. [Commentaries on Insanity.] THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 703 secretion; the patient, although hungry, will 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 somewhat 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 invafid ; she is silent, listless, and indifferent to everything passing around her; the pulse is normal, with more or less deranged digestion. In one word, she is an object painful to contemplate, and it is one of those pictures in real life well calcu- lated deeply to impress the observer, and call forth his sympa- thies. Diagnosis.—From what has been said of the symptoms and divisions of this disorder, the diagnosis cannot be difficult. The time and circumstances of its occurrence will also aid in facilitating a just opinion. Puerperal mania might possibly be misapprehended for phrenitis, but proper attention would 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 will very soon tell the story to the vigilant physician. Prognosis.—Many will be the anxious inquiries as to the proba- ble issue of the disease, and these inquiries wiU be directed to two points—in the first place, whether the disorder is likely to termi- nate fatally—and secondly, if not, whether the mind wiU be perma- nently affected ? I need not dwell on the constancy with which these appeals wHl 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 well 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 well shown by the following reports: in ninety-two cases recorded by Esquirol, fifty-five re- covered, six died, and thirty-one incurable, or one in three; Dr. Haslam says, of eighty-five admitted into Bethlem, only fifty recovered, and thirty-five incurable; Dr. Burrows reports fifty- seven cases, of which thirty-five recovered, 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, which have been admitted because they have been unusually permanent, having already disappointed the hope, which is generally entertaired 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 oi omitted in the inspection of hospital reports. 704 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. ence. 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 which 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 vapid pulse, and continued restlessness at the very inception of the malady. When these two 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 watchfulness 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 few days or weeks. Sometimes, however, the re- # covery is protracted, and the loss of reason, more or less complete, will continue for many months. According to the most reliable data on the subject, well sustained by clinical observation, it may be affirmed that the average duration of the malady is from one to six mouths, while 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, will be extremely apt to commit a grave error in the management of the malady. The excitement and violence of the patient he will probably attribute to vascular fulness, a phlogistic state of system—it may be to phrenitis. With this view of the case, he will of course resort to depletory measures, the first of which will be the free use of the lancet. This is oftentimes a fatal mistake. Puerperal phrenitis, it would be well 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 will have the key to the treatment. I was forcibly struck some years since with 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 wHl probably die; if otherwise, most puerperal cases of mania issue well." If this language of the distinguished physiolo- gist were incorporated into a maxim, and inscribed upon the tablets of memory, well, indeed, would it be for the invalid attacked with puerperal insanity. If what has been said be true—that puerperal mania is most commonly a disease of exhaustion and irritation, then it would follow as a legitimate consequence that the two broad indications are to repair, as promptly as may be, the waste 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 waste 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 wish 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 very uniform attendant upon puerperal mania is a disordered digestion, as is shown by the coated tongue, foetid breath, loss of appetite, and irregularity of the bowels. 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: Sulphat. Magnesise 3 i Infus. Sennae f. § iv Mannse 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 derived from an emetic of ipecacuanha—gr. x. to gr. xii. in half a tea-cup of warm water. When the bowels 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 will sometimes act admirably; 10 grains of Dover's powder ; or the following may be prescribed: Syrup. Papav. f 3 vi MucH. Acacise f § Hi Sol. Sulph. Morphias (M.) gtt. xx. M. A table-spoonful every half-hour until sleep is obtained. Hyoscya- mus and camphor, five grains of each, was a favorite prescription with Dr. Gooch, especially where opiates could not be tolerated. It can scarcely be necessary to enjoin, that whichever 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 with much thirst. Cooling but gentle aperients, together with diaphoretics, wHl soon remove these latter symptoms. The spirits of mindererus, a table-spoonful every two 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 will be of service, together with warm water fomentations to the feet; and if there be an approach—as sometimes will 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 when not contra-indicated, animal food may be allowed freely. On the sapae principle, also, malt liquors, in proper quantity, will aid in accompUshing the object in view—the building up of the dilapi- dated forces. In one word, 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 with 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 what 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 which females, affected with this disease, have taken advantage of their soKtude, 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, without permitting the patient to become conscious that there is the sHghtest 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 m 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 undei 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 XLVI. Phlegmasia Dolens, although generally incident to the puerperal state, is not always so—It may develop itself in the non-puerperal woman, and also in the male sex; but little understood by the early Fathers—Mauriceau the first to direct special attention to it—His Yiews of its Pathology—The Views of Puzos and Levret— Historical Sketch of the Disease—Mr. White, of Manchester—Mr. Frye, of Glouces- ter—Dr. Ferrier—Mr. Hull—M. Albers—M. Bouillaud—Professor Davis, of Lon- don—Dr. Robert Lee—Is Phlegmasia Dolens a Crural Phlebitis?—Dr. Macken- zie, of London—Is Phlegmasia Dolens a Toxaemia ?—Synonyms—Causes of the Dis- ease ; Symptoms—Why is (Edema a Symptom of Phlegmasia Dolens ?—Causes of Dropsical Effusion; the relation between the oedema of Phlegmasia Dolens, and Obstructed Venous Circulation—Proof—Are the Veins Absorbents ?—Lower's Ex- periments—Boerhaave; Van Swieten, Hoffman, Morgagni, Cullen—Majendie and Bouillaud— The Oedema of Pregnancy—How Explained—Which of the Inferior Ex- tremities is most liable to Phlegmasia Dolens?—The Causes of the Difference—At what Period after Labor does the Disease most usually occur ?—Frequency of Phleg- masia Dolens—Statistics—Diagnosis—Prognosis—Progress, Duration, and Termina- tion of the Disease—Complications—What are they ?—Purulent Collections—Their Consequences—Peritonitis—Metro-Peritonitis—Treatment of Phlegmasia Dolens— Its Indications—Local Applications with the view of diminishing Pain. Gentlemen—The disease known as Phlegmasia Dolens is usually classed among the affections incident to the puerperal state; but, at the same time, it should be recollected that it is not exclusively restricted to this period, for it will occasionally develop itself in the non-puerperal woman ; and examples of the disease have even been observed in the male sex. I have looked in vain for a descrip- tion of this interesting affection among the early Fathers of our science; there is the slightest possible allusion to it by Hippocrates; and if, perhaps, we except Rodericus a Castro,* we have nothing in addition touching it, until the time of Mauriceau, who appears to have been the first to have directed special attention to the dis- order. His views, as we shall presently see, of its pathology, are not the views recognised by science in our day; nor did his imme- diate successors, Puzos, Levret, and others, succeed in throwing any additional light on the true nature of the malady. It must, however, be conceded, that these observers, although their pathology was crude and without a basis, exhibited remarkable cleverness in describing the more prominent symptoms of the disease, nor were their therapeutics of the affection, considering the times in which they lived, less worthy of note. * 1603. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 709 Historical Sketch of Phlegmasia Dolens.—Mauriceau attributed « the origin of the affection to a collection of humors, which should have passed off with the lochial discharge ; and he says the legs and thighs become cedematous and greatly swollen, sometimes extend- ing from the groin to the foot; the oedema and enlargement may in- volve one or both extremities.* Puzos supposed the disease to result from a deposit of milk in the part affected, this deposit commenc- ing in the groin and upper portion of the thigh; the pain experi- enced by the patient was usually in the direction of the large vessels coursing along the limb.f Levret, who also believed in the milky metastasis, tells us that the swelling caused by this deposit ordinarily terminates in infiltration of the cellular and adipose tissues of the parts affected, and that all these parts become very cedematous.J Mr. White,§ of Manchester, in 1784, maintained that the disease was due to an obstruction of the lymphatic vessels of the parts, and that these vessels became obstructed during the process of labor. Mr. Frye, of Gloucester, in an essay published in 1792, taught that the lymphatics at the brim of the pelvis, just under Poupart's liga- ment, became ruptured, and, as a consequence, there was an escape and diffusion of lymph into the cellular tissue of the limb. Dr. Fer- rier, on the contrary, believed that there was neither obstruction nor rupture of the lymphatic vessels, but that the pathology of the disease consisted essentially in inflammation of these vessels and glands. In 1800, Mr. Hull| advocated the opinion that the proxi- mate cause of the disorder was an inflammation of all the organs * " J'ai vu plusieurs femmes apres etre accouchees assez heureusement, avoir les jambes et les cuisses toutes cedemateuses et extraordinairement grosses, quelque- fois depuis l'aine jusques a l'extremite du pied, par fois d'un seul cote, etd'autres fois de tous les deux. Cet accident survient souvent ensuite d'une douleur sciatique causee par un reflux, qui se fait sur ces parties, des humeurs qui devroient etre eva- cuees par les vindanges, dont le gros nerf de la cuisse s'abreuve quelquefois telle- ment, qu'il en peut rester a. la femme une claudication dans la suite." [Traite des Maladies des femmes grosses, et de celles qui sont accouchees. Tome premier, p. 446. (1740).] f " Les depots laiteux les plus communs, apres ceux des mamelles, sont ceux qui se font sur les extremites inferieurs. Ces depots ne se forment gueres avant le douzieme ou la quatorzieme jour de la couche. C'est dans l'aine et dans la partie superieur de la cuisse que le depot commence a donner des signes de sa presence par la douleur que l'accouchee y ressent; et la douleur suit ordinairement le trajet des gros vaisseaux qui descendent le long de la cuisse." [Traite des Accouchemens, p. 350. (1769).] % " II est cependant encore plus ordinaire de voir cet engorgement laiteux se ter- miner aux depens de l'infiltration du tissu cellulaire qui garnit les interstices des muscles de l'extremite du meme cote, ensuite du tissu graisseux qui est sous la peau de la cuisse, de la jambe, et du pied. Toutes ces parties deviennent alors fort oedemateuses." [L'Art des Accouchemens, p. 177. (1766).] § An Inquiry into the Nature and Cause of that Swelling in one or both of the Lower Extremities, which sometimes happens to Lying-in Women. J An Essay on Phlegmasia Dolens, by John Hull, M.D., Manchester, 1800. 710 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. and tissues of the affected limb, resulting in a profuse pouring out of coagulable lymph; and in this way he explained the tension and swelling, two of the prominent characteristics of the disease. Albers says the nerves are primarily affected—that the pain accompanying the disorder is essentially a neuralgia, and the oedema one of its effects.* It may here be remarked, that the opinion of Albers was, to a certain extent, sustained by Duges, Siebold, and others, but they did not altogether reject the pathological changes in the other tissues. So far, we have, I think, what may be appropriately termed mixed opinions as to the true nature of phlegmasia dolens, without much approach to a concurrence of sentiment among the authors cited. In January 1823, however, a new theory was advanced by M. Bouillaud,f who referred the disease to an inflammation and obstruction of the crural veins, and it is well to remark that this explanation is the one now very generally accepted by the profes- sion. It is claimed for M. Bouillaud, that he was the first to point out this pathological condition of the disease; but it seems very satisfactorily demonstrated that the credit really belongs to the late Professor Davis, of London. As early as 1817, he proved by dissection of a fatal case, which had occurred to him, that phleg- masia dolens involved an inflammation of the iliac and femoral veins; the dissection was witnessed by Mr. Lawrence. In May, 1823, Prof. Davis read before the Medical and Chirurgical Society,! an interesting paper on the disease. It will, therefore, be seen, that although Dr. Davis's essay did not appear until four months subsequently to the paper of M. Bouillaud, yet he had actually observed in dissection, six years previously, the pathological fact under consideration. Dr. Robert Lee, of London, concurs in the view that the patho- logy of the disease is really a crural phlebitis; but, at the same time, he maintains that the inflammation commences in the veins of the uterus.§ It is proper here to state that, in 1826, Mr. Guthrie had sug- gested the opinion that crural phlebitis was simply an extension of inflammation from the veins of the uterus ; and it was not until 1829 that Dr. Lee demonstrated the coincidence of uterine and crural phlebitis. In a more recent paper on this subject he writes thus :|| " The results of the last twenty-four years' experience con- firm my previous observations, and I am satisfied that inflammation * Hufeland's Journal, p. 16, Feb. 1817. f De l'obliter. des veines et de son influence sur la format, des hydrop. partiel. Archives generales de med.. Janvier 1823, p. 188, T. 11. X Med. and Chirurg. Trans., vol. xii., 1823. § Pathological Researches on Inflammation of the Veins of the Uterus, Medicc- Chirurg. Trans., vol. xv., 1829. J Cyclopa3dia of Pract. Med., 1845, vol. iii., Art. Phlegmas. Dolens, p. 529, et seq THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 711 of the iliac and femoral veins is the proximate cause of the disease, and that, in puerperal women, the inflammation commences in the uterine branches of the hypogastric veins." There is no doubt that Dr. Lee is correct in some cases, and that the crural phlebitis, which results in phlegmasia dolens, does, in certain instances, com- mence in the veins of the uterus; but that this is not always so is clearly shown by two facts: 1st. Phlegmasia Dolens has been recog- nised in the puerperal woman under circumstances in which the uterine veins were in no way involved. 2d. There are examples of the disease occurring in which the veins of the lower part of the extremity were alone the seat of inflammation, without the slight- est manifestation of disturbance in the vessels of the uterus. That clever pathologist, Virchow, believes that the incipient morbid condition of the disease consists in the presence of a coagu- lum in the veins; and that the inflammation of the vessels, the effu- sion of lymph and purulent secretion, the breaking down of the coagulum and the presence of pus in it, are purely incidental to the occlusion of the veins. The last special writer on phlegmasia dolens, Dr. T. W. Macken- zie, of London, while admitting that the phlebitic theory of the affection is better sustained by facts than any other, which had preceded it, believes that he has demonstrated the following con- clusions at which he has arrived: " 1st. Crural Phlebitis, in a pure and uncomplicated form, cannot give rise to all the local and general phenomena of the disease, and, therefore, cannot be its proximate cause. " 2d. Phlebitis itself is, for the most part, not a primary, but a secondary affection; and, in the great majority of cases, is a conse- quence of the circulation of impure or morbid blood in the veins. " 3d. The proximate cause of the disease is, therefore, presum- ably a morbific condition of the blood, which I have experimentally shown to be capable of producing not only the lesions of the veins met with in the disease, but all its other phenomena."* I have read with much interest the excellent monograph of Dr. Mackenzie, but really I do not see that he has proved anything which all good observers are not willing freely to admit. In the first place, it seems to me that crural phlebitis,f like pneumonia, * The Pathology and Treatment of Phlegmasia Dolens, etc., 1862. ■j- It may be remarked, that phlebitis which precedes phlegmasia dolens, differs in no sensible particular from ordinary phlebitic inflammation. In men, as in women, this latter has been occasioned by carcinoma of the rectum, the introduction of a sound into the bladder, giving rise to inflammation of the veins of the prostate, and thus involving the adjacent venous trunks. An example of this is recorded by Cruveilhier. Valleix mentions two interesting cases of phlebitis caused by the pressure of an ovarian tumor. It is also well established that inflammation of tie iliac and femoral veins is not only not peculiar to women recently delivered, but may arise from suppression of the menses, malignant disease of the os and cervix uteri and from enlargement of the organ from any pathological cause. 712 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. pleurisy, or any other inflammation, is, if you please, a product oi an effect of some antecedent; it will not, I think, be attempted to be shown that it has a spontaneous origin, and, therefore, it must be rightfully classed among the secondary affections. Again, in main- taining that a " morbific condition of the blood " is the proximate cause of the disease, he says what every experienced obstetrician will readily concede, is often, but not always, the case; or, in other words, that this state of the blood is frequently the starting point of the malady. If we look at the phases through which the puer- neral woman passes, we cannot be surprised that she should, under certain circumstances, have her blood contaminated, exhibiting a veritable toxaemia. At the same time, I do not doubt that many other influences, such as cold, a protracted or instrumental deli- very, injury to the parts, &c, will cause crural phlebitis, which may result in the production of phlegmasia dolens. I cannot myself see much force in the position assumed by Dr. Mackenzie, that " crural phlebitis, in a pure and uncomplicated form, cannot give rise to all the local and general phenomena of the disease, and, therefore, cannot be its proximate cause." My own opinion is—and this opinion is founded on clinical experience—that although crural phlebitis is undoubtedly an essential element of phlegmasia dolens, yet it by no means follows that this latter affec- tion will necessarily succeed every case of phlebitic inflammation; and, on the other hand, I am quite confident that I have observed examples of phlegmasia dolens developing itself as the consequence of a " pure and uncomplicated form>' of crural phlebiti^ Synonyms.—Phlegmasia Dolens has been described under a variety of names, depending on the peculiar pathological view entertained by different authors. The foUowing brief summary will fairly exhibit its varied nomenclature: Mauriceau called it swelling of the leg of the puerperal woman; Puzos and Levret, milky deposit, milky engorgement; Callisen, oedema puerperarum ; White, phlegmasia alba dolens pxierperarum; Good, spargosis puerperarum; Young, ecphyma oddematicum ; Robert Lee, phle- bitis crxiralis; Rayer, hydrophlegmasia of the cellular tissue of the inferior extremities ; Duparcque, lymphatic, painful and leuco- phlegmasia. It has received, in addition, the following designa- tions : oedema lactium, phlegmasia lactea, anasarca serosa, swelled leg, white leg, milk leg. Causes.—Among the causes of phlegmasia dolens maybe enu- merated—exposure to cold and dampness, errors of diet, too soon getting up after delivery; and there can be no doubt, that rude manipulations on the part of the accoucheur, instrumental delivery, a protracted labor during which the organs have undergone undue pressure, and the artificial extraction of the placenta, may be men. tioned as among the predisposing causes of the affection. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 713 Symptoms.—The symptoms which usually characterize this dis- ease cannot be said to be uniform, while they are ordinarily coined dent with those of iliac and crural phlebitis. In the first place, the first indication of trouble may be a chill of more or less duration. Again, the first development of the disease will be a local pain on one or other side of the pelvis. It may be said that pain is one of the most constant symptoms of phlegmasia dolens, but it will vary in its type, severity, and seat; sometimes superficial, extremely acute and lancinating; at other times dull and deep-seated. It may be felt in the entire limb, or be confined to one portion only. It will usually commence in the groin, and extend downwards in the direction of the affected limb. Again, the first evidence of the malady will be an acute pain in the calf of the leg; when this occurs it will generally be observed that the swelling, a constant element of the disease, wHl commence at this point, or at the foot, and gradually travel up the leg and thigh. There is one circum- stance which may be regarded as pathognomonic of phlegmasia dolens when it attacks the thigh, and it is this—The finger can dis- tinctly trace the femoral vein from the groin as it courses down the thigh ; it imparts a sensation of hardness, and rolls, as it xoere, wider the finger like a cord* Pressure upon this vein occasions very intense suffering, whilst pressure on other portions of the limb is ordinarily accompanied by little or no sensibility. The pain of phlegmasia dolens is occasioned by inflammation of the venous trunks, and it is worthy of remark that the pain follows very exactly in the direction of the inflamed vessels. The exten- sion of the limb will increase the suffering, and hence the patient of her own accord usually places it in a state of semi-flexion, and requests that it may be retained in this position by means of a pil- low. The pain, under ordinary circumstances, is most acute dur- ing the first two or three days. It usually precedes the oedema; and yet there will sometimes be a simultaneous development of the two phenomena. The swelling or oedema of the limb, like the pain, is a uniform accompaniment of the disease. The general rule is that it appears first at that portion of the affected extremity at which the pain is originally experienced; this, however, is not always so, for it will occasionally be observed at some remote part of the limb distant from the seat of suffering, but always between this latter and the ultimate venous ramifications. It must, however, be remembered * The fact of feeling this cord is conclusive evidence of inflammation of the vein, and at the same time of the coagulation of the blood within the coats of the vessel. M.. Lugol mentions, as an exceptional circumstance (Journal des Progres, t. xiv.) a remarkable fact, and cites an example in illustration—that nearly all the veins of kho affected limb may become hard and knotty, presenting the peculiar feel of a cord. 714 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. that no matter where the oedema first appears, it soon involves the entire extremity. Its progress is almost always from the first seat of pain towards the lower portion of the limb. At times the swell- ing is enormous, giving to the affected extremity a volume twice the size of the other; at this period the integuments undergo extra- ordinary tension; they present a more or less glistening transpa- rence, and assume a marked white color. In consequence of the extreme tension of the parts, the finger will not pit them on pres- sure ; and it is not until the lapse of some days, when the tissues become more relaxed, that the impression of the finger becomes visible. There is, as a general rule, a decided diminution in the size of the limb after twelve or fifteen days. The engorgement, when excessive, may be much lessened by slight apertures made with the lancet, as in other examples of cedematous swellings. Occasionally there will be observed, on the white and glistening surface of the extremity, reddish bands or spots running along the course of the inflamed vessels; sometimes, in lieu of these, there will be seen vesicles of a dark or blackish hue. Conjoined to the local symptoms, just described, may be men- ■tioned certain constitutional disturbances more or less incident to the affection. For example, the pulse will become accelerated, varying from 100 to 140 and upwards; the tongue coated, with oftentimes marked thirst; countenance usually pale; the bowels sometimes torpid, at other times diarrhoea will supervene; loss of appetite, and derangement of the urinary secretion, the latter being ordi- narily dark colored and turbid. The patient is irritable and restless. Sometimes the skin is dry and burning; again it will be covered with perspiration. Should the disease occur during preg- nancy, as will sometimes happen, there will be a diminished secre- tion of milk, and the breasts will become notably lessened, unless the malady should be of short duration. The lochial discharge is neither so constantly diminished or suppressed as would naturally be inferred would be the case. Why is CEdema a symptom of Phlegmasia Dolens ?—This is an interesting inquiry, and is readily explained. Anasarca, or oedema, is an infiltration of serum or the watery element of the blood into the cellular tissue, and represents, therefore, one of the numerous forms of dropsical effusion. There are various causes of anasarcous engorgements, such as disease of the liver, kidney, heart, etc., but of the pathology of these organs, and its conse- quences, it is not my purpose to speak at present. I shall limit myself to the solution of the simple inquiry— Why is anasarca the uniform accompaniment of phlegmasia dolens? The answer to this interrogatory is, in my opinion, conclusive evidence of what has already been stated, viz. that the pathology of phlegmasia dolens ia an iliac or crural phlebitis. Anasarca, then, accompanies phleg THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 715 masia dolens because of venous obstruction, the obstruction in this special case depending upon the blocking up or occlusion of one or more of the veins of the affected limb, as the result of inflamma- tion. Let us examine this point a little in detail. It has been shown, I think, very conclusively, that one of the attributes of the venous system is its power of absorbing fluids; and it has been demonstrated that fluid substances may pass into and out of the veins, through the process of transudation or imbibition. But this physical act—imbibition or transudation—requires for its accom- plishment a certain condition of the veins; for example, if these latter be greatly distended with watery fluid, the further entrance of this material will be prevented; and when the vessels reach a maximum point of distension, the watery element of the blood will, through exosmosis, pass out through the coats of the engorged veins. Thus it will be seen that excessive plenitude of the veins will necessarily result in an effusion of fluid; and it must also be recollected that this fulness of the vessels is almost invariably in- duced by an obstacle to the free passage of the blood through the veins to the heart. In phlegmasia dolens, as has already been remarked, the femoral and iliac veins becoming the seat of inflam- mation are occluded, thus necessarily obstructing the circulation of the blood in these vessels; and this, therefore, is the true expla- nation of the relation which is found to subsist between phlegmasia dolens and anasarca. As early as the sixteenth century, Dr. Lower* satisfactorily established by experiments on living animals that an obstacle to the circulation of the blood through the veins would result in the effusion of serum. He placed a ligature around the ascending vena cava of a live dog, and then closed the wound; the animal soon became exhausted, and died in a few hours. The post-mortem examination revealed a large accumulation in the abdomen of a serous fluid similar to what would be observed in ascites. In another dog, he tied the jugular veins; after some hours, all the parts situated below the ligatures became very much tumefied; in two days the animal died as if from suffocation. In this case, also, a collection of serum was observed in the parts above the liga- tures. I might likewise cite Boerhaave and his illustrious commen- tator Van Swieten,f Hoffman,\ Morgagni,§ Cullen,|| and others, in confirmation of the same view. Majendie, it may be here observed, was one of the strongest advocates of venous absorption. His experiments, quite conclusive * De corde, item de motu et calore sanguinis, etc. Cap. ii. p. 123, et sequent f Van Swieten's Commentaries, t. iv., p. 186 et seq., 1770. X Med. Prat., t. iv., cap. xiv., p. 431. § De sed. et caus. morb., epist. 38, § 19. jj Elements of Practice, t. ii.. p. 556, 1787. 716 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. in themselves, was the starting-point, if I may so term it, of nume- rous learned researches on this and kindred questions. M. Bouillaud,* in 1823, wrote as follows: "I shall now speak of those dropsical effusions, reputed passive, and shaU endeavor to prove, by facts and observations, that they all result from obstruction of some sort in the venous circulation; and, in a great number of instances, the obstruction consists in the occlusion of the veins of the part which is the seat of the dropsy." Andral,f too, has recorded his testi mony in very positive terms of the relation between serous infiltra- tion and venous obstruction. Which of the Inferior Extremities is ?nost frequently the Seat of Phlegmasia Dolens ?—It is well shown by statistics that the left limb is more frequently attacked than the right; at the same time, it should be stated that sometimes both limbs become involved. This latter circumstance, however, is comparatively rare. Various theories have been suggested in explanation of the preference exhi- bited by the affection for the left extremity—such as the greater frequency of the position of the occiput of the foetus to the left; tho greater frequency of the attachment of the placenta to the left side of the uterus ;J the tendency of the female to rest on the left side rather than on the right side. One or other of these circumstances, or all of them conjoined, may or may not be the true cause, but further observation, I think, is needed to decide the question. Ad- mitting, however, that this is really the explanation, I do not see that science can be much benefited by it, for, with the exception of correcting the disposition to recline on the left rather than on the right side, nothing could be done to avert the more frequent occur- rence of the disease in the left extremity, and, indeed, if this could be accomplished, I can perceive no possible advantage derivable from it; for whether phlegmasia dolens attack the right or left limb, the progress of the affection, its phenomena, and therapeutics are identical. At what period after labor does the disease usually occur ?— From the most accurate information on this subject, it would seem that there is nothing positive; the affection may present itself from the first to the thirty-fifth day; but, as a general rule, it will be found to appear not later than three weeks from the time of partu- rition, although there are exceptional cases in which it has not manifested itself until the lapse of two months. * Arch. gen. de Med., t. ii., p. 188 et seq. f Precis d'Anat. Path., t. i, p. 328. X M. Naegele, Jr., has proved, from his researches on the subject that the pla- centa is situated most commonly on the left surface of the uterus. For an account of these researches, as well as those of Dr. Von Ritgen, on the same subject, see page 373 of this volume. It may also be stated that Dr. Carriere, of Strasburg, records that in sixty-six cases in which the placental sound was detected, it was heard on the left side of the uterus in thirty-eight, and on the right in twenty-eight cases THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 717 Frequency of Phlegmasia Dolens.—This disease cannot be said to- be of common occurrence. The best observers will, I think, concur in the following statistics gathered by M. Raige Delorme, as presenting a fair approximation to the facts touching this point.* In 1,897 females delivered in the Westminster Dispensary, White observed the disease five times; in 8,000 confinements in his own practice, and at the Manchester Hospital, there were but four cases of the disease. Again, in 900 deliveries, Wyer records five cases; in 1897, Bland five cases; in 200, Sankey one case; in a practice of 26 years, Siebold has met with it five times ; Struve fifteen times in 18 years; Robert Lee 28 times in six years. With an extended field of observation, I find but three cases of phlegmasia dolens recorded in my note-book, and two of these occurred in consultation, one with Dr. Philips of Harlaem, the other with Dr. Forbes of Brooklyn. Diagnosis.—The diagnosis of phlegmasia dolens is not difficult. There are certain evidences of this disease, which cannot readily be mistaken—such as the pain along the vessels of the limb, the oede- ma, and especially the hard cord felt by the finger as it presses on the inflamed vein. Sometimes, however, it may be difficult to reach the inflamed vessel, and this may arise from one of two circum- stances—either because of the excessive engorgement of the part, or the profound position of the affected vein. But even in these events there can be no embarrassment; for the progress of the symptoms, and the particular nature of the oedema, will broadly indicate the affection. It may not be altogether unimportant to remark, that the anasarcous swelling of the limb may possibly be mistaken for the oedema symptomatic of disease of the liver, heart, or kidneys. But an error of this kind would disclose great carelessness on the part of the medical man. In these latter cases, for example, there would have been previous indications of disease of these organs; and, in addition, a proper local examination would disclose derange- ment in them, either functional or organic. Prognosis.—Phlegmasia Dolens is not, as a general rule, a grave affection, and it may, therefore, be said to terminate favor- ably; when it destroys life, it does so through some of the more serious complications, which occasionally develop themselves in the progress of the disease. Progress, Duration, and Termination.—The febrile excitement, together with the pain and oedema, so characteristic of the disease, become gradually diminished. The pain subsides first; but the swelling continues more or less stationary from three to six weeks, and, under some circumstances, for a much longer period. Occa- sionally, however, when the disease is slight, the swelling will clis- * Compend. de Medecine Pratique, T. Sixieme, p. 471. 718 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. appear from twenty-four to forty-eight hours. As soon as the size of the limb begins sensibly to diminish, the tension is correspond- ingly less, and the impression of the finger on the surface much more evident. It will sometimes happen that the two extremities will become successively the seat of the disease, and precisely the same phenomena will present themselves as at the commencement of the attack. The usual termination oi phlegmasia dolens is in reso- lution, which commences with the cessation of pain, and a dimi- nished size of the limb. But it should be recollected that this yielding of the symptoms will sometimes be promptly followed by a return of the pain and oedema, from error of diet, exposure to cold, or too early getting up. WhHe resolution is progressing, an interesting change often takes place in the superficial veins of the limb ; they become more or less distended with blood, showing that a new collateral circulation is going on. M. Duplay* was, I believe, the first to direct attention to this latter fact. The disease wHl sometimes lapse into a chronic state; the extre- mity then becomes enormously enlarged, the surface is hard and irregular, and looks not unlike elephantiasis. Indeed, in some females the extremity doos not resume its natural size for months, and even years. It should also be mentioned that the affected limb will occa- sionally become the seat of abscesses, and these may be single or multiple; they may develop themselves in the subcutaneous or in the sub-aponeurotic cellular tissue; hence they will be superficial or deep-seated. In the latter case, the abscesses will frequently prove mischievous. Other complications may ensue, such as peritonitis, metro-peritonitis, ascites, etc. These latter, however, cannnot be regarded as the veritable accompaniments or sequelse oi phlegma- sia dolens. Treatment.—This will be modified by two circumstances, which should be constantly borne in mind—the activity of the attack, and the constitution of the patient. If the pain and febrile excitement be severe, and the system plethoric, a dozen or more leeches may be applied, with signal advantage, to the groin, and over the inflamed femoral vein; these should be followed by warm poul- tices for the purpose of promoting the bleeding. The leeches may be repeated two or three times, in smaller number, depending on the indication which may present. Cathartics, unless there be diarrhoea, are especiaUy proper. Commence with : R Hydrarg. c. creta gr. xij. followed by two wine glasses of the following saline mixture every four or six hours, until free purgation is accomplished : * Diet, de Med., Art. Phleg. Dolens, 2d ed., p. 247. THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 719 R Sulphat. magnesise, Sup. tart, potassse, aa ^ i- Aquae destillatse Oj. Ft. Sol. If there be evidences of sluggish liver with dry skin, it will b proper to administer occasional doses of calomel with antimony or Dover's powder—say gr. ii. of calomel with gr. a of antimony, or gr. iv. of Dover's powder. It is very important to relieve the patient of pain, and procure her comfortable sleep. For this pur- pose a table-spoonful of the foUowing may be given every half hour until the object is attained: R Syrup, papav. f. 1 j. Mucil. acacia? f. 5 ij. SoL sulph. morphia (Majend.) gtt. xii. M. When the limb is much engorged, great care should be observed in promoting a free secretion of urine; for this purpose let cremor tartar water be freely taken as a drink; or the nitrate of potash given, gr. xv. in a tumbler'of water or thin gruel, twice or thrice a day. The diet to be bland, and the most perfect rest enjoined, with the limb slightly raised from the plane of the body; the nurse should be directed to protect the part from contact with the bed- clothes, which may be accomplished by means of a cradle. After the leeching and purging, marked benefit will oftentimes ensue from the application of small blisters, repeated according to circum- stances, not to the thigh, but to either the internal or external malleolus. I have great faith in the derivative action of blisters thus applied in the acute stage of phlegmasia dolens. If the vital forces become depressed, quinine, together with a nutritious diet, will be indicated. One word with regard to local applications, after the inflamma- tory state has passed, for the purpose of soothing pain. A warm bran poultice wHl sometimes give much relief—wrapping the limb in flannel, secured by oil silk; the extract of belladonna smeared over the painful portion of the extremity; gentle friction with lau- danum and sweet oil, camphorated oil, or soap liniment; and if the surface preserve its integrity, a good local application will be equal parts of chloroform and olive oH. It may here be mentioned that when the oedema is excessive, relief will be afforded by slight punctures, thus, through the escape of the serum, diminishing the tension, and consequently mitigating the pain. ' In the event of purulent collections, either superficial or pro- found, they are to be treated on general principles. LECTURE XLVII. 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. 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. Gentlemen—It must be universally conceded that the contribution which science has made to suffering humanity—anaesthesia, or insensibility to pain—whether 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 what are known 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 word 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 woman, is of recent origin, yet the idea and actual practice of having recourse to certain agents with the view 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 ; with this view, I shall endeavor to indicate under what circumstances, in my judgment, etherization or anaesthesia will be a justifiable,resort. It is needless to remind you that the THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 721 first introduction of these agents into the lying-in room was very generally hailed by what may be properly denominated a wild enthusiasm; and, as too often happens in the advent of new remedies, there was more zeal than judgment displayed in their administration. Hence, with 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. With such an unrestricted and indiscriminate employment of these agents, two 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 whom 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 thi3 agent in parturition, which he did on the 19th of Jan., 1847, and became satisfied of its anaesthetic properties without its interfering with the parturient effort. In our own country, sulphuric ether was administered for the first time in labor, April 7th, 1847, by E". C. Keep, M.D., f of Boston, with most satisfactory results. It is an interesting fact that sulphuric ether was 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 we 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 anaesthetic properties most satisfactorily demonstrated, anxious for something still better, which would 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 Journa*, April 14th, 1847. 46 722 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. posed objections, the untiring mind of Prof. Simpson, always 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 own person to experiments, with a view of testing the value of the new agent; the reader will be more than amused with the graphic description by Prof. Miller, of the scene which 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 with this sub- stance were most satisfactory to the gentlemen, who had submitted themselves to its influence; and the result was a paper from Prof. Simpson,f which although it provoked controversy, soon gave popularity to the new 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, was Prof. Murphy,J of the London University—it was most successful in his hands, and he is since entitled to be ranked among its warmest 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 Snow,|| is due the credit of having been the first to employ amylene as an anaesthe- tic, which he did in Kings College Hospital, in Nov. 1850. He 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 over chloroform oi many cases. Although it has not as yet been generally employed either in America or Great Britain, it has been extensively used, with 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 Ethei in Midwifery and Surgery, by J. T. 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 Anaesthetics, by John Snow, M.D. London, 18581 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. 723 rily shown 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 have always found safe and reliable. I have had no experience with amylene, yet it has received very high commendation from those who have tested it. Dr. Snow has employed it in seven cases of labor with the most entire satisfaction ; aud he says " the great ease with which it can be breathed, owing to its entire want 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 how 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 with a function, properly so called, as long as its exercise is normal, and within the true record of nature ? I think not. Again, there is another argument, which has always struck me with force, why anaesthesia should not be employedin 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 new 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 „eart. 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 in the brain. Again, he says, I am aware of only two deaths, which have been recorded as occurring during the administration of ether, and it is not probable that the death in either case was due to the ether. I hold it, therefore, he continues, to oe almost impossible that a death from this agent can occur in the hands of a medi- cal man, who applies it with ordinary intelligence and attention. [Op. citat. p. 262.] + The pupil may consult with advantage, " A Treatise on Etherization in Child- Birth." By Prof. "Walter Channing, M.D. Boston, 1848. 724 THE PRINCIPLES AND PRACTICE OF OBSTETRICS. the event of certain contingencies which, in the judgment of the accoucheur, would justify their administration. The employment of these agents will be proper in cases of operative midwifery, whe- 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 womb, vagina, or perineum ; in a woman of excessive nervous irritability; in certain cases of irregular contraction of the uterus, in which the strength of the mother is severely tested with- 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, where 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 rebeUious dysmenorrhoea. Let me here add that, in the irritability and convulsions of children,* etheriza- tion will oftentimes exhibit the happiest results. The Influence of Anaesthetics on Uterine Contraction.—One of the original and chief objections to the employment of anaesthetics in midwifery was 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, tain the existence of pregnancy, 193; application of the bandage to the, aftei childbirth, 404; presentations of the, 555. Abdominal parietes, pain in and relaxation of the, in pregnancy, 226 Abdominal pregnancy, 205. Abdominal tumors, 196. Abortion, statistics exhibiting the frequency of, 266, 267; various divisions of, 267, 268; period of pregnancy at which it is most frequent, 268, 269; causes of, 269-273; symptoms of; 274; prognosis and treatment of, 275-282; induction of; is it ever justifiable ? 678, 679. Abscess, mammary, treatment of, 426, 427. Accoucheur, the, cardinal object of, 11, 548; his duties in the lying-in chamber, 351 et seq.; case evidencing the culpable indifference of an, to professional obli- gation, 658. After-birth. See Placenta. After-pains, 407, 411. Albuminose, 262. Albuminuria, often the cause of abortion, 272; causes of, 505; change in the com- position of the blood in, 506; change in the kidney, 507; pressure on the renal veins, 508; less frequent in multipara? than in primipara?, 508, 509 ; not neces- sarily followed by uraemia, 510 ; summary of conclusions respecting, 515. Amnios, the, 244; source and uses of the liquor amnii, 245, 246. Amylene, use of, as an anaesthetic, 722. See Anaesthetics. Anaemia, connexion between abortion and, 271. Ansesthetics, advantages of, in the Caesarean section, 637; in midwifery, a recent discovery, 701; sulphuric ether, chloroform, and amylene, 721, 722; compara- tive safety of the three anaesthetics, 722, 723; indications for the use of, in par- turition, 723 ; influence of, on uterine contraction, 724; time and mode of using, 725 ; influence of, on the pulse, 726; relaxing effects of, ib. Andral, M., on the increase of fibrin in the blood as a sign of inflammatory action, 133. Animalcula, question of their presence in the spermatic fluid, 115. Animalculists, doctrine of the, upon fecundation, 116. Animals, menstruation in, 104. Ante-version of the uterus, 234 Anterior sacral plexus, 4. Anus, circumstances necessitating internal examination of the female by the, 201; occlusion of the, in the infant, 423, 424. Aorta, abdominal, compression of the, as a means of checking uterine hemorrhage, 395. Apoplexy, placental, 273. Appetite, depraved, an evidence of pregnancy, 147. Areola, discoloration of the, as an evidence of pregnancy, 151; Dr. Montgomery's remarks on its essential characters, 151, 152. Arm, protrusion of the, in shoulder presentations, 559. Arneth, Dr., on the contagion of puerperal fever, 686. Articulations of the pelvis, the, 12 ; question as to their relaxation and separation during gestation and parturition, 15; of the foetal head, 32. 748 INDEX. ASC-CAR Ascites, or peritoneal dropsy, 197. Asphyxia, treatment of, in the new-born infant, 369. Assafcetida, advantages of, in cases of habitual abortion, 273. " Aunt Betty," case of, simulating pregnancy, 181. Aura seminalis, the, 116. Auscultation, mediate and immediate, 188 ; of the foetal heart, 201. Axes of the pelvis, the, 19; their inclination, 20; necessity of an accurate know ledge of their direction 21. B. Back, the, presentation of, 557. Ballottement, or passive motion of the fcetus, 185; rules for detecting, 186. Barker, Prof. Fordyce; on the Caesarean section, 639; on the use of veratrum viride in puerperal fever, 698. Barnes, Dr. Robt., on vesicular mole, 285; on fatty degeneration of the placenta, 320; on artificial detachment of the placenta, 476, 47 7 ; on application of the forceps, 575. Baudelocque, his six different positions of the vertex at the superior strait, 37; his pelvimeter an accurate instrument, 69; case of spontaneous reduction of inverted uterus, reported by, 452; on the Caesarean section, 627; on elytro- tomy, 641; remarkable case recorded by, in which the child proved to be alive, in spite of the strongest evidence of death in utero, 657. Belladonna, its efficacy in arresting abortion, 277; in spasm of the os uteri, 380; in convulsions during labor, 498. Binder, the, application of, 404. Bischoff, on spermatozoa, 118. Blisters, an important auxiliary in the treatment of puerperal fever, 696. Blood, discharge of, from the vagina, 168; discharge of, in animals, at the period of heat, 313; constituents of, in a state of health, 133; buffy coat not always an index of inflammatory action, ib.; changes of, in the pregnant woman, 129- 134; circulation of, in the adult and the fcetus, 257-261; elaboration of, in the placenta, 261; change in the circulation in the infant after birth, 264; change in the composition of the, in uraemia, 505. Bloodletting, in pregnancy, remarks upon, 130, 217, 361; objections to, in the treat- ment of convulsions during gestation, 493, 494; when indicated in convulsions, 495 ; importance of, in inflammatory puerperal fever, 695 ; caution against, in puerperal mania, 704. Blood-poisoning, or toxaemia, 411, 504, 683; characteristic of diseases produced by, 684. Blood-vessels of the placenta, 247, 248. Blundell, Dr., on the operation of transfusion, 400, 401; on the Cesarean section, 628. Boivin, Madame, on vertex presentations, 37; on the muscularity of the uterus, 126. Braun, Carl, on uraemia, 515. Breasts, the, changes in, after impregnation, 148. Breathing, oppressed, in pregnancy, treatment of, 230. Breech presentations, statistics of, 344; diagnosis, 345; prognosis, 346; first or left anterior sacral position, ib.; second or right anterior sacral position, 347; third or right posterior sacral position, 348; fourth or left posterior sacral position, ib.; manual delivery in, 547. Bright's disease, no necessary relation between, and uraemic convulsions, 515. Brown-Sequard, his conclusions on the subject of transfusion, 401, 402; on the influence of carbonic acid on non-striated muscular fibres, 678. Bruit placentaire, the, 189. Buffy coat of the blood, not always the index of inflammatory action, 133. C. Owsarean section, the, 626; controversy with regard to the benefit or evil of the, 626-629; contrast between the, and craniotomy statistics, with many illustra- tive cases, 629-635; dangers to the mother from the, 636, 637; post-mortem Cesarean section, 638, 639 ; how the operation should be performed, 639-642; dressing the wound, 642, 643; vaginal Caesarean section, or vaginal hystero- tomy, 644. Capuron, on the compressibility of the arch and base of the fcetal head, 32. Carbonic acid, injection of, as a means of inducing artificial dehvery, 678. CAT-CUM INDEX. 749 Catalepsy, characteristic peculiarity of, 502. Catamenia, retention of the, mistaken for pregnancy, 7£ period between puberty and their final cessation, 93; influence of climate oa, 95—of education and mode of life, 96—of temperament, constitution, and race, 97 ; precocious and tardy, 98; causes of, ib. See Menses and Menstruation. Cathartics, in pregnancy, 218. Catheter, the, directions for the introduction of, 233, 357, 412-414; obstacles to the ingress of the, 414. Caudle, caution against the use of, 405, 406. Cazeaux, on shortening of the neck of the womb, 168 ; embryotomy forceps, 663. Centric causes of abortion, 271. Cephalalgia, treatment of, in exhausting hemorrhage, 399. Cephalic version, 540 ; mode of performing, 541 et seq. Cephalotribe, the, 663; directions for its use, 663, 664. Cephalotripsy, meaning of the term, 663. Cervix, the, of the uterus, 87; progressive changes in its condition during the pro- gress of gestation, 164-169. Child. See Infant. Chloroform, first introduced by Prof. Simpson, 710. See Ansesthetics. Chorion, the, and its villi, uses of, 243, 244; in a case of twin labor, 441. Churchill, Dr., his statistics on breech presentations, 344; statistics on multiple preg- nancy, 431, 432; statistics upon the frequency and mortality of post-partum hemorrhage, 390; statistics of podalic version, 538 ; statistics of crotchet cases by, 629, 630—of Caesarean section, 630, 631; tables by, showing the diameters of the head at the different periods of pregnancy, 667 ; on a case of premature artificial delivery, 673. Circulation, difference between the adult and the fcetal, 257-261; change in the, after birth, 264. Clark, Prof. Alonzo, interesting details on the use of opium in puerperal fever, 697, 698. Clarke, Dr. Joseph, on the comparative size and weight of the male and female foetus, 27. Clarke, Dr. Joseph, statistics of cases of craniotomy and Caesarean section by, 630, 631. Clay, Charles, on duration of pregnancy, 303. Clitoris, the, 75 ; Parent-Duchatelet on the, ib. Coagula, removal of after the delivery of the after-birth, 375. Coccyx, anatomy of the, 6; exercises an important influence during childbirth, 6, 7, dislocation and fracture of, 7. Cohen, his method of inducing artificial delivery, 678. Colchicum autumnale, value of, in ursemic poisoning, 514. Cold, application of, in cases of threatened abortion, 278; in post-partum hemor- rhage, 393-395. Collins, Dr., his statistics on breech presentations, 344; on the prophylactic treat- ment of puerperal fever, 693. Colostrum, the, 409. • Colpeurynter, the, 474. Commissure, the superior and inferior, 73. Constipation, in pregnancy, 162 ; treatment of, 222; after delivery, 416, 422; in the infant, 423 ; sometimes a cause of accidental flooding, 482. Convulsions, connexion between, and the presence of coagula, 376; puerperal, 485; treatment of, during pregnancy, 492-497; during labor, 497-500; after deli- very, 500; centric causes of, 504. Cord, umbilical, composition of the, 250, 251; ordinary length of the, 251; knot- ted cords, 252; question of nervous tissue in the cord, 253. See Funis. Coronal suture, the, 30. Corpus luteum, theory concerning the, 91; of pregnancy and menstruation, 112; interesting question concerning, 114. Cough, in pregnancy, 160, 230. Coxal bone, the, 7. Craniotomy, contrast between the statistics of, and those of the Coesarean section, 629-635 ; condemnation of, 634; the Caesarean section to be preferred to, ib. Cristoforis, Drl, his substitute for the Cesarean section and symphyseotomy—sectin subperiostea, 643. _ ' Crotchet, the, as modified by the author, 579, 580; statistics of crotchet cases, 629 Cummings, Dr., natural and artificial lactation, 419. 750 INDEX. DAL--FEM D. Dalton, Prof. J. C, on the corpus luteum of pregnancy, 113. Decidua reflexa, mode of origin of the, 243; uses of the, ib.; decidua membrana, 242. Deformity, pelvic, examination of the propriety of version in cases of, 544-546. Dehvery, manual, diagnosis and prognosis of, 517, 518; indications of, 518, 519; most suitable time for termination of, 519, 520; mode of terminating, 520-522; division of, 522 et seq.; in pelvic presentations, 547 ; in trunk or transverse, 555; in hip and shoulder, with protrusion of the arm, 558 et seq.; instrumental (see Forceps and Instruments), 565; premature artificial, 665—the objections to, considered, 668—674; statistics of, 673; the various modes of operating for the induction of premature artificial delivery, 674 et seq. Denman, Dr., on spontaneous evolution, 562; on the application of the forceps, 581. Desormeaux, interesting case recorded by, bearing on the duration of pregnancy, 300, 301. Deville, on muscularity of the uterus, 126. Diarrhoea, of pregnancy, treatment of, 223. Diet of the parturient woman, 360. Disease, transmission of, from parent to offspring, 263. Douglass, Dr., on spontaneous evolution, 563. Dropsy, cases of, simulating pregnancy, 179, 183; of the ovary, 197 ; of the uterus, 194; peritoneal, 197. Dubois, on vertex presentations, 38. Dubois and Pajot, table by, showing the influence of climate on menstruation, 96. Dyspnoea, in pregnancy, 160. E. Elytrotomy, description of the operation of, 641. Embryonic nutrition, 255. Embryotomy, the space through which a child may be extracted by, 66; the operation of, 651; amount of pelvic contraction justifying, 651, 652; case of Elizabeth Sherwood, as narrated by Dr. William Osborn, 652-656; evidences of the child's death in utero, 656-658 ; melancholy results of the fondness for, 660; mode of performing the operation, 660-663. Emetics, in pregnancy, 218. Encysted dropsy, 197. Ephemeral fever or weed, 430. Ergot, use of, to arrest uterine hemorrhage, 280 ; caution on the use of, 392 ; in pla- centa praevia, 480; in inertia of the uterus, 553 ; administration of, in premature artificial delivery, 676. Esquirol, statistics by, relating to the period of the development of puerperal fever, 700. Ether, sulphuric, use of, in convulsions during pregndncy, 496; first employed by Dr. Morton, 721; first used in parturition by Prof. Simpson, ib.; to be preferred to chloroform, 722, 723; mode of using, 725, 726. See Anaes- thetics. Etherization. See Anaesthetics. Evolution, spontaneous, observations on, 562, 563. Evrat, tampon suggested by, for reducing retro-version of the uterus, 238. Excito-motory action, phenomena of, 184. Extra-uterine pregnancy, its varieties, 203. F. Face presentations, statistics of, 339, 340; diagnosis of, 340; prognosis of, 341; in the first or right mento-iliac position, 341, 342, 612 ; in the second or left mento-iliac position, 342, 343, 612 ; use of the forceps in, 611-617 ; mento-ante- rior and mento-posterior positions, 614. Facies hippocratica, the, 692. Fallopian pregnancy, 204. Fallopian tubes, the, 89; how the fecundated ovule finds admission to, 119. Farr, Dr. William, summary of his statistics on marriage in France, derived from tha census of 1851, 123. Fecundation, meaning of the term, 110; theories of, 116 ; effect of, on the develop- ment of the uterus, 163 ; case of, effected at a menstrual period, 307, 308. Feet, presentation of the, 348, 550; four positions, 349. Female children, mortality of, compared with that of male, 28. FEV-GAS INDEX. 751 Fever, milk, 422 ; puerperal, 680 ; nature and origin of, 681-684; connexion between, and erysipelas, 684; the divisions of, 685; diversity of views on the question of contagion, 686-688 ; causes and symptoms of, 689; lesions, 690; diagnosis, 691,692; prognosis, 692 ; prophylactic treatment, 692-694; remedial treat- ment, 694-698 ; ephemeral or weed, 430. Fibrin, increase of, in the blood, in acute inflammation, 133; in pregnancy, 134. Fibrous growths of the uterus, 196. Fibrous tumor, case of, simulating pregnancy, 138. Figg, E. Garland, startling views of, on the subject of version, 538, 539. Figueira, M., tables from, showing the diameters of the head at the different period! of pregnancy, 667. Fillet, the, circumstances under which it may be applied, 566. Finnell, on extra-uterine pregnancy, 204. Fistula, urethro-vaginal or vesico-vaginal, diagnosis of, 78; sometimes a consequence of careless use of the forceps, 570. Flatus in the intestinal canal, after childbirth, treatment of, 415. Flooding, in pregnancy, 168 ; after the birth of the child, 388, 390. See Hemorrhage. Flourens, M., on the influence of anaesthetics on the nervous system, 725. Fcetal movements in utero—how can they be excited ? 183; ballottement, or pas- sive motion of the foetus, 185; pulsations of the fcetal heart, 187. Foetation, extra-uterine, causes, progress, and phenomena of, 206; diagnosis of, 208. Foetus, bones of the, 3; the fcetal head, its regions, diameters, sutures, fontanelles, &c, 27 ; difference between presentation and position of the, 35 (and see Head and Labor); quickening of the, in utero, the result of muscular contraction, 178 ; movements of, simulated, 181; nutrition of the, 255 ; does it breathe in utero? 264; viability of the—incapable of existence previous to the termination of the sixth month, 268, 666; the annexae, or appendages of the, 241; death of the, a cause of abortion, 272; is the determining cause of labor due to the action of the ? 310 ; conditions for labor on the part of the, 338 ; presen- tations of, in natural labor, 339; face presentations, 339-343; pelvic presenta- tions, 343 ; breech presentations, 343-346 ; presentations of the feet and knees, 348-350; presentations in twin labors, 435; superfoetation, 442-445 ; malposi- tion of the, 458; spontaneous evolution of the, 562. Fontanelles, the anterior and posterior, 30, 31. Forceps, the, fundamental principle to be observed in delivery by, 56; in instru- mental delivery, 569 ; principles on which forceps delivery should be based, ib.; case illustrating abuse of the, 570 ; statistics of forceps delivery, 574; the true power of the, 575 ; dangers of forceps delivery, 576 ; the part of the child to which the instrument should be applied, 576; how the head should be grasped by the, 577 ; modifications of the. ib.; improvements in, devised by the author, 578; indications for the use of the, 580 ; time of resorting to the, 581-584; rules for the application of the, 585 et seq.; method of introduction. 587, 588 ; locking, 589 ; force employed in delivery by the, and method of traction, 589, 590; unlocking, 590; mode of applying the, in the various positions assumed by the head at the inferior strait, 591-596; mode of applying with the head at the superior strait, 596-601 ; application of the, in locked-head, 601-606; use of the, when the head is retained after expulsion of the body, 607-611; in face presentation, 611-617 ; cases illustrating the application of the, 615-617; the embryotomy forceps, 663. Fossa, the triangular or recto-uterine, 82. Fossa navicularis, the, 73. Fourchette, the, 73. Fox, Dr. George, interesting case reported by, illustrative of the advantage ot tne Caesarean section over cephalotomy, 635. Frerichs, his exposition of the true cause of uraemic intoxication, 513. Funis, the, pulsations of, 191; method of ligating, 367, 368; directions for traction on the, 375, 377; manner of dressing the, 406, 428; umbilical hemorrhage, 429 ; peculiarity of the, in a case of twin labor, 440; mortality, causes, diagno- sis, and treatment of prolapsion of the, 460-466. G. Galvanism, a means of artificial delivery, 678. Gardner peerage case, points in the, bearing on the duration of pregnancy, 299, 300. Gariel treatment suggested by, for retroverted uterus, 239. Gastrotomy, danger of the operation of, in extra-uterine pregnancy, 214. 752 INDEX. GEN-HIP Generation, the organs of, 72; external, ib.; internal, 77 ; the ovaries, the essentia] organs of, 90; ancient theory of, 108. Gerdy, M., his explanation of external rotation of the head of the fcetus, 51. Germ-cell, 90, 111; seat of contact between the germ and sperm cells, 117. Gestation, evidences of, 143; suppression of the catamenia, 144; is ovulation com' patible with ? 145; nausea and vomiting, with depraved appetite, 146; secre- tion of saliva, 148; changes in the breasts—the secretion of milk—the areola, 148-153 ; changes in the uterus and abdomen, 154; descent of the gravid ute- rus during the first two months, 155; positions of the gravid uterus, 156-161; change in the direction of the urethra, 161; oedema of lower extremities, ib.; effect of, on the development of the uterus, 163; phases through which the cer- vix of the uterus passes during, 164-169; enlargement of the uterus and dis- coloration of the vaginal walls, 170-174; quickening, 175; simulated quicken- ing, 179; how the movements of the fcetus can be excited, 183; pulsation of the fcetal heart, 187; uterine murmur, 189; pulsations of the umbilical cord, 191; extra-uterine, causes, progress, and phenomena of, 206; premature and protracted, 268, 666. See Pregnancy. Glandular apparatus, the, of the external genitals, 77. Glans clitoridis, the, 75. Gooch, Dr., his testimony on the subject of the recurrence of puerperal mania, 701. Graaffian vesicles, the, 90, 111, 112. Graves, Dr., on the use of opium in puerperal fever, 697. Gubler, M., on milk in the breasts of the new-born infant, 421. H. Hall, Dr. Marshall, his "ready method," 370; on puerperal convulsions, 485, 486; on depletion in puerperal mania, 704. Halmagrand, statistics by, on the Caesarean section, 633. Halpin, treatment suggested by, for retroverted uterus, 238. Haunch bone, the, 7. Head, the, of the fcetus, 27; description of its regions, diameters, sutures, fonta- nelles, etc., 27 ; sutures of the fcetal and adult head, 31; respective diameters of the fcetal head and adult female pelvis, 32; articulations and movements of the fcetal, ib.; frequency of head presentations, 33; cause of the frequency, 34; the author's classification of head presentations, 43; relations of, to the pelvis, 45; movements imposed upon the, 46; flexion, ib.; descent and rotation, 48; extension, 49; practical application, 54; presentation of the, calling for manual delivery, 524 et seq.; mode of applying the forceps with the head at the infe- rior strait, 591-596—at the superior strait, 596-601; application of the forceps in locked-head, 601-606; use of the forceps when the head is retained after expulsion of the body, 607-611; diameters of the, at the different periods of pregnancy, 667. Headache, treatment of, in exhausting hemorrhage, 399. Heart, the foetal, pulsations of, 187-189 ; palpitation of the, in pregnancy, 160, 224; hypertrophy of the, 225. Heat, the period of, in animals, 313. Hemorrhage, in pregnancy, 168; a symptom of abortion, 274, 275; difference between the, of menstruation and miscarriage, 275; treatment of, 280; true explanation of, in childbirth, 312; management of the placenta, in cases of, 388; frequency and mortality of, 390; divisions of post-partum, 390, 391; external, and its treatment, 391 et seq.; treatment of exhaustion from, 396, 397 ; treatment of internal, ib ; secondary, 402, 403 ; umbilical, of the new- born infant, 429; in a case of inverted uterus mistaken for the placenta, 454, symptoms, diagnosis, and treatment of, as connected with placenta praevia, 466- 474; accidental, from partial separation of the placenta, 480-483; accidental, at the time of labor, 484 ; secondary, 402*. Hemorrhoids, in pregnancy, 162, 228. Hereditary transmission of disease, 263. Hermaphroditism, enlargement of the clitoris mistaken for, 75. Hernia of the gravid uterus, a rare affection, 240; in labor, 460. Hewitt, Graily, on hydatiform mole, 285. Hewson, Dr., measurements of the fcetal head by, 30. Hip, the, presentations of, 558. Hippocrates, doctrine of in head presentations, 338; his directions for version, 540 facies hippocratica, 692. HOD-LAB INDEX. 753 Hodge, Prof., on the non-contagion of puerperal fever, 686. Hook, the blunt, mode of using in instrumental delivery, 567. Hour-glass contraction of the uterus, treatment of, 380-383. Humoral pathology, 683. Hunter, his theory of the membrana decidua, 242. Hunter, Dr. Septimus, case of malpractice in which the inverted uterus was mis- taken for the placenta, 454-456. Hydatiform moles, 284. Hydatids, can they form in, and be expelled from the uterus? 294, 295; premature delivery in a case of, 672. Hydrocephalus, rupture of the womb a not unusual accompaniment of, 662. Hydrometra, or dropsy of the uterus, 194. Hymen, the presence of the, no test of virginity, 78. Hysterotomy, vaginal and abdominal, 626; two interesting cases of vaginal 645 See Caesarean section. L Ilium, the, anatomy of, 8. Impregnation, aptitude for, 107; two orders of phenomena following, 124; effected at a menstrual period, 307, 308. India-rubber ball, advantages of the, as a support to the uterus, 58. Indigestion, convulsions induced by, 487, 488. Inertia of the uterus, causes of, 552 ; treatment of, 553. Infant, new-born, management of the, 367; treatment of asphyxia in, 369-371; wash ingand dressing the new-born, 406; caution against physicking and cramming the, 409; when it should be put to the breast, ib.; feeding the, 418 ; suppres- sion and retention of urine in the, 420; milk in the breasts of the new-born, 421; torpor of the bowels in the, 423; occlusion of the anus, 423, 424; puru- lent ophthalmia, 424, 425 ; umbilical hemorrhage of the new-born, 429 ; morta- lity of the. in podalic version, 539 ; evidences of the death of the, in utero, 656- 658. Instrumental delivery, 565. See Forceps and Instruments. Instruments, obstetric, the author's case of, 578; cutting, prerequisites for the use of, 618. See Symphyseotomy, Caesarean section, Craniotomy, Embryotomy. Interstitial pregnancy, 121, 205. • Intra-uterine growths, 193. Inversio uteri, 446* et seq. Ischium, the tuberosity of the, 10; spinous process of, when malformed, may inter- fere with delivery, 11. J. Jacquemin, on discoloration of the walls of the vagina, 172. Jones, T. Wharton, his experiments showing the effects of belladonna on the circu- lation, 498. Jorg, on elytrotomy, 640. K. Keating, Prof., details furnished by, on the use of opium in puerperal fever, 697, 698. Keep, Dr. N. 0., the first to use ether in parturition in this country, 721. Keiller, Dr., case of spurious pregnancy and spurious parturition, reported by, 182. Keyser, of Copenhagen, statistics by, on the Caesarean section, 633. Kiestein, explanation of its presence in the urine of the pregnant female, 135. Kiwisch, his plan of the water-douche, for the induction of premature delivery, 677 Knees, presentation of the, 349, 551; four positions, 349, 350. Krahmer, Prof, statistics by, on the duration of gestation in the cow, 302. L. Labia externa, or majora, 73; interna, or minora, 75. -,.*,. Labor how affected by the sex of the child, 28; mechanism of; 44; first vertex position, ib.; flexion, 46; descent and rotation, 48; extension, 49; expulsion of the shoulders and body, 52; second and third vertex positions, ib.; fourth 48 754 INDEX. LAC-MEI vertex position, 53 ; necessity of a practical knowledge of the principles of, 54 supposed case practically illustrating the mechanism of, ib.; obstruction to, from pelvic deformities, 57—from morbid growths, 63; case of, obstructed by polypus, ib.; the author's classification of, into natural and preternatural, 296 ; definition of natural, 297; order of sequence of the processes of, ib.; determin- ing cause of, 309; expulsive forces, 309, 310; the ovarian theory of, 312; Dr. John Power's theory of the determining cause of, 314-316 ; the author's expla- nation of the determining cause of, 318; seat and origin of the expulsive forces in, 321; primary and secondary forces of, 323, 324; preliminary signs of, 325- 328; essential or characteristic signs of, 328-331; the pains of, 329; true labor pains, 331; false labor pains, 332; cause of the dilatation of the os uteri in, ib.; rigors and vomiting during, 334; muco-sanguineous discharge in, ib.; formation and rupture of the membranous sac, or bag of waters, 334-336; con- ditions for, on the part of the mother and fcetus, 337, 338; presentations in natural labor, 339-350; detailed directions for the guidance of the accoucheur in a case of, 351 et seq.; stages of, 357 et seq.; management of the puerperal woman after the birth of her child, 404-418, 427-430; after-pains, 407; management of a twin labor, 436 et seq.; superfoetation, 442-445 ; preternatu- ral, 457 ; exhaustion during, 459; accidental hemorrhage at the time of, 484; treatment of convulsions during, 497-500; manual labor, 516; complications of, rendering manual interference necessary, 530; detailed directions for the application of the forceps, 591-601; use of anaesthetics in, 720. Lactation, in pregnancy, and other conditions of the system, 149, 150 ; sometimes a cause of abortion, 270; forbidden in puerperal fever, 694; Dr. Cummings on natural and artificial, 419. La Chapelle, Mad., on period of abortion, 268. Lambdoidal suture, the, 30. Laserre, M., on epidemics of puerperal fever, 689. Lee, Dr. Robert, his hypothesis with respect to puerperal fever, 681. Lever, the, in instrumental delivery, 568 ; contrast between the forceps and, ib. Levret, on the Caesarean operation, 632. Light, intolerance of, arising from exhausting hemorrhage, 399. Linea ileo-pectinea, the, 17. Liquor amnii, source and uses of the, 245, 246; does it contain nutrient properties ? 256. Lochial discharge, the, 417, 418. Locked-head, remarks on, 601, 602; definition of, 603 ; dangers of, to the child and mother, ib.; diagnosis of, 604 ; application of the forceps in, 605, 606. Lying-in chamber, detailed directions for the guidance of the young accoucheur in the duties of the, 351 et seq. M Macauley, Dr., the first to practise premature artificial dehvery when the fcetus is viable, 666. Malacosteon, a cause of pelvic deformity, 62. Male children, mortality of, compared with that of female, 28. Mammae, the, their relations to the uterus, 149; pains in the, during pregnancy, 226. See Lactation. Mania, occurrence of, after parturition, 503; puerperal, its pathology, 699; the period at which it is most apt to occur, 700; not of rare occurrence, ib.; its liability to recur, 701; causes and symptoms, 702; diagnosis and prognosis, 703; duration, 704; treatment, medicinal and moral, 704^707 Manual delivery. See Delivery. Manual labor, 457. Marriage, conducive to health and longevity, 123. Martin, Edward, his monograph on transfusion, 400. Mattei, A., on cephalic version by external manipulation, 542. Maunsell, Dr., statistics of craniotomy operations by, 631. Mauriceau, on moles, 283; on the Caesarean section, 627. Meatus urinarius, the, 76. Meconium, the, 409. Medulla spinalis, the reflex action of the, 178. Meigs, Prof, measurements of the foetal head by, 30; on the non-contagions cha- racter of puerperal fever 686 MEI-OPI INDEX. 755 Meissner, his plan for perforating the membranes in premature artificia. delivery 675. Membrana decidua, Hunter's theory of the, 242 ; its true structure, ib. Membrana granulosa, the, 111. Membranes, perforation of the, in premature artificial delivery, 675. Menstruation. Menses, the; retention of, mistaken for pregnancy, 79; period be- tween puberty and their final cessation, 93; influence of climate on, 95—of education and mode of fife, 96—of temperament, constitution, and race, 97; average age at which they first appear, 96; precocious and tardy, 98 ; causes of, ib.; dependent on organic development, 99; do not consist in the discharge of blood, but in the maturity of the ovules, 100; the ovular theory, 101; periodicity, ib.; source and nature of the menstrual fluid, 102, 292; duration and quantity lost at each menstrual period, 103; is menstruation peculiar to women ? 104; does the menstrual fluid contain poisonous elements? ib.; time of final cessation, 106; aptitude for impregnation just before the catamenial period, 107 ; suppression of, as a sign of pregnancy, 144; sometimes occur only during pregnancy, 146; retention of the, with interesting case, 194, 195; difference between the, and the hemorrhage of miscarriage, 27 5; case of fecundation effected at a menstrual period, 307, 308. Merriman, Dr., on the application of the forceps, 581; on the Caesarean section, 628 ; objection by, to premature artificial delivery in a primipara, 668. Meso-rectum, the, 4. Metrorrhagia, common occurrence of, at the critical period, 106. Metroscope, the, description of, 201. Midwifery, an exact science, 1. Milk, secretion of, an evidence of pregnancy, 149; instances of its secretion in othei conditions, 150; in the breasts of the new-born infant, 421; milk fever, 422. Milk leg, 712. Mills, Dr. Charles S., interesting case of Caesarean section reported by, 635. Miscarriage. See Abortion. Moles, various opinions of authors respecting, 283, 284; the true moles—vesicular or hydatiform, 284-291; false moles—molae spuriae, 291-294. Mollities ossium, a cause of pelvic deformity, 62. Monkeys, menstruation in, 104. Monneret, on the puerperal state, 685. Mons veneris, the, 73. Montgomery, Dr., summary of his remarks on the areola of pregnancy, 152; on the temporary loss of mind during labor, 365. Morton, Dr., the first to administer ether to prevent the pain of a surgical opera- tion, 709. Mucous follicles, increased secretion of the, as pregnancy advances, 166. Multipara, modifications of the cervix uteri in a, 169. Murphy, Dr., on the Caesarean section, 628. N. Naegele, on the incUnations of the planes of the pelvis, 19; his views on the mechanism of parturition, 38; on vertex presentations, 42 ; on oblique distor- tion of the pelvis, 65; on the period of pregnancy, 306. Nausea, in pregnancy, 128, 146; importance of, 128, 129; treatment, 220. Neboth, glands of, an erroneous appellation, 83. Nerves, sacral plexus of, 4. Nervous force as a determining cause of labor, Dr. John Power's theory of, 314-316 Nipple, how to remedy a sunken or flat, 410; treatment of sore, 426. Nutrition, a fundamental law of life, 254; objects of, ib.; embryonic, 255; pla- cental, 256. Nymphae, the, 75; enlargement of, simulating breech presentation, 76. 0. Obstetric case, the author's, 578. ffidema of the lower extremities, during pregnancy, 161. Ophthalmia neonatorum, causes, symptoms, and treatment of, 424, 425. Opium, comments on the use of, in the convulsions of pregnancy, 494; treatment by, in puerperal fever, 697. 756 INDEX. OS-PLA Os coccyx, anatomy of the, 6; important influence during childbirth, 6, 7; disloca- tion and fracture of, 7. Os innominatum, anatomy of the, 7. Os ischium, the, 10. Os pubis, the, 10. Os sacrum, the, description of, 3. Os sedentarium, the, 10. Os tincae, the, 81; cicatrices upon, not always reliable as evidences of childbirth, 88 condition of the, as pregnancy advances, 165; peculiar moisture of the lips of, an accompaniment of pregnancy, ib.; extraordinary thinness of the, at tho time of labor, 172 ; cause of its dilatation in labor, 332; rigidity of the, 360 ; spasm of the, treatment of, 378-380; mode of effecting artificial dilatation of the, 520; dilatation of, by prepared sponge, in cases of premature artificial delivery, 676. Osborn, Wm., on the amount of pelvic contraction consistent with the birth of a living child, 619; on the Caesarean section, 627 ; his report of the performance of embryotomy in the celebrated case of Elizabeth Sherwood, 652-656. Ovarian pregnancy, 203. Ovarian theory of parturition, 312. Ovaries, the, the essential organs of generation, 90. Ovary, the, the seat of contact between the germ and sperm cells, 119; enlargement of the, 196 ; diagnosis of prolapsed, 240. Ovisac, the, 112. Ovulation, is it incompatible with gestation ? 145. Ovule, the fecundated, manner of admission to the Fallopian tube, 119; the deci- duous and the vitalized, 176. Ovum, blighted, interesting case of enlarged uterus caused by, 287-291. P. Paul, as a sign of labor, 329 ; true labor pains, 331; false labor pains, 832 Paralysis, treatment of, after delivery, 428. , Paraplegia, after delivery, treatment of, 428. Parent, influence of the, upon progeny, 263. Parent-Duchatelet, on enlargement of the clitoris, 75. Parturition, primary forces of, 323; secondary forces, 324. See Labor. Pathology, humoral, 683. Pelvic axis, true meaning of the term, 19. Pelvic extremities, presentation of the, 343. Pelvic version, 539; spontaneous, 562. Pelvimeter, the, method of using, 69; the finger the best, 70, 668. Pelvis, the human, its position in the skeleton, and anatomy of the, 2; bones of, in the adult and foetus, 3; its uses, 12; articulations or joints, ib.—question of their relaxation, 15; the greater and lesser, 16; the straits of the, 16, 17; planes of the two straits, 18; axes of the pelvis, 19; remarkable differences between that of the new-born child and that of the adult, 23; varieties of, depending upon the sex and age of the individual, 22, 23; its connexions with the soft parts, 23, 24; measurements, 24-26; respective diameters of the fcetal head and adult female pelvis, 32 ; deformities of| two classes—increased capacity and diminished capacity, 57; illustrative case, 58, 59; varieties of pelvic deformity, 61, 619, 620; causes of, 62; oblique distortion of the, 65; determination of the smallest space through which a living child may be extracted, 66; exami- nation of the propriety of version in cases of pelvic deformity, 544-546; amount of polvic contraction consistent with the birth of a living child, 619 , amount of pelvic deformity through which a child may be extracted piecemeal, 620. Perineum, directions for supporting the, in labor, 363-365; paralysis of the, after delivery, 417. Peritoneal dropsy, diagnostic guides of, 197. Peritonitis, puerperal, 691. Peu, M., thrilling case of Caesarean section by, 639. Phlegmasia dolens, 708. Phlegmasise, treatment of, during pregnancy, 13 Physometra of the uterus, a rare affection, 195. Piles, treatment of in pregnancy, 228, 229. Placenta, description of the, 246; fcetal and maternal divisions of the, 247-249; blood-vessels of the, 247, 248; fatty degeneration of the, 250; nutrition by the, 256; manner in which the blood is conveyed from the. to the fcetus. 258. 259; PLA-PUB INDEX. 757 elaboration of the blood in the, 261; connexion between abortion and disease of the, 272; placental apoplexy, 273; fatty degeneration of, towards the close of gestation, 320; function of the, when terminated, 372; situation of, 373; natural detachment of, ib.; removal of, after detachment, 374; examination of, after removal, 376; how the expulsion of, may be aided, 377 ; artificial extrac- tion of, 378, 385; excessive volume of, 378; morbid adhesion of, to the uterus, 383 ; absorption of retained, 386; management of, in cases of hemorrhage or flooding, 388 ; in multiple pregnancy, 432. 437, 438, 440 ; case of malpractice in which the inverted uterus was mistaken for the placenta, 454-456 ; artificial detachment of the, 475-479 ; accidental hemorrhage from partial separation of the, 480^183; detachment of, in the Caesarean operation, 642. Placenta praevia, 168; connexion between hemorrhage and, 467-469; symptoms, diagnosis, and treatment of, 470-475. Placental souffle, the, 189. Plethora, its connexion with pregnancy considered, 130. Podalic version, 531; delivery of the lower extremities and trunk, 533 ; delivery of the arms, 535; extraction of the head, ib.; statistics of, 538; case of, con- nected with malposition of the uterus, 564. Polypus, case of labor obstructed by, 63. Position, of the parturient woman, 359, 360 ; of the foetus, difference between, and presentation, 35. Power, Dr. John, his digest of the ovular theory of menstruation, 101; his theory of the determining cause of labor, 314-316. Pregnancy, definition and divisions of, 121; not a pathological condition, 122 ; occa- sionally subject to derangements, 216 ; changes in the uterus during, 124 (and see Uterus); connexion between, and gastric irritability, 128; changes in the blood, 129 ; not, per se, a condition of plethora, 131; treatment of phlegmasia? during, ib.; modifications in the urinary secretion, 135; how is pregnancy diagnosed? 136: difficulty of distinguishing, 137; remarkable and touching case of fibrous tumor simulating, 138; how the evidence of, should be examined, 142 (and see Gestation); cases of simulated, 179-183 ; period of, at which the placental murmur can be first recognised, 190 ; method of examining the female to ascertain the existence of, 192; ovarian, 203; tubal or fallopian, 204; abdo- minal, and interstitial 205; causes, progress, and phenomena of extra-uterine, 206; symptoms and diagnosis of extra-uterine, 208; dangers of extra-uterine, 212; treatment of extra-uterine, 213; blood-letting in, when indicated, 217; cathartics and emetics in, 218; nausea and vomiting in, treatment of, 220; salivation in, 221; constipation in, 222; diarrhoea in, 223; palpitation of th6 heart in, 224; syncope in, 225; pain and relaxation of the abdominal parietes, 226; painful mammae, ib.; pain in the right side, 227 ; pruritus of the vulva, ib.; hemorrhoids, 228; varicose veins, 229; cough and oppressed breathing, 230 ; complications of, from displacement of the uterus, 232; period of, at which abortion is most frequent, 268, 269 ; duration of, 297-303; peculiar sensations as a guide for computing the period of, 303, 304; the period of quickening, 304; rule for calculating the duration of, from the last menstrual period, 306; multiple, 431 et seq.; superfoetation, 442-445 ; treatment of convulsions during, 492-497 ; frequent occurrence of albuminuria, 508. Preputium clitoridis, 75. Presentation and position of a foetus, difference between, 35; influence on presentation exercised by the life or death of the foetus, 33 ; vertex presentations, 33-43,188. Presentations, of the foetus in natural labor, 33, 339; statistics of face, 339; dia- gnosis, 340; presentation of the pelvic extremities, 343 ; of the breech, 344, 547 ; diagnosis and prognosis of breech presentations, 345, 346; of the feet, 348, 349, 550; of the knees, 349, 350, 551; in twin pregnancy, 435; classification of; calling for manual delivery, 522 et seq.; pelvic, 547, 552; trunk or transverse, 555; of the thorax, 556; of the back, 557 ; of the hip and shoulder with the protrusion of arm, 558 et seq. Preternatural labor, 457 et seq. Primipara, modificat>. ons of the cervix uteri in a, 169. Procidentia uteri, 233. Progeny, as influenced by the parent, 263. Prolapsus uceri, three degrees of, 232. Pruritus of the vulva, in pregnancy, treatment of, 227, 228. Ptyalism, sometimes a result of pregnancy, 148; treatment of, 221. Puberty, changes in the physical condition at the time of, 95. 758 INDEX. PUB-S1G Pubic arcade, the, deformity of, 64. Pudendum, the, or external organs of generation, 73. Puerperal convulsions, 485; pathology of, 485, 486; eccentric causes of, 487-491; treatment of, 491; symptoms, diagnosis, and prognosis of, 501-503; centric causes of, 504. Puerperal fever. See Fever. I'uerperal woman, management of the, after the birth of her child, 404 ct seq.; diet of the, 427 ; recumbent position enjoined, ib. Pulsations of the foetal heart, 187; directions for recognising, 188, 189; of the umbi- lical cord, 191. Purgatives, prescriptions for, in puerperal fever, 695, 696. Q. Quickening, ancient theory of, 175 ; English law with regard to, 176; the true import of the term, 177 ; not a psychical act, but the result of excito-motory influence, 177,178; period of, 178; simulated, 179-183; difference between, and ballotte- ment, 185; the period of, as a guide for calculating the duration of preg- nancy, 304. Quinine, sulphate of, in puerperal fever, 697 R. Rachitis, a cause of pelvic deformity, 62. Ramsbotham. Dr., on premature artificial delivery, 674. "Ready-Method," the, of Marshall Hall, 370. Rectum, distension of the, by faeces, occasioning symptoms of retro-verted uterus, 239. Reflex movement, explanation of 269; sometimes a cause of abortion, 270. Reid, Dr. James, table by, exhibiting the duration of pregnancy dating from a single coitus, 305. Reproduction, its importance and necessity, 109; early opinions concerning, 110; what is the vitalizing element? 115. Respiration, oppressed, in pregnancy, treatment of, 230; artificial, 370, 371. Respiratory organs, derangements in the, sometimes occurring in pregnancy, 160. Retro-version of the uterus, 235. Rigors, in labor, 334. Ritgen, on elytrotomy, 640; tables from; showing the diameters of the head at the different periods of pregnancy, 667. Roberton, Mr., statistics of the influence of climate on menstruation, 96. Roger, Dr., on the occlusion and ossification of the anterior fontanelle, 31. Rouget, Dr. Charles, his researches as to whether the uterus is an erectile organ, 84, EL Sacral plexus of nerves, 4. Sacro-coccygeal symphysis, the, 12. Sacro-iliac symphyses, the, 13. Sacro-vertebral articulation, the, 14. Sacrum, the, description of, 3. Sagittal suture, the, 30. Salivary glands, sympathy between the sexual organs and the, 148. Salivation, sometimes a result of pregnancy, 148; treatment of, 221. Scanzoni, on head presentations, 34; his cephalotribe, or embryotomy forceps, 668. Scheller, his method of inducing artificial delivery, 677. Scholer, Dr., on trismus nascentium, 367. Sciatic plexus, the, 4. Schwartzenberg, the Princess of, post-mortem Caesarean section performed on, 638. Secale cornutum, efficacy of, in uterine hemorrhage, 280; caution on the use of, 392 in placenta praevia, 480. Secondary hemorrhage, 402*. Semmelweiss, Dr., observations of, on puerperal fever, 686, 687. Sequard. See Brown-Sequard. Sex of the child, the, its influence upon labor, 28. Sexual organs, sympathy between the, and the salivary glands, 148 Shoulder, the, presentations of, 558. Show, the, a sign of the approach of labor, 334. Sigault, perseverance of, in introducing the operation of symphyseotomy, 622, 6231 BIM-TJR.E INDEX. 759 Simon, statistics by, on the Caesarean section, 633. Simpson, Prof, on labor as affected by the sex of the child, 28; on vertex piesenta- tions, 39; statistics by, on presentations in twin labors, 435; his plan of artifi- cial detachment of the placenta, 475, 476 ; on version in pelvic deformity, 544, 545, 596; the first to use ether in parturition, 709; introduction of chloroform by, ib. Smellie, on the Caesarean section, 627. Smith, Dr. Stephen, on umbilical hemorrhage, 429. Smith, Dr. Tyler, his theory of the determining cause of parturition, 312. Snow, Dr., on anaesthetics in parturition, 723, 724. Souffle, the placental, 189; of the funis, 191. Spasm of the uterus, 378 et seq. Spermatozoa, 115, 116, 118. Spinous process of the ischium, the, 11; how, when malformed, it may interfere with delivery, ib. Stoltz, on shortening of the neck of the womb, 87, 168. Strangury, case of nervous perturbation occasioned by, in a pregnant woman, 489, Sub-pubic arcade, the, 17. Sugar, pr.esent in the urine of pregnant women, 135. Sulphuric ether. See Ether. Superfcetation, remarks on, with cases, 442-445. Sutur.es, the, of the fcetal head, 30. Symphyseotomy, history of the operation of, 622, 623; the objects of, 624; statistics of, 625. Symphyses of the pelvis, the, 12; do they become relaxed during gestation, and separate during parturition? 15. Symphysis pubis, the, 13. Syncope, treatment of, in pregnancy, 225. T. Tampon, the, when to be employed for the arrest of hemorrhage, 280, 393; use of, in placenta praevia, 472,473; the vaginal, as a means of inducing artificial delivery, 677. Tarnier, on the puerperal state, 685. Tessier, observations by, on the gestation of the lower animals, 302. Testes muliebres, 90. Thomas, Dr. T. Gaillard, his plan of postural treatment in prolapsion of the funis, 464. Thompson, Dr. Cyrus M., case of extra-uterine gestation, 208. Thorax, the, presentations of, 656. Thrombus of the vulva, 430. Toucher, the, directions for making, 70. Toxaemia, or blood-poisoning, 505, 683 ; characteristic of diseases produced by, 684 Transfusion, observations on, 400-402 ; method of performing the operation, 402. Trask, Dr., abstract of his researches on artificial detachment of the placenta, 477- 480; interesting facts from his monograph on rupture of the womb, 573. Trismus nascentium, Dr. Scholer on, 367. Tubal pregnancy, 204. Tuberosity of the ischium, the, 10. Tumor, fibrous, case of, simulating pregnancy, 138. Tumors, polypous and fibroid, labor obstructed by, 63; uterine and abdominal, 193, 196; phantom, 197. Turpentine, internal use of) in puerperal fever, 696. Twin pregnancy, signs of, 433; twins not always equally developed, 434; not ir ;om- patible with natural labor, 434, 435; management of a twin labor, 436; inte resting case of twins, 439-442; superfcetation, 442-445; deductions, 445. Tympanites of the abdomen, 197. Tympanites intestinalis, 692. U. Umbilical cord, pulsations of the, 191. See Cord and Funis. Umbilical hemorrhage of the new-born infant^ 429. Uremic intoxication, 411. 760 INDEX. UR.E-VAN Uraemia, 505 ; not necessarily a consequence of albuminuria, 510: definition of, ib.; not necessarily produced by excess of urea in the blood, 512; the true cause of, 513 ; treatment of 514; anaesthetics in, ib.; summary of conclusions respecting, 515. Urea, not a virulent poison, 511, 512. Urethra, change in the direction of the, during pregnancy, 161. Urethro-vaginal fistula, diagnosis of, 78. Urinary secretion, the, modifications in, during pregnancy, 135. Urine, the, constituents of, in pregnant women, 135; retention of, after childbirth, 411, 412; incontinence of, 415; suppression and retention of, in the infant, 420. Uterus, the, advantages of the India-rubber ball as a support of, 58; displacements to which it is liable, 59; its position and relations to the adjacent organs, 80 ; its divisions, ib.; the fundus, body and neck, surfaces, angles, and borders, 81; its size variable, ib.; shape pyramidal, ib.; composite structure, ib.; external coat, 82 ; anterior and posterior broad ligaments, ib.; triangular fossa—recto- uterine fossa, ib.; internal or mucous lining, 83 ; intermediate tissue, 84; is it an erectile organ? ib.; blood-vessels, 85; lymphatic vessels, 86; nerves, ib.; cervix, the, its volume and form, 87, 88; the round ligaments, 88 ; the Fallopian tubes, 89 ; the ovaries, 90; reciprocal relations of the general and uterine sys- tems, 93; malformations and absence of, 89; special functions or physiological offices of, 92; commencement of menstruation, 94: changes in the, during pregnancy, 124,154; development of the impregnated—the mucous membrane, peritoneal or serous membrane, and muscular structure, 125; constitutional sympathies, 127 ; descent of the gravid uterus during the first two months, 155 ; positions of the grav',d, from the earliest moment of conception until the completion of gestation, 155-161; effect of fecundation on the development of the, 163; changes in the cervix, 164-169; difference of the cervix in the primipara and multipara, 169; development of the annexae and the external genitalia, 169; how the gravid, enlarges, 170; thickness of the walls during gestation, 171; discoloration of the vaginal walls, 172; the uterine murmur, 189; different causes other than gestation, capable of inducing enlargement of, 193; dropsy of the, 194; physometra, 195 ; hypertrophy and scirrhus of the, 196; extra-uterine pregnancy, its varieties, 203; prolapsus uteri, 232 ; ante- version of the, 234; retro-version of the, 235-239; hernia of the, 240; hyperae- mic or plethoric condition of, a cause of abortion, 272 ; treatment of hemorrhage from the, 280; substances expelled from the—moles, 284; interesting case of enlarged, from a blighted ovum, 287-291; can true hydatids form in and be expelled from the? 294, 295; the true seat of the determining cause of parturi- tion, 311, 318-320; fatty degeneration and other changes in the recently delivered, 320 ; difference in the parturient force exercised by the, 322; various excitors of reflex action in the, ib.; independent contractions of the, prior to the commencement of actual labor, 326; are the contractions of the, and the pains of labor identical ? 329 ; cause of the dilatation of the os uteri in labor, 332; direct result of the contractions of the, 374; removal of coagula, 375; spasm, of the os uteri, 378-380; hour-glass contraction of the, 380-383; morbid attachment of the placenta to the, 383-386; hemorrhage proceeding from iner- tia of the, 390; the lochial discharge, 417, 418; pain in the, when the child is applied to the breast, 429; inversion of the, 446*; causes of inversion, 447*; diagnosis of inversion, 448,449; treatment of inversion, 450, 451; spontaneous reduction of inverted, 451, 452 ; extirpation of the inverted, 452, 453; malprac- tice in a case of inverted, 454-456; influences capable of exciting contractions in the, 498; inertia of the, in connexion with pelvic presentations, 552; case of podalic version, connected with malposition of, 564; results of treatment in rupture of, extracted from Dr. Trask's monogram on rupture of the womb, 573; rupture of the, a not unusual accompaniment of hydrocephalus, 662; premature delivery in a case of hydatids of the, 672 ; influence of anaesthetics in contraction of the, 724. Vagina, the, 77; anterior and posterior relations, 78; internal surface of, 79; not an erectile organ, ib.; arteries and nerves, whence derived, 80; the discharge of blood from, 168; discoloration of the internal surface of the, not a certain sign of pregnancy, 172-174; anatomical relations of the, 199. Vaginal examination, directions for making the, 70, 197, 353; impropriety of fre- quent, 360. Vaginal hysterotomy, two interesting cases of, 645; and see Caesarean section. Van Pelt, Dr., measurements of the diameter of the fcetal head at term, 30. 7AN-WRI INDEX. 761 Van Swieten, on the sensations connected with impregnation, 304. Vectis, the, in instrumental delivery, 568. Veins, varicose, treatment of, 229, 230. Veit, Dr., on the mortality of male infants, 28. Veratrum viride, a remedy in puerperal fever, 698. Vertebrae, the false sacral, 3. Version, conditions under which it is to ve resorted to, in prolapsion of the funis, 465, 466; directions for, in placenta praevia, 473,474; cephalic, 516, 540, 541; rules for, in manual delivery, 520-522; podalic, 531, 564; mode of performing 540, 541; mode of performing cephalic, by external manipulation, 543, 544; in pelvic deformity, 544-546; spontaneous pelvic, 562. Vertex, the, discrepancy among authors as to the number of positions of, 36 ; sta- tistics of vertex presentations, 37; the author's classification of vertex presen- tations, 43; mechanism in the first vertex position—left occipito-acetabular, 44; mechanism in the second and third vertex positions—right occipito-ace- tabular and right posterior occipito-iliac, 52 ; mechanism in the fourth vertex position—left posterior occipito-iliac, 53; presentations of, in cases calling for manual delivery, 526 et seq. Vesico-vaginal fistula, diagnosis of, 78. Vesicular moles, 284. Vestibulum, the, 76. Virchow, his theory of extra-uterine foetation, 206. Vomiting, in pregnancy, 128, 146; importance of, 128, 129; treatment of, 220; In labor, 334; excessive, as a motive for premature dehvery, 671. Vulva, the, or external organs of generation, 72; treatment of pruritus of the, in pregnancy, 227, 228; thrombus of, 430. Vulvo-vaginal gland, the, 77 W. Water-douche, the, as proposed by Kiwisch for the induction of premature deli- very, 677. Waters, the bag of, 245; formation and rupture of the, 334-336, 358. Weed or ephemeral fever, 430*. Weidemann, on the Caesarean section, 627. West, Dr., statistics by, on extirpation of the uterus for inversion, 453. Whitehead, Dr., his statistics of abortion, 266, 267. " Whites," the, a vague and unmeaning disease, 166. Womb. See Uterus. Wright, Dr., on the mode of performing cephalic version. 641 SUPPLEMENT TO INDEX. A. Aberration of mind, pregnancy complicated with, 742 ; greatly aggravated under the influence of pregnancy, 743. Anaesthetics, effect of, on the perineum during labor, 727 ; are they admissible in pregnancy before the commencement of labor ? 728. Amaurosis, a not uncommon accompaniment of pregnancy, 741. C. Chorea (or St. Vitus' Dance), 729; statistics of, 730; its essential character, ib.; connection between chorea and rheumatism, 731; is it a blood poisoning ? 732; the chorea of pregnancy, ib.; cases related, 733-735. Churchill, Dr. Fleetwood, on paralysis occurring in pregnancy, 741. D. Deafness, the puerperal woman liable to, 741. F. Faust, C. J., letter from, on a case of multiple births, 447. G. Galen, definition of jaundice by, 744. H. Hemiplegia, not unfrequent during pregnancy, 740. J. Jaundice, sometimes observed as a complication of pregnancy, 743 ; description and definition of, 744; treatment, 745; fatal epidemic in the island of Martinique, 745, 746. L. Liver, adipose condition of, in pregnant women, 743, 744. M. Martinique, fatal epidemic of jaundice in, 746, 746. P. Paralysis, varieties of, complicating pregnancy, 736; centric and eccentric causes, ib.; facial, 741; Dr. Fleetwood Churchill on, ib. Paraplegia m pregnancy, case of, caused by pressure of a tumor on the sacral plexus, 739. Perineum, how affected by anaesthetics during labor, 727. Pregnancy, anaesthetics in, before labor has commenced, 728; complicated with chorea, 732; with paralysis, 736; amaurosis, facial paralysis, and deafness in, 741; complicated with aberration of mind, 742; with jaundice, 743. SUPPLEMENT TO INDEX. 763 R. Rheumatism, as connected with chorea, 731. Rilliet, minute investigations by, as to the alliance between rheumatism and chorea, 732. Romberg, on the connection between rheumatism and chorea, 731. S. Saint Vel, Dr., his description of a fatal epidemic of jaundice in the island of Mar- tinique, 745, 746. St. Vitus' dance, or chorea, as a complication of pregnancy, 729. T. Tumor of the uterus, paraplegia caused by, 738. 3 R 3 3 i tf# NATIONAL LIBRARY OF MEDICINE NLM 03SDbDbA A ytnliiuivriii HttMHlHttft « NLM032060688